A comparative cross-sectional evaluation of the Field Epidemiology Training Program-Frontline in Ethiopia

The Field Epidemiology Training Program (FETP) is a globally recognized practice-oriented training that builds the capacity of health professionals in preventing, detecting, and responding to public health emergencies [1‐5]. FETP has been adopted by many countries, including Ethiopia [1, 3, 6‐12]. The curricula and activities of FETPs are based on the Epidemic Intelligence Service (EIS) training of the US Centers for Disease Control and Prevention (CDC) [13‐15], which requires that most parts of training be spent on the field and a smaller amount of time in deductive training. Although FETP has a long history in public health, it was adapted by many countries [4, 5, 16] following the International Health Regulations (IHR) 2005. IHR 2005 and subsequent evaluations of its progress [17] also recommended the training strategy as a tool to fulfil health workforce development, one of the eight IHR core competencies [18, 19].

FETP-Frontline was initiated in African countries following the West African Ebola outbreak of 2014–2016 [20, 21]. It was designed as a three-month in-service training program with the purpose of improving surveillance officers’ capacity to prevent, detect, and respond to public health emergencies. Specific objectives of the training include improving completeness, timeliness, and quality of surveillance data; enabling early detection of diseases; and taking prompt and appropriate public health actions. FETP-Frontline participants spend up to 14 days in three classroom workshops: workshop 1 (6–7 days), workshop 2 (5 days), and workshop 3 (2 days). The remaining 8–10 weeks are dedicated to on-the-job fieldwork to practice, implement, and reinforce what they have learned in the workshops. The classroom lectures are tailored around topics such as surveillance systems and IHR; descriptive statistics and epidemiology; surveillance data quality; data analysis, interpretation and taking actions; monitoring and evaluation; outbreak investigation; linking surveillance and laboratory investigation; analysis of surveillance data quality problems; introduction to Microsoft Excel, Word, and PowerPoint; and scientific communications. Each topic is accompanied by practical group exercises, where participants discuss and share experiences.

FETP-Frontline was established in Ethiopia in 2016 with support from the CDC, the World Health Organization (WHO), and other stakeholders. The program is hosted by the Ethiopian Public Health Institute’s (EPHI) center for Public Health Emergency Management (PHEM). The curriculum adopted by Ethiopia from the CDC’s FETP-Frontline model [21, 22] is shown in Fig. 1. From December 2017 to March 2019, the program graduated about 250 district surveillance officers, reaching about 25% of the country’s over 1,000 district surveillance officers. Selection criteria to participate in FETP-Frontline include the experience of at least six months as a district surveillance officer and a willingness to serve in the position for at least one year after enrollment into the program. The target of the program was to have at least one FETP-Frontline graduate in all districts of the country.

Despite providing the training to large cohorts, the level of program effectiveness in improving the capacity of surveillance officers was not well documented. This study was aimed at evaluating the impact of FETP-Frontline on surveillance officers’ knowledge, skills, and practices of surveillance and public health emergency response activities.

This evaluation provided evidence that demonstrated the effectiveness of the FETP-Frontline in improving the knowledge and skills of surveillance officers in Ethiopia. Our study suggested that the capacity of surveillance officers in performing activities, such as collecting data, producing summary reports, conducting active case searches, analyzing data quality problems, conducting supportive supervision, and giving training have been improved.

Most evaluations of FETPs are based on output indicators in which the role of FETP graduates in outbreak detection, investigation, and response was reported [1‐3, 6‐9, 14, 24‐27]. Another means of FETP evaluation is by assessing the number or quality of scientific manuscripts produced by FETP residents and graduates, which are considered indicators of the program’s success [9, 28]. In addition, the involvement of FETP residents in investigations and control of pandemics and public health concerns, including Ebola [29], Zika, malaria, HIV/AIDS, malignancies, diabetes, hypertension, and COVID-19 have been regarded as achievements of the training programs [7, 8, 20, 24, 30, 31]. These studies recommended disease-specific specialty training to equip the workforce with the necessary skill to combat public health emergencies such as the ongoing COVID-19 pandemic [32]. Literature on the evaluation of the effectiveness of the FETP, especially for the FETP-Frontline, is scarce [7, 9, 24, 33]. A few publications reported FETP-Frontline project activities [34‐37].

Our study fills the gap in the literature by showing how FETP-Frontline improved graduates’ skills in all areas of the surveillance cycles [21], including data collection, data analysis, interpretation, monitoring, and evaluation. Trained officers showed timely and complete reporting of weekly surveillance data. The trained officers also showed better performance in preparing quality surveillance summary reports. Finding from the evaluation of Kenya’s FETP-Frontline also showed improved on-time reporting and data quality auditing among trained surveillance officers [38]. During FETP-Frontline training, surveillance officers complete the practical exercise of writing up a surveillance summary report, visiting health facilities, and conducting data quality audit, which could have led to better timeliness and completeness of surveillance data. They also practiced how to compute timeliness and completeness of surveillance reports during the training, which could have led to better performances.

Trained officers provided more surveillance training to health facility surveillance focal persons than their untrained counterparts. This could have also led to improvement in many surveillance system components. Trained officers could have also benefitted from gaining skills in scientific presentation and PowerPoint preparation during second and third workshops of the training, which could have improved the overall data summarization and presentation practices.

This study had some limitations. First, trained surveillance officers were more likely to have completed other training, such as the PHEM basic and disease-specific training, than untrained officers. PHEM basic training is a four-day training where major components of the PHEM system (e.g., surveillance, preparedness, response, and recovery) are introduced to newly assigned surveillance officers. Disease-specific training focuses on preparedness, prevention, and control of the outbreaks for vaccine-preventable other diseases, including malaria. The trained group had an additional year of experience, which could have allowed them to attend more training. Therefore, this additional training and experience might have some effect on improving the skills of these officers. Further studies could identify the independent effects of other training on the performance of the surveillance officers. Secondly, this study did not include analyses of challenges [33], such as drop-outs and turnover of trained staff. Thirdly, a higher number of FETP trained participants (84%) were bachelor’s degree holders than the untrained group (67%) which included more diploma holders and nurses. Regional Health Bureau leadership used terminal degree in their selection criteria, in part, because some are expected to join FETP-Advanced, which requires a bachelor's degree. The pre- and post-training self-comparison analysis was incorporated into this study to address these limitations.

This evaluation identified improved skills, knowledge, and practices among FETP-Frontline trained surveillance officers compared to untrained officers. Improvements were reflected in better timeliness and completeness of surveillance reports, greater knowledge and skills at preparing epidemiological bulletins, conducting active surveillance, providing surveillance training, and conducting SWOT analyses. The trained surveillance officers also had more computer skills, which they used to manage surveillance data and produce graphs and reports. In participants’ self-assessment of perceived surveillance knowledge and skills, trained officers reported higher skills after FETP-Frontline than their skills before the training. Trained officers were also more likely to have surveillance formats and quality reports readily available at their workplaces than untrained group.

FETP-Frontline can be used to build the capacity of district surveillance officers in Ethiopia and perhaps in other countries. We recommend scaling up the program to reach all districts to have at least one FETP-Frontline graduate in each district of the country. The training can help the country fulfil the IHR 2005 workforce development core capacity requirement. Further studies that use longitudinal research design might be beneficial for an in-depth analysis of why and how performance was improved among the trained group and why some of the surveillance components didn’t show any significant differences among trained and untrained groups.