Methods
Study design
A national cross-sectional online survey titled “National DrPH leaders & practitioners needs assessment” was conducted among DrPH students and alumni from November 2020 to February 2021 to assess and explore their perceptions related to (1) self-identified current level of DrPH foundational competencies set by CEPH and (2) DrPH identity. The survey had two goals. First, we sought to identify whether a movement was needed to further establish the DrPH identity. The second goal was to identify if standardization of the DrPH training was desired. The survey was collected through Google Forms hosted on a secure server. The authors consisted of two DrPH alumni (CP: started in 2016, graduated in 2020; AI: started in 2018, graduated in 2021) and one DrPH student (CD: started in 2017) at the time of research, all of whom had expertise in DrPH education and development of the survey instrument. All of them started their DrPH education after CEPH DrPH competencies were introduced.
Setting and participants
We used a nonprobability sampling technique, the snowball convenience sampling approach as a network-based convenient sample [
43], to recruit participants who self-identified as public health practitioners and leaders, without using a strict definition of public health leaders and practitioners. We contacted a total of 36 DrPH directors from CEPH-accredited DrPH programs in the United States to request the dissemination of recruitment materials through their social media (e.g., Twitter and LinkedIn), membership lists, and an email listserv. Subsequently, we reached out to national public health organizations, such as the Student Assembly from APHA and the DrPH Coalition. Thus, our sample was dependent on the authors’ professional contacts and resources. The eligibility criteria for participation were restricted to self-identified current DrPH students or alumni in the United States, without a restriction on the year of graduation. Therefore, the main purpose of this study was to focus on those individuals who indeed have/had experienced with the DrPH curriculum as a student in the United States to better understand potential implications for the DrPH identity and future public health workforce development in the United States.
Data collection and measurement
The total number of participants who completed the survey was 222 (current DrPH students: 140; alumni: 82). Data collection started on November 23, 2020, and stopped on February 15, 2021. According to the Accreditation Criteria amended in October 2016 [
7], CEPH introduced 20 foundational competencies through the following domains: (a) Data & Analysis (3 competencies), (b) Leadership, Management & Governance (10 competencies), (c) Policy & Programs (4 competencies), and (d) Education & Workforce Development (3 competencies). Participants were asked how well their DrPH training prepared them to achieve each of the CEPH competencies. We defined “DrPH Training” as the training that students or alumni are/have/had received in their DrPH program. The 1–10 rating scale (1: not at all, 10: absolutely) was used to measure the level of alignment between DrPH training and CEPH competencies. A total of 26 questions (6 questions from Data & Analysis, 13 questions from Leadership, Management, & Governance, 4 questions from Policy & Program, and 3 questions from Education & Workforce Development) were extracted by adding a prompt, “Has your DrPH training prepared you to …?” to each of the original CEPH competency sentences (e.g., “Has your DrPH training prepared you to design a system-level intervention to address a public health issue?”). If a CEPH competency sentence contains more than one component, we further dissected that competency sentence into more than one survey question to ask each component. For example, one of the CEPH competencies from the domain of Leadership, Management & Governance, “Assess one’s own strengths and weaknesses in leadership capacities, including cultural proficiency,” was divided into two survey questions to separately ask about “leadership capacities” and “cultural proficiency.”
In addition, we measured the participants’ level of establishment of DrPH identity via four domains: (1) perceptions of competency training, (2) distinction from PhD, (3) recognition, and (4) standardization. Two types of questions were used: Likert scale questions asked the range of 1–10, and binomial questions asked Yes or No.
Statistical methods
To analyze survey data, we used Stata/MP 14.2 (StataCorp, LLC, College Station, TX). Once the survey period was finished, the collected data from Google Forms were exported as Microsoft Excel (.xlsx) and then imported into Stata. Demographic statistics were conducted to measure the characteristics of the survey participants. To measure the level of current alignment between DrPH training and CEPH competencies, we used means and standard deviations (SD) for a 1–10 rating scale and then compatibility intervals (CI) for mean differences. Cronbach’s alpha was used to measure the internal consistency of each domain as well as across all domains from CEPH competencies. In addition, the Pearson correlation matrix was used to measure a linear correlation between two sets of those domains. For the level of current or desired establishment on DrPH identity, both binary and 1–10 rating scale questions were used. Two-tailed paired t-tests were conducted when comparing two questions that provided significant mean differences.
Human subject protections
The research study was approved by the San José University Institutional Review Board (IRB Protocol Tracking Number: 20,270) as part of a larger mixed-methods study focusing on DrPH students’ and alumni’s needs assessment and future directions. Respondents read and consented to an electronic consent form before proceeding with completing the survey.
Discussion
Prior research that included perspectives of academic heads of the programs (i.e., DrPH directors) did not show intentions of standardizing DrPH programs across the nation [
42]. Thus, this study raised important perspectives from actual recipients of DrPH education. This study builds on existing core competency DrPH literature [
16], Roemer’s vision [
6] for a practice-based doctoral degree, and Northbridge and Healton’s question of ‘Who Will Deliver on the Promise of the DrPH Core Competency Model?’ [
44]. Nearly a decade later, those challenges of aligning DrPH education with the needs of public health practitioners have remained stubbornly the same [
4,
45]. Additional literature on the development of specific DrPH programs presenting case studies, such as the University of California, Berkeley [
9], the University of South Florida [
39], and Harvard University [
8], also highlighted similar challenges of bridging the gap between academia and practice.
This study was one step forward in better understanding the needs of the DrPH alumni and DrPH students to assist standardization efforts and improve the identity of the degree. Results from the survey demonstrate that among those individuals that participated in the study, the majority felt that the CEPH competencies adequately reflected the skills needed to be trained in the public health workforce. However, an interesting finding is that more than half of the participants looked for professional development/training opportunities outside of their DrPH program to meet the CEPH competencies. One possible consideration for this result is the changing landscape of public health and the diverse skills needed to solve complex problems. The need for transdisciplinary skills—such as combining elements from the disciplines of organizational change, implementation sciences, and strategic planning—in executing solutions to complex public health issues could be another reason why students sought professional development opportunities externally. This could be a reflection of the dissonance between the need for practice-based skills/training and the theory-oriented DrPH education received by the participants. It is important to note that the CEPH requirements for accredited DrPH programs, unlike some other professional degrees such as MD, do not have a standardized practice-based training, residency, or immersion experience requirement. Universities/schools interpret the practice requirement in a variety of different ways, including reflection portfolios, immersions embedded in organizations, and varying numbers of practice-based experiential learning.
In regard to DrPH identity at a national level, participants expressed their training was not significantly distinct from the PhD degree, demonstrating an opportunity for programs to create and develop distinctions between the two degrees. When we asked
how distinct the two degrees
should be, participants expressed interest in distinction. This presents an opportunity to consider how the DrPH and PhD degrees can be defined by their unique differences. For example, another professional terminal degree, such as a Doctor of Psychology (PsyD) focuses more on a wide range of practical or clinical aspects of applied skills, while a PhD degree emphasizes research [
46]. PsyD in Clinical Psychology at The George Washington University provides clinically-focused training and research methods and requires a yearlong internship [
47]. Similarly, the EdD is a program geared towards professionals seeking to advance their leadership skills [
48‐
50]. At the University of Southern California, the EdD program focuses on educational leadership training and utilizes research to provide practical solutions [
51]. Their research methods address practical problems that hinder access to educational outcomes and opportunities [
49].
Participants felt the DrPH was recognized as a prestigious degree within their public health professional network. However, outside of their network, participants felt that a DrPH degree was not well-recognized. For example, outside the field of public health, there appears to be a persisting stereotype that DrPH programs have less rigorous training than PhD programs. In particular, participants expressed that employers were not knowledgeable about their DrPH training. A marketing strategy thus will be needed to advocate the unique benefits that the DrPH degree brings to the field of public health and beyond.
To meet the needs of DrPH students, DrPH programs should take a leading role in distinction efforts. First, standardization of DrPH’s educational credentials is one possible response to address this identified challenge. Participants strongly agreed that standardization could be the key to creating a clear understanding of the training that DrPH graduates should have. Additionally, participants expressed an interest in standardizing the core curriculum to have a standard national training. Standardizing the curriculum across the nation would not only better support the identity of the DrPH degree but also become a tool for creating a clear distinction from the PhD degree requirements. Second, an educational campaign to inform practitioners and educators about the distinctions of the programs might be another possible approach that was not evaluated extensively. Professional development opportunities offered by ASPPH or APHA could assist not only in educating the public regarding distinctions between PhD and DrPH but also in providing training for DrPH programs to meet some of the critical training needs in key fields and offering lifelong learning in critical current subject areas, such as through Continuing Education Program offered by APHA. Third, DrPH institutions can take community-centered approaches and reflect DrPH students’ and alumni’s needs in class design and curriculum development. Fourth, DrPH institutions can consider sharing lessons learned to distinguish DrPH programs from PhD programs.
The COVID-19 pandemic presents unique challenges that require the expertise of DrPH graduates. It is essential to distinguish COVID-19 from other generalized public health issues, as it has caused significant global disruptions and resulted in substantial loss of life and economic impact [
52]. The effects of the pandemic, including high unemployment rates [
53,
54], loss of loss of health care insurance [
55,
56], delayed care [
57,
58], housing [
59] and food insecurity [
60], and increased domestic violence [
61,
62], have had far-reaching consequences. Therefore, future leaders with a DrPH degree must be equipped to tackle multi-level systemic challenges, including the impact of COVID-19. In addition, within a team of public health professionals in an organization or community, individuals with a DrPH can provide the following: leadership and strategic planning, applied research and evaluation, policy development and advocacy, community engagement and collaboration, and program implementation and management.
To address complex public health problems, Welter et al. (2022) discussed the importance of collaborative action, systems change leadership, and health equity and social justice [
63]. These components should be considered in curriculum and professional development training for DrPH graduates to better support their workforce needs. Additional components to consider adding to the curriculum include finance, anti-racism and health equity, crisis and emergency management, ethical leadership, and public health law among the practice areas, to prepare public health leaders.
In order to bridge education and public health practice with the DrPH, Ocampo et al. (2020) suggested three solutions [
64]. First, training should include systems thinking, business management, communications, and strategy. Second, institutions should provide training in systems thinking, communication, strategy, and political processes to support public health leaders in their roles. Third, opportunities to train with diverse experts (e.g., community leaders, consultants, politicians, environmentalists, and social workers) should be provided to address interdisciplinary problems. To support the training needs of public health professionals, the incorporation of public health topics as well as continuous professional development opportunities are needed. DrPH institutions should provide emerging class topics and include diverse experts to teach those courses comprehensively.
Strengths and limitations
To date, there has not been a concerted effort to actively involve the DrPH community (students and alumni) in discussions about DrPH’s alignment with CEPH competencies, standardization, identity distinction from PhD, and recognition across employment. This study contributes to the existing DrPH literature in the United States by highlighting the perspectives of the DrPH community based on their academic experiences. This survey provided an overview of the broader spectrum of DrPH stakeholders who were direct beneficiaries of the DrPH education and its core DrPH competencies. We explored whether DrPH alumni and DrPH students want to create the identity and distinction for their degree. In addition, we investigated whether the core competencies for the DrPH education have been applied to their professional development and educational needs.
In this study, several limitations were encountered and should be acknowledged. First, the sample size was limited due to the non-probability convenience sampling method, snowball sampling, which may underrepresent the target population [
43,
65], and thus results cannot be generalized to the whole DrPH population [
66]. Despite the limitations of snowball sampling, this was still the best method to contact perhaps hard-to-reach alumni and students [
67]. Additionally, the convenience of network-based participants could introduce selection bias [
43]. However, recruitment expanding to educational institutions and organizations increased our sample size and representativeness. The survey data collected were at the national level, with 222 respondents (140 current DrPH students and 82 graduates). We did not collect the participants’ DrPH institutions to maintain anonymity, but instead collected their current location in the United States. Although most participants were in the Northeast, South, and West of the nation (Table
1), this distribution may not necessarily represent the entire doctoral-granting institutions in the United States offering DrPH programs. To make the results more generalizable and applicable to other countries, future studies could use probability sampling and census data to provide a larger number of perspectives regarding the CEPH competencies and DrPH education. Second, the survey did not include detailed questions on experiential learning (e.g., practicum, residency) which is one of the key components of DrPH programs. Third, this study did not collect data on the year of graduation, which further limits its generalizability. This would limit the applicability of the study’s findings that some of the alumni may have graduated before the CEPH competencies were implemented. Fourth, this study could not distinguish between the field sector in which individuals were already working and the ideal field where they wish to be working in after graduation. To fully understand the training needs of DrPH graduates, identifying this distinction will be essential in creating the unique identity of the DrPH degree while standardizing the curriculum. Lastly, it is important to note that there could be an inherent potential bias in this study, as all the authors are recent recipients of a DrPH degree, and no input was sought from employers or other public health stakeholders who do not hold a DrPH degree. Nevertheless, our study made an initial endeavor to collect the viewpoints of individuals who have obtained the DrPH degree, which would significantly contribute to the future enhancement of the DrPH program by incorporating their feedback.
Implications and future research
The results from this study reflect the exigency for standardization to improve future training and value for current and future DrPH leaders in the United States. Addressing the perspectives of degree holders and students will be important for creating a clear identity of the DrPH degree. The COVID-19 pandemic has demonstrated the importance of transdisciplinary leaders who create sustainable, equitable, and inclusive solutions to complex public health problems. The core competency model was designed to create “a national discussion” on the competency needs of DrPH students [
16]. This model was a historical step in creating standardized training and improving the infrastructure of public health. Northridge and Healton (2012) called on public health programs to “do more than create generalists” and consider the opportunities of the DrPH degree to be more globalized [
44].
There is a clear demand for the DrPH degree [
68] that emphasizes the need to explore its identity within both community and global contexts in future studies. In response to addressing demands of DrPH education, several potential areas of future research can be pursued. First, further studies can focus on how to establish the DrPH degree as a widely recognized and indispensable practical terminal degree that effectively serves population health needs. For instance, future investigations should delve into identifying any remaining gaps in the implementation of CEPH competencies within DrPH education. Furthermore, it is important to explore the types of additional training that students have pursued to address gaps in their education. Future research will thus need to consider exploring how to build a nationwide direction and understanding of the DrPH degree when designing a standardized training model. Second, future studies can investigate the perceptions about or the need for a DrPH degree from employers and other public health stakeholders who do not possess a DrPH degree. Additionally, these studies can review public health job descriptions to identify the preferred or required degrees for different positions, thereby enhancing our understanding of the gap between the current job requirements and the expertise that DrPH recipients can actually offer.
Lastly, it is important to build upon the DrPH trends during 2017–2019 reported by CEPH [
22] and gain an understanding of the overall changes in the DrPH landscape, particularly considering the growing demand for public health workforce during the COVID-19 pandemic. Additionally, given the existence of different types of DrPH programs, such as different format of delivery mode for learning, it is crucial to explore which format of DrPH programs has emerged as the ideal choice, with clear distinctions from PhD programs, for addressing unexpected complex public health issues in the modern era. The format of DrPH programs varies, with part-time online programs catering to a distinct target audience of working professionals, while full-time residential programs require individuals to leave their jobs and relocate. The current demand for DrPH degrees is largely driven by the growth of part-time online programs. Thus, in future studies, it is important to investigate whether this demand is primarily influenced by the feasibility and affordability of pursuing doctoral training in public health while maintaining current employment, rather than being primarily attributed to differences in curriculum between PhD and DrPH programs.
Conclusions
In the United States, DrPH is the terminal degree for the field of public health. It is well acknowledged and valued within the academic public health practice sphere. However, according to our findings, distinguishing DrPH from PhD programs is a challenge among public health employers and organizations, and it needs to be addressed from a higher education programmatic perspective. Moreover, outside of the participant professional network, DrPH is not widely recognized or distinguished as a unique degree. This is of high concern for effective public health governance and leadership perspectives. The DrPH programs uniquely train public health leaders and practitioners, equipping them with critical public health practice skills. However, from the participants’ perspective, employers do not seem to see its full value. To increase DrPH’s recognition and convey its value to employers, schools and programs of public health, ASPPH, and CEPH should consider focusing on systematic outreach to employers across sectors to create standardization of DrPH training. To progress towards health equity, public health should be led by competent practitioners and leaders. This can be achieved by engaging employers both domestically and globally, emphasizing the value of the DrPH, and placing competent professionals in leadership roles they were trained to fill. By establishing a clear DrPH identity, it is expected that DrPH graduates should be the ones who address urgent, diverse public health issues through a leadership position/role to contribute to creating a safe and healthy public health environment around us, including effective control of the COVID-19 pandemic.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.