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Public health

INTRODUCTION:

The concept of public health focuses on the health of all members of a population. In 1920, public health was defined by Charles Edward-A Winslow as "the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health".{{204 Maurer,Frances A. 2005}} This definition was all encompassing, and formed the basis of the WHO definition of health in 1948.{{211 World Health Organization 1948}}

The challenges outlined in this definition are the principal responsibility of health care professionals, especially public health specialist who receive training from Schools of Public Health (SOPH). SOPH is a term used to describe a department in an institution of higher learning concerned primarily with provision of postgraduate Public Health tutoring, mainly in the form of a master's degree in Public Health (MPH){{212 Evans,D. 2009}}.

BACKGROUND:

Globally, there have been significant changes in public health, with massive improvements in developed countries, while stagnation and even decline has been observed in the health status of developing and under-developed countries. In developed countries like the United Kingdom, the course of health care during the nineteenth and twentieth centuries focused on provision of potable water and improving sanitation, and clean air. These aims have largely been achieved to a reasonable standard, but sadly, the situation is far from what is desired in most developing countries {{213 Bick,Debra 2006}}. The current trend is typified by the "inverse care law", where relatively few schools of public health exist in regions with the greatest public health challenges, and an excess number exist in the developed world, where focus has shifted to confront new epidemics of ill health resulting from, for instance drug abuse, obesity and smoking. Reducing these gross inequalities within the health system requires a dynamic and innovative approach aimed at tackling poverty, provision of potable water, minimizing climate changes and addressing a host of other health determinants. The key to addressing these issues lies with the training of competent public health specialist; this responsibility lies primarily with SOPH. {{212 Evans,D. 2009}} With the evident importance of public health, the training process is far more significant as it forms the underlying basis for the future of this sector. Selection is an integral part of any training programme and its importance cannot be overemphasized. It can be described as the first one of the most important steps in the delivery of effective population based health care.

The course structure of most Masters Programme in public health was traditionally centered on the subjects of around areas such as epidemiology, health policy, health promotion, health management, environmental health, human biology and health economics.{{205 Fineberg,H.V. 1994; 206 Davies,A.M. 1996; 207 Biesma,Regien 2008}}

Currently however, the scope has been expanded to include courses involving statistical analysis and the use of computer programmes; the ability to access, manage and work with information; the ability to present and disseminate information in an effective manner; interview and communication skills; sensitivity to health inequalities; and social skills.

{{207 Biesma,Regien 2008}}

Most SOPH in the United Kingdom are organized around the themes of capacity building, multidisciplinary, balanced teaching and research. Information is dissipated in traditional class room setting, either as full-time 12 month programmes, or as part time 24-60 months programmes{{219 Kohler,Lennart 1991}}. Certain SOPH have adopted more advanced means of education delivery, opting for electronic means for provision of distance learning. The criteria used for student selection into a masters degree programme in public health in the United Kingdom has significant implication on future quality of the public health sector in the UK, and indeed the world considering the large influx of foreign students seeking quality education in public health.

SCHOOLS OF PUBLIC HEALTH: HISTORICAL PERSPECTIVES

Institutions of learning concerned with educating students in the principles of public health started emerging in the early part of the twentieth century. The first of its kind was formed in 1916, when the Rockefeller foundation funded the endowment of John Hopkins University in the United States. This Institution differed in its technical approach to public health in contrast to the more social and environmental approach adopted by Charles Edward Winslow at Yale.{{212 Evans,D. 2009}}

In line with the Rockefeller foundation's objectives of developing the science of public health, it went ahead to fund the establishment of numerous SOPH within the United States and internationally. Its first international bequest was in the UK, where in 1922, it sponsored the formation of the public health department in the London school of Hygiene and Tropical Medicine (LSHTM). However, soon after the second worlds war, the Rockefeller foundation shifted its focus to other priorities. Despite this, there was still an expansion of the number of SOPH, with the World Health Organization collaborated with National government's specifically to train and educate public health professionals from 1948. These efforts have seen the establishment of about 357 SOPH in 54 countries as at 2006{{212 Evans,D. 2009}}.

However, these institutions are not geographically distributed according to where they are most needed. Some of the best and most reputable schools are sited in developed countries, while poorly organized and funded SOPH are located in developing countries. According to WHO, there are about 112 adequately resourced schools of public health in the Americas alone, with just about 50 small and poorly managed institutions in Africa.{{212 Evans,D. 2009}}

SCHOOLS OF PUBLIC HEALTH IN THE UNITED KINGDOM:

An internet based search of the Universities in the UK offering different forms of public health at post graduate level revealed about seventy eight of such institutions. However, there are differences in the quality and focus of public health research offered by these institutions. These differences were highlighted after the 2008 Research Assessment Exercise (RAE), which identified the number of research active staff and conducted a peer assessment of the quality of research within different universities.{{227 Anonymous}}

Another significant difference in UK SOPH is the designation between programmes offering a Masters in public Health (MPH) and an MSc in public health as differentiated by institutions established before and after 1992. Evans (2009) identified 'pre-1992' universities as institutions that offer intensive courses and are staffed by internationally recognized researchers and have programmes usually labelled as 'Masters in Public health(MPH)'. The 'post-1992' universities are mostly former polytechnics that run mostly part-time courses and often have less internationally renowned staff labelling their programme as 'MSc in Public Health'. He referred to the MPH programme as being superior to most MSc Public health programmes for these reasons. However the full time MSc public health programme the London School of Hygiene and Tropical medicine(LSTHM) is internationally renowned and stands as an exception to the facts stated above.{{212 Evans,D. 2009}}

Over the last two decades, there has been significant increase in the number of postgraduate public health courses, especially in new universities. These courses usually have a wider focus reflecting the more social aspects of public health coupled with an admission of students with multidisciplinary backgrounds. It wasn't until 1992 that the LSTHM opened its public health degree to students with first degrees other than medicine. It took a couple of more years till the Faculty of Public health admitted non-medical graduates into its training programme in the year 2000.{{228 Davis,A.M. 2007}}

One major challenge of SOP's in the UK has been the issue of balancing research with teaching. Schools that have very low RAE ranking will more likely lose funding. Also, the focus on research is driven by the desire for peer reviewed publications as a measure of the degree of academic success. This trend has resulted in the prioritization of research over teaching for most institutions of public health.

However, there has been a link between the National Health Service and some SOPH, where the MPH course forms the first year of public health specialist training programme which runs for 5 years. This arrangement it has been argued will probably help balance research and teaching.{{212 Evans,D. 2009; 206 Davies,A.M. 1996}}

THE PROCESS OF SELECTION:

The United Kingdom is home to some of the most reputable learning institutions in the world and as such attracts a diverse group of individuals every year, who come in search of quality knowledge. The criteria used for student selection into a masters degree programme in public health in the United Kingdom has significant implication on future quality of the public health sector in the UK, and indeed the world considering the large influx of foreign students seeking quality education in public health. {{214 Tokozile Mayekiso 2004}}

Student selection is usually based mainly on academic background/achievements. However, in recent years, the criterion has been widened to include other factors like individual attitudes, interests, and personal characteristics desired goals and work experience. Selection policies based on the traditional academic ability are fast fading out for a number of reasons. One reason is the lack of evidence showing a correlation between previous academic performance and subsequent success in health professional courses/practice. Also, the use of academic performance is also likely to result in discrimination against certain groups and perhaps the most important reason is that the community has called for graduating health care practitioners who display an ability to relate with patients, in addition to possessing the requisite skill and knowledge base which their profession demands.{{225 Anonymous}}

The aim of any selection process is to choose individuals who best fit certain defined criteria. Thus an essential part of this process is the definition of one or more criterion by which applicants can be judged. This step is extremely important, as schools of public health are expected to choose and train future public health practitioners who will be equipped with the requisite skills expected to address the challenges of this demanding profession. {{214 Tokozile Mayekiso 2004}}

Until recently in the United Kingdom, training under the Faculty of Public health was open to only medical practitioner and as a result, availability of spaces on medically oriented public health programmes for non-medical applicants were limited. However, in 2000, the faculty membership was opened to non-medical graduates. Despite this change, there has been a decline in faculty membership. However, theses occurrence has prompted questions about the skills required to be competent public health practitioners and if it was necessary to have a medical degree before studying public health. {{230 El Ansari,W. 2003}}

LITERATURE REVIEW:

This literature review seeks to identify similar done on the selection criteria for students intending to study for a Masters degree in Public Health. It will attempt to identify what the current knowledge on student selection in the UK is, identify areas that have already been researched and highlight what aspects may require further research.

SEARCH STRATEGY:

A search for available literature on Master of public health student selection criteria was carried out on numerous internet databases/resources. These included; PUBMED, MEDLINE, ERIC, OVID, ETHOS and INTUTE. The key words used in the key words "MASTER OF PUBLIC HEALTH" and "POST GRADUATE STUDENT SELECTION CRITERIA". However, as this search came up with limited relevant literature. The literature search criteria were expanded to include "UNDERGRADUATE MEDICAL STUDENT SELECTION CRITERIA".

QUALITY OF PAPERS IN LITERATURE REVIEW:

All papers included in this review were written in English and includes studies done in the UK and other countries. The literatures directly relevant to the subject of this project are limited. After a review of the abstract of all articles matching the search strategy, papers found to be relevant were selected for review, despite their shortcomings and flaws.

SELECTION PROCESS FOR MPH ADMISSION IN OTHER COUNTRIES

The selection of students into the MPH programme in the United States follows a different format than what applies in the UK. In the US, all SOPH and public health programs are accredited by the nationally recognized Council on Education for Public Health (CEPH). Students intending to apply for a postgraduate degree in public health send their application through the Schools of Public Health Application Service (SOPHAS). SOPHAS then completes the application to different schools, on behalf of individual students. Before students can submit their application to SOPHAS, they must sit for an entrance examination. Most schools accept the Graduate Record Exam (GRE), although requirements may vary for some schools. {{231 Associations of Schools of Public Health}}

SELECTION CRITERIA FOR UNDERGRADUATE MEDICAL STUDENTS IN THE UK:

The criteria used for selection of undergraduate medical students are largely undefined being more of an administrative exercise to match the number of applicants to the available spaces on the course using a movable marks threshold. The results are that the greater the number of applicants that year, the higher the threshold mark used for admission. {{223 Powis,David 1998}}

Nonetheless, most medical schools strive to ensure that the few available positions available for medical student admission are open to students who will make the best doctors*.

With the current awareness that non-academic personal qualities are essentially as important in the practice of medicine as academic ability, many medical schools require applicants to undertake entry tests that measure other qualities and characteristics in addition to academic ability.

One of such test is the personal qualities assessment test (PQA){{225 Anonymous}}, which is designed to assess verbal, numerical, and spatial reasoning. It contains a personality inventory and also has an ethical reasoning paper. The PQA has added value alongside the A - levels allowing for an objective assessment of non-cognitive characteristics of aspiring medical students. {{221 Nicholson,S. 2005}}

Many studies have been done to assess the qualities of medical student which will make them good doctors in the future{{220 Hur,Y. 2009}}{{29 McManus,I.C. 2008; 221 Nicholson,S. 2005}}. A twenty year prospective cohort study was carried out to determine whether A- level grades and intelligence abilities of medical students could be used to predict doctor's careers. The study was carried out on 511 medical students who entered West-minister medical school between 1975 and 1982 with follow up to 2002. The outcome measures assessed were the time taken to reach different career grades, postgraduate qualifications obtained, number of research publications, and measures of stress and burnout related to A- level grades and intelligence at entry to clinical school. The results of the study showed that A-level grades which has particular widespread application in UK student selection has long-term predictive value for undergraduate and postgraduate careers.{{224 McManus,I.C. 2003}}

Parry J et al carried out a review of the admission process of five medical courses in UK universities. The objectives of the study were to describe the current methods used by medical schools to identify prospective medical students for admission to the five year degree course. The review was carried out on a total of twenty two universities using documentary analysis and interviews with admission tutors. Their findings revealed that there was a common criteria for medical student admission, based on academic ability, coupled with a suitable personality comprising motivation for medicine, leadership skills, teamwork abilities and extracurricular interest. The review concluded that despite the common underlying criteria for medical student admissions, universities differed in their application of their requirements for student selection.( http://www.bmj.com/cgi/content/abstract/332/7548/1005 ).

Brown and Lilford in their paper titled "selecting medical students" noted that it cost about £200,000 pounds to train each medical student in the United Kingdom. However, the implications, financial and otherwise of choosing the wrong student to train in the first instance are far greater. Three broad attributes that a suitable student should have include; appropriate cognitive ability, diligence and humanity. However, the current selection tools can only screen appropriately for cognitive ability. Most medical schools have introduced aptitude test based mostly on cognitive tasks. There is evidence to show that the test correlate well with preclinical examination results, but have not been a reliable predictor of clinical performance. They also questioned the accuracy of psychological as a predictor of diligence noting the difficulty in determining the appropriate mixture of traits that is most predictive of diligent service and personal progression. They also noted that although short medical student interviews were effective recruitment tools, they had low predictive value{{58 Brown,C.A. 2008}}. Another study noted that while most medical schools may wish to select future doctors both cognitive and non-cognitive test, employing the use of interviews was noted to be labour intensive and time consuming.{{221 Nicholson,S. 2005}} Test of cognitive ability seemed to be the most valid method with the highest predictive.

A recent article proposed a comprehensive model for the selection of medical students based on informed self selection, academic achievement, general cognitive ability (GCA) and aspects of personality and interpersonal skills. They used data (n=1000) from real selection procedures to demonstrate how their proposed model can be applied to increase the chances of making accurate and defensible student selection. {{198 Bore,M. 2009}}

It is clear from a review of the literature that the underlying principles of student selection process is geared towards identifying individuals who are most suited to the entry requirements which are designed to select candidates that are most likely to succeed in the course. It also aims to prevent the acceptance of candidates that will most likely constitute a risk to the profession.

RATIONALE:

The idea for this project was conceived by Dr Tom Marshall after it was observed that admissions into the University of Birmingham's MPH courses had increased significantly following the introduction of an online selection exam, as a pre-requisite for entry* in March 2009. Additionally, questions generated following a meeting of twelve MPH/MSc programme directors in September 2009 to discuss matters of mutual interest, also inspired this project.

RESEARCH QUESTIONS:

1. What are the criteria used by SOPH in the UK for student selection?

2. What are the underlying principles that inform the choice these entry requirements?

3. What are the desired qualities of MPH students?

AIMS AND OBJECTIVES

This project aims to assess how students are selected for admission into a Master's programme by various schools of public health the United Kingdom.

Specific objectives will include:

* To evaluate the differences in MPH student selection process used by different Universities.

* To determine the desired qualities of a suitable MPH student.

* To ascertain if entry requirements differ for first year public health trainees when compared to other students

* To ascertain if entry requirements differ for candidates with or without medical training

* To examine the differences in entry requirement for home and international students

METHODOLOGY: