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O R I G I N A L A R T I C L E

Main competences and skills to perform Essential Public Health Operations, offered by Schools of Public Health in four European countries: a short pilot report

Robert Otok . Anders Foldspang

Received: 26 January 2016 / Revised: 25 June 2016 / Accepted: 22 July 2016 / Published online: 10 August 2016

� Swiss School of Public Health (SSPH+) 2016

Abstract

Objectives To consider the stage of implementation of

main competences and EPHO skills in selected schools of

public health in four European countries—France, Poland,

Portugal, and the UK.

Methods By use of visual analogue scales (VAS) ranging

1–5, the leads of three schools of public health (SPH) in

each of the four countries, France, Poland, Portugal and

the UK, reported the strength of intellectual and practical

competences as well as skills to perform essential public

health operations (EPHOs), offered by their education and

training programmes.

Results The self-reports indicated substantial coverage of

the multidimensional public health discipline. Each coun-

try representation had its overall characteristic profile, and

there was found noteworthy within-country as well as

between-country variation.

Conclusions The schools should meet the challenge of

establishing collaborative networks, which will be impor-

tant for public health strategy making and implementation,

for shaping a coherent public health profession, and thus

ultimately for population health. This pilot report should be

followed up by more systematically penetrating and com-

prehensive analyses to identify met and unmet needs in

public health education and training.

Keywords Public health � Public health education � Public health training � Public health competences, essential public health

operations

Introduction

The World Health Organization’s European Action Plan

for Strengthening Public Health Capacities and Services

(EAP) (World Health Organization 2012) underscores that

‘investing in a multidisciplinary public health workforce is

a prerequisite for a modern effective public health function.

A sufficient and competent public health workforce con-

stitutes the most important resource in delivering public

health services.’ (Point 67, p. 16). The EAP also stresses

that ‘given the complex challenges facing public health, a

wide range of existing and new competences and expertise

is called for, including social epidemiology, information

systems, health promotion, environmental health, man-

agement and leadership, and collaborative working’ (Point

68, p.16).

The Association of Schools of Public Health in the

European Region (ASPHER) in 2006 started its pro-

gramme for the development of intellectual and practical

core competences for the comprehensive public health

discipline (Foldspang 2007, 2008; Birt and Foldspang

2011a), with the subcategories of public health methods;

population health and its social and economic

This comment refers to the article available at doi:10.1007/s00038-

016-0824-x.

R. Otok (&) Association of Schools of Public Health in the European Region,

ASPHER, Brussels, Belgium

e-mail: [email protected]

R. Otok

Department of International Health, CAPHRI, Maastricht

University, Maastricht, The Netherlands

A. Foldspang

Department of Public Health, Aarhus University, Bartholins

Allé, 8000 Aarhus, Denmark

e-mail: [email protected]

Int J Public Health (2016) 61:633–639

DOI 10.1007/s00038-016-0870-4

123

determinants; population health and its material determi-

nants; health policy, economics, organizational theory,

leadership and management; health promotion: health

education, health protection, disease prevention; ethics.

Subsequently, ASPHER’s 2011 lists for professionals

and for Master of Public Health (MPH) education (Birt and

Foldspang 2011b, c) were in 2012 endorsed by WHO

member states as basis for public health education in

European countries (World Health Organization 2012),

supporting the competences and, additionally, the educa-

tion-based definition of the profession provided by the lists

(Foldspang 2015; Bjegovic-Mikanovic et al. 2015).

Since then, ASPHER has constituted its European

Public Health Reference Framework (EPHRF) with a

Council responsible for the further development of lists of

competences and their relationship to WHO’s Essential

Public Health Operations (EPHOs) (Martin-Moreno 2015),

in the development of ASPHER’s European Public Health

Core Competences System, including its IT function

(Foldspang et al. 2014).

Clear definitions of public health workforce categories

are of course central to the development of a sufficient and

competent public health workforce [WHO Europe’s

Essential Public Health Operation (EPHO) No. 7] (World

Health Organization 2012; Foldspang 2015; Bjegovic-

Mikanovic et al. 2015) and a prerequisite for public health

strategies and their human resources policy as well as

education and training programmes to be efficiently goal

oriented:

1. Public health professionals.

2. Health professionals.

3. All others acting within and for public health.

Based on a census including those occupied in Swiss

public health positions, Frank et al. (2013) found that, at a

general level, respondents were well educated, so that 2/3

had at least a Bologna masters degree, but 69 % of

respondents in the workforce actually had no specific

public health degree, suggesting that current workers, at all

levels, could benefit from further training in specific public

health skills. They stressed that systematic and regular

monitoring of the public health workforce is essential to

increase our understanding of its needs and related strate-

gies to training the workforce (Paccaud et al. 2013).

When in 2012 mapping the pattern of competences and

EPHO skills offered by 80 ASPHER member schools

through a total of 130 programmes, Bjegovic-Mikanovic

et al. (2013) found the best teaching output for health

promotion, followed by disease prevention and identifica-

tion of health hazards in the community, while the least

output was in emergency preparedness. They found con-

siderable fragmentation of the institutional infrastructure;

however, still with considerable harmonization of

programme content and thinking. A 2011–2012 survey

among European employers of public health workforce

revealed significant lower current levels of EPHO perfor-

mance as compared to employers’ expectations (Vukovic

et al. 2014). In balance with this, Bertoncello et al. in 2014

found Italian public health residents to perceive a need for

more competences in health systems governance and thus

for training plans tailored to the needs of the national and

local health systems (Bertoncello et al. 2015).

Focussing on the education and training of public health

professionals, the present short pilot report accordingly

considers the stage of implementation of main compe-

tences and EPHO skills offered by selected schools of

public health in four European countries—France, Poland,

Portugal, and the UK—and discusses cross-country varia-

tion and the availability of means to meet the challenge of

covering the comprehensive discipline, including the tool

of networking between the schools.

Methods

In each of the four countries, France, Poland, Portugal, and the

UK, three schools of public health, each of them a member of

ASPHER, were conveniently selected and consented to par-

ticipate. Based on the classifications of the European, WHO

endorsed lists (Birt and Foldspang 2011b, c), the school leads

filled in a questionnaire on the theoretical and practical

competences and the EPHO skills (Martin-Moreno 2015)

offered by their schools. To deliver an overall view, compe-

tences and EPHOs were represented by their respective

chapters and not by sub-chapters or individual competences.

EPHO 7 activities—development of the public health work-

force—were not included, as the focus was on the

programmes offered to public health students, and knowledge

and skills for, e.g., communication are included among health

promotion competences and is covered by EPHO 9, com-

munication. The strength of competences and EPHO skills

offered in the programmes were rated 1–5 by the school leads,

by use of visual analogue Likert scales (VAS). In the present

context, the schools are considered individual cases and were

not sampled systematically or at random. Consequently, only

parsimonious statistical description and comparison has been

performed in the present context, which presents itself as a

collection of national case studies rather than statistical

samples.

Results

Based on the self-reports of competences offered, the three

French schools, considered together, cover the full spec-

trum relatively well, with competences in environmental

634 R. Otok, A. Foldspang

123

science being the weakest (Table 1; Fig. 1). As concerns

EPHOs (Table 2; Fig. 1), self-reports appear more mod-

erate with the greatest emphasis on EPHO 1

(surveillance), EPHO 4 (health promotion) and EPHO 10

(research). There is considerable overlap, so that the

schools, all in all, would be able to complement one

another in covering the comprehensive public health cur-

riculum at a high level of quality.

With one exception, the Polish schools reported relatively

moderate emphasis on competences within socio-economic

determinants of population health, but, taken together, the

combined programmes would be comprehensive (Table 1;

Fig. 2). The same applies to their presentation of EPHOs,

where EPHO 2 monitoring, however, appears to be a com-

paratively weak field (Table 2; Fig. 2).

The three Portuguese schools themselves reported more

moderate provision of competency components, with rel-

atively strong weight on methods and ethics (Table 1;

Fig. 3). The same applies to the EPHOs, where the picture

seems rather heterogeneous and thus suggests a potential to

develop programmes based on mutual collaboration

between the schools (Table 2; Fig. 3).

Table 1 Sums of self-reported scores and percentages of maximum possible scores of provision of competences (knowledge and skills) offered by three selected schools of public health in each of the four European countries—France, Poland, Portugal and the UK, 2014

Competences chapter France Poland Portugal United Kingdom All 4 countries

Score sum (%) Score sum (%) Score sum (%) Score sum (%) Score sum (%)

Methods 11.00 11.50 11.25 13.75 47.50

73 77 75 92 79

Population health and its socio-

economic determinants

12.00 12.50 10.25 15.00 49.75

80 83 68 100 83

Population health and its

material environmental

determinants

09.00 13.75 09.50 10.00 42.25

60 92 63 67 70

Health policy, economics,

organisational

theory, management

15.00 12.75 07.75 14.00 49.50

100 85 52 93 83

Health promotion, health

education, health protection,

disease prevention

11.00 13.25 10.00 13.00 47.25

73 88 67 87 79

Ethics 11.00 10.00 12.00 13.00 46.00

73 67 80 87 77

Italics indicate the highest scores within competences chapters, when countries are compared

MET

SED

MED

HPM

HP

ETH

EPHO1

EPHO2

EPHO3

EPHO5EPHO6

EPHO9

EPHO10

EPHO8 EPHO4

Fig. 1 Strength of competences and Essential Public Health Oper- ation (EPHO) skills offered at three selected schools of public health

in France, 2014. Competences: MET methods, SED population health

and its socio-economic determinants, MED population health and its

material environmental determinants, HPM health policy, economics,

organisational theory and management, HP health promotion, health

education, health protection, disease prevention, ETH Ethics. Essen-

tial Public Health Operations (EPHOs): EPHO 1 surveillance, EPHO

2 monitoring, EPHO 3 health protection, EPHO 4 health promotion,

EPHO 5 disease prevention, EPHO 6 governance, EPHO 8 organ-

isation and financing, EPHO 9 communication, EPHO 10 research

Main competences and skills to perform Essential Public Health Operations, offered by… 635

123

The three UK schools present with fair coverage of

competences chapters (Table 1; Fig. 4) but report rela-

tively weak coverage of EPHOs 3 (health protection), 8

(organisation and financing) and 9 (communication)

(Table 2; Fig. 4).

When comparing the self-reports of competences

offered by schools of public health in the four countries,

substantial variation was found (Table 1). Thus, sum-

marising across countries, the highest competency scores

for methods, for population health and its social and eco-

nomic determinants, and for ethics were reported by the

three UK schools. The highest scores for population health

and its material environmental determinants and for health

promotion were reported by the Polish schools, whereas the

Table 2 Sums of self-reported scores and percentages of maximum possible scores of provision of Essential Public Health Operations (EPHOs) skills offered by three selected schools of public health in each of the four European countries—France, Poland, Portugal and UK, 2014

EPHO chapter France Poland Portugal United Kingdom All 4 countries

Score sum (%) Score sum (%) Score sum (%) Score sum (%) Score sum (%)

EPHO1 surveillance 12.00 10.00 09.00 15.00 46.00

80 67 60 100 77

EPHO2 monitoring 09.00 09.00 08.00 11.00 37.00

60 60 53 73 62

EPHO3 health protection 10.00 14.00 10.00 10.00 44.00

67 93 67 67 73

EPHO4 health promotion 12.00 14.00 10.00 15.00 51.00

80 93 67 100 85

EPHO5 disease prevention 09.00 13.00 13.00 11.00 46.00

60 87 87 73 77

EPHO6 governance 11.00 12.00 10.00 13.00 46.00

73 80 67 87 77

EPHO8 organisation and financing 11.00 13.00 07.00 08.00 39.00

73 87 47 53 65

EPHO9 communication 11.00 12.00 08.00 10.00 41.00

73 80 53 67 70

EPHO10 research 14.00 11.00 10.00 15.00 50.00

93 73 67 100 83

Italics indicate the highest scores within EPHO chapters, when countries are compared

MET

SED

MED

HPM

HP

ETH

EPHO1

EPHO2

EPHO3

EPHO4

EPHO5EPHO6

EPHO8

EPHO9

EPHO10

Fig. 2 Strength of competences and Essential Public Health Oper- ation (EPHO) skills offered at three selected schools of public health

in Poland, 2014. Competences: MET methods, SED population health

and its socio-economic determinants, MED population health and its

material environmental determinants, HPM health policy, economics,

organisational theory and management, HP health promotion, health

education, health protection, disease prevention, ETH Ethics. Essen-

tial Public Health Operations (EPHOs): EPHO 1 surveillance, EPHO

2 monitoring, EPHO 3 health protection, EPHO 4 health promotion,

EPHO 5 disease prevention, EPHO 6 governance, EPHO 8 organ-

isation and financing, EPHO 9 communication, EPHO 10 research

636 R. Otok, A. Foldspang

123

highest scores for health policy, economics, organisational

theory and management were reported by the French

schools.

National characteristics were relatively marked, and the

Portuguese schools reported scores close to 50 % as con-

cerns competences in health policy, economics,

organizational theory and management (Table 1). The

competences concerning material environmental determi-

nants we reported to be the weakest competences

chapter among the French schools and the UK schools,

whereas ethics was the competences chapter scored lowest

among the Polish schools.

Concerning EPHOs (Table 2), the highest scores for

surveillance (EPHO 1), monitoring (EPHO 2), health pro-

motion (EPHO 4), governance (EPHO 6) and research

(EPHO 10) were reported by the UK schools. The highest

scores for health protection (EPHO 3), disease prevention

(EPHO 5), organization and financing (EPHO 8) and

communication (EPHO 9) were reported by the Polish

schools, with the Portuguese schools reporting equally high

scores for disease prevention (EPHO 5).

The French schools scored relatively low on monitoring

(EPHO 2) and disease prevention (EPHO 5) and the Polish

schools on monitoring (EPHO 2) (Table 2). The

MET

SED

MED

HPM

HP

ETH

EPHO1

EPHO2

EPHO3

EPHO4

EPHO5EPHO6

EPHO8

EPHO9

EPHO10

Fig. 3 Strength of competences and Essential Public Health Oper- ation (EPHO) skills offered at three selected schools of public health

in Portugal, 2014. Competences: MET methods, SED population

health and its socio-economic determinants, MED population health

and its material environmental determinants, HPM health policy,

economics, organisational theory and management, HP health

promotion, health education, health protection, disease prevention,

ETH Ethics. Essential Public Health Operations (EPHOs): EPHO 1

surveillance, EPHO 2 monitoring, EPHO 3 health protection, EPHO

4 health promotion, EPHO 5 disease prevention, EPHO 6 gover-

nance, EPHO 8 organisation and financing, EPHO 9 communication,

EPHO 10 research

MET

SED

MED

HPM

HP

ETH

EPHO1

EPHO2

EPHO3

EPHO4

EPHO5EPHO6

EPHO8

EPHO9

EPHO10

Fig. 4 Strength of competences and Essential Public Health Oper- ation (EPHO) skills offered at three selected schools of public health

in the United Kingdom, 2014. Competences: MET methods, SED

population health and its socio-economic determinants, MED popu-

lation health and its material environmental determinants, HPM

health policy, economics, organisational theory and management, HP

health promotion, health education, health protection, disease pre-

vention, ETH Ethics. Essential Public Health Operations (EPHOs):

EPHO 1 surveillance, EPHO 2 monitoring, EPHO 3 health protec-

tion, EPHO 4 health promotion, EPHO 5 disease prevention, EPHO 6

governance, EPHO 8 organisation and financing, EPHO 9 commu-

nication, EPHO 10 research

Main competences and skills to perform Essential Public Health Operations, offered by… 637

123

Portuguese schools reported low scores on surveillance

(EPHO 1), monitoring (EPHO 2), organisation and

financing (EPHO 8), and communication (EPHO 9).

Finally, the UK schools reported low scores as concerns

organisation and financing (EPHO8).

Discussion

The present study is based on individual self-reports and not

on an objective, validated standard observation procedure.

Thus, it is a valid statement that the reports indicate how

public health school leads will answer in front of questions

on their programmes’ content and yield in terms of compe-

tences and skills for EPHOs. To what extent this would

correspond to, e.g., an external, independent and penetrating

expert assessment remains less clear. First, school leads are

not independent. Second, lacking competences within a

certain field eo ipso pose a challenge of merely under-

standing the question and, furthermore, operationalization

by quantification can be expected to vary based on à priori

insight. Thus, the precise face values should be considered

with substantial scepticism. On the other hand, we believe

that the data collected basically are informative when com-

prehended as expressing individual cases, which then may be

compared on a very rough and nearby dichotomous scale:

low scores actually are lower than high scores.

Without estimating generalizability, the patterns shown

here, of self-reported competences (knowledge and skills)

and EPHO skills offered by the schools of public health of

the four countries, present with national characteristics.

Such characteristics will depend on various traditions in the

public health environment, e.g., the balance between health

professionals, not least physicians, and people with other

backgrounds among planners and leaders of schools of

public health, teachers, and students. Also the compre-

hensiveness and internal cohesion of the public health

service delivery system as such, where a uniform system

exists, and of the multitude of individual public health

services offered, will play important roles for the devel-

opment and implementation of sufficient practical and

scientific expertise in the required fields.

On one hand, these cross-country variations can be said

to indicate the challenges for the individual school of

public health of today to cover the entire public health

discipline in its full comprehensiveness. On the other hand,

coverage obviously could be close to complete at a national

level in France, Poland and the UK (Figs. 1, 2, 4), whereas

the Portuguese reports indicate relatively weak social sci-

ence involvement (Fig. 3).

At a cross-country level the comprehensiveness of high-

quality public health curricula could be paved by the

possibility of developing national, regional and European

centres of excellence in public health education, training

and continuing professional development schemes. This, in

turn, would support the shaping of the public health pro-

fession also at a European level. Mobility schemes for staff

as well as students will be central components of such

development, which will include the potential of opti-

mization of intellectual resource consumption and can lead

to rationalization of efforts also in, e.g., collaboration in

fund-raising.

Conclusion

Self-reports from selected schools of public health in

France, Poland, Portugal and the UK, in general, indicated

substantial coverage of the multidimensional public health

discipline as offered in their educational and training pro-

grammes. There was shown noteworthy within-country as

well as between country variation, indicating a potential as

well as a need to develop national as well as international

collaborative networks between schools. Meeting this

challenge will be important for public health strategy

making and implementation, for shaping a public health

profession and thus ultimately for population health. This

pilot case report should be followed up by more penetrating

and systematically comprehensive analyses to identify

needs in public health education and training.

Acknowledgments We are grateful to our colleagues, who partici- pated and performed the data collection in the four countries.

Compliance with ethical standards

Conflict of interest There are no conflicts of interest.

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