Three hundred and thirty individuals consented to participate, of which 282 (85%) completed the survey; 268 (95%) respondents completed the survey in English and 14 (5%) in French. Although the denominator for this survey was unknown due to our multiple recruitment methods, the primary means for survey distribution was the TEPHIconnect field epidemiology database, with 1700 registered active members as of September 2019. Using this as an indicative sampling frame, and the response rate from a previous unpublished survey by TEPHIconnect of 9.8%, we assessed that the final sample size of 282 in this study would to lead to estimates of a single proportion with a 95% confidence interval, with precision of 6%, after employing the finite population correction.
There were equal numbers of respondents recruited from the combined social media platforms (Facebook, Twitter, and LinkedIn) (n=104, 32%) and through the TEPHINET/TEPHIconnect alumni network (n=105, 32%). Respondents alerted to the survey through country specific FETPs contributed 22% (n=71) of the responses. Personal or professional contact snowballing identified 13% (n=42) of respondents.
Demographics
Gender distribution of respondents was almost equal, with 51% female (n=144). The median age of respondents was 39 (range: 23-77 years) (Table 1). Gender and age distribution were similar between FETP and non-FETP respondents, and education level.
Epidemiology was the technical background most frequently reported by respondents, followed by public health (Table 1). Respondents predominately reported that they held post graduate and/or Doctorate level qualifications (n=258, 91.5%) (Table 2). With the exception of laboratory specialists and social scientists, there were no significant differences between gender and reported technical backgrounds. There were twice as many male laboratory specialists (n=23, 65.7%, p=0.028) and significantly more female social scientists (n=11, 78.5%, p=0.038). Gender disparity between other technical backgrounds was not observed, however, numbers were small when broken down by profession. There were more females who identified as epidemiologists (n=120, 53%), nurses (n=16, 64%), and public health specialists (n=84, 53%).
Table 1: Demographic characteristics of epidemiology emergency response survey respondents, 2019-2020 (n=282)
|
Category
|
Variable
|
Number (%)
|
|
Gender
|
|
|
|
|
Female
|
144 (51.1%)
|
|
Male
|
135 (47.9%)
|
|
Non-conforming
|
0 (0%)
|
|
Prefer not to answer
|
3 (1.1%)
|
|
Age (years)
|
|
|
|
|
<20
|
0 (0%)
|
|
20-29
|
18 (6.4%)
|
|
30-39
|
140 (49.6%)
|
|
40-49
|
78 (27.7%)
|
|
50-59
|
37 (13.1%)
|
|
60-69
|
7 (2.5%)
|
|
70+
|
2 (0.7%)
|
|
Technical background*
|
|
|
|
Epidemiology
|
225 (79.8%)
|
|
Public Health
|
158 (56%)
|
|
Medicine
|
70 (24.8%)
|
|
Laboratory
|
35 (12.4%)
|
|
Nursing
|
25 (8.9%)
|
|
Data science
|
21 (7.4%)
|
|
Veterinary
|
19 (6.7%)
|
|
Social Science
|
14 (5.0%)
|
|
Other
|
23 (8.2%)
|
|
|
|
|
|
|
*multiple technical backgrounds per respondent
Respondents came from 64 countries; the highest number of respondents reported being from the United States of America (n=47, 16.7%), Australia (n=39, 13.8%), and Nigeria (n=20, 7.1%). Respondents came from all WHO regions, with the America’s (PAHO) contributing the highest participation (Figure 2). Respondents in AFRO and SEARO were more likely to be male (n=51, 76%, n=23, 85% respectively), compared to more female respondents in PAHO and WPRO (n=53, 69%, n=41, 71% respectively). Gender distribution within EMRO and EURO respondents was equal. The age distribution of respondents was similar between regions. Across all regions, FETP respondents made up between 65-89% of respondents (Figure 2).
Respondents reported a variety of formal public health and epidemiology training, ranging from Masters Programmes, PhDs, FETPs, Physician Public Health Training, and short courses in specified public health and epidemiology topics (Table 2). FETP trainees/ graduates made up 74% (n=210) of respondents, of whom 11% (n=32) were trainees at the time of survey participation. Of the 210 FETP’s, 93% (n=189) reported to have studied the advanced model (Table 2). Respondents largely had graduated from their FETP within the past 10 years (74.4%) (Table 2), however graduation went as far back as 1992. Respondents reported varying periods of epidemiology experience with 40% (n=112) reporting less than five years of experience, and 20% (n=59) with more than 12 years of experience (Table 2).
Table 2: Professional background characteristics of Epidemiology Emergency Response Survey respondents, 2019-2020 (n=282)
Category
|
Variable
|
Number (%)
|
Epidemiology and Public heath training*
|
n=282
|
|
Master of Public Health (or similar)
|
92 (32.6%)
|
Other relevant Masters
|
13 (4.6%)
|
Public Health Physician training
|
10 (3.5%)
|
PhD
|
18 (6.4%)
|
Field Epidemiology Training Programme (FETP)
|
210 (74.5%)
|
FETP alumni
|
|
n=282
|
|
Yes
|
178 (63.1%)
|
Trainee at time
|
32 (11.3%)
|
No
|
72 (25.5%)
|
FETP level
|
|
n=210 (including trainees)
|
|
Advanced (2 years)
|
189 (90%)
|
Intermediate (9months – 1 year)
|
7 (3.4%)
|
Frontline (<6 months)
|
7 (3.4%)
|
Unanswered
|
7 (3.4%)
|
Years since FETP graduation
|
n=210
|
|
10 or less
|
157 (74.8%)
|
10+
|
37 (17.6%)
|
Unanswered
|
16 (7.6%)
|
Epidemiology experience
|
n=282
|
|
<1 years
|
12 (4.3%)
|
1-<2 years
|
23 (8.2%)
|
2-<5 years
|
77 (27.3%)
|
5-<8 years
|
64 (22.7%)
|
8-<12 years
|
42 (14.9%)
|
12+ years
|
59 (20.9%)
|
not applicable
|
4 (1.4%)
|
Unanswered
|
1 (0.4%)
|
*multiple training types per respondent
Epidemiology Training
Outbreak and Surveillance
Basic outbreak and surveillance training was commonly reported by the respondents, however less common was targeted training in emergency response surveillance, community based surveillance or syndromic surveillance (Table 3a). When comparing the respondents who had completed an FETP with those who had not participated in an FETP, FETP graduates reported higher levels of formal training in all surveillance and outbreak investigation questions (Table 3a).
Table 3: Reported epidemiology training, comparison between FETP and non-FETP epidemiology emergency response survey respondents 2019-2020 (n=282)
Section
|
Category
|
Topic
|
Total
n=282
|
Total %
|
Non FETP n=72
|
Non FETP %
|
FETP n=178
|
FETP %
|
a
|
Training in outbreak and surveillance
|
|
|
|
|
|
|
|
|
Basic principles of surveillance
|
262
|
92.9
|
58
|
80.6
|
173
|
97.2
|
|
Syndromic surveillance
|
165
|
58.5
|
23
|
31.9
|
118
|
66.3
|
|
Community based surveillance
|
157
|
55.7
|
34
|
47.2
|
104
|
58.4
|
|
Emergency response surveillance
|
168
|
59.6
|
29
|
40.3
|
119
|
66.8
|
|
Outbreak investigation steps
|
250
|
88.7
|
51
|
70.8
|
168
|
94.4
|
|
Outbreak investigation methods
|
238
|
84.4
|
47
|
65.3
|
160
|
89.9
|
b
|
Training in analysis and methods
|
|
|
|
|
|
|
|
|
Rapid survey
|
162
|
57.4
|
35
|
48.6
|
107
|
60.1
|
|
|
Mortality survey
|
84
|
29.8
|
21
|
29.2
|
51
|
28.6
|
|
|
Nutrition survey
|
52
|
18.4
|
13
|
18.1
|
32
|
18
|
|
|
Other survey
|
107
|
37.9
|
17
|
23.6
|
75
|
42.1
|
|
|
Denominator estimation
|
83
|
29.4
|
20
|
27.8
|
52
|
29.2
|
|
|
Needs assessment
|
101
|
35.8
|
24
|
33.3
|
66
|
34.1
|
|
|
Risk assessment
|
152
|
53.9
|
34
|
47.2
|
98
|
55.1
|
|
|
Managing complex datasets
|
78
|
27.7
|
23
|
31.9
|
47
|
26.4
|
|
|
R
|
34
|
12.1
|
12
|
16.7
|
18
|
10.1
|
|
|
Stata
|
123
|
43.6
|
28
|
38.9
|
79
|
44.4
|
|
|
Epi Info
|
205
|
72.7
|
31
|
43.1
|
149
|
83.7
|
|
|
Excel
|
187
|
66.3
|
35
|
48.6
|
131
|
73.6
|
|
|
Data visualisation
|
112
|
39.7
|
26
|
36.1
|
67
|
37.6
|
|
|
Transmission trees
|
36
|
12.8
|
11
|
15.3
|
20
|
11.2
|
|
|
Spatial analysis
|
71
|
25.2
|
19
|
26.4
|
38
|
21.4
|
c
|
Training in leadership and management
|
|
|
|
|
|
|
|
|
Evidence based decision making
|
159
|
56.4
|
35
|
48.6
|
108
|
60.7
|
|
|
Mentoring
|
98
|
34.8
|
10
|
13.9
|
74
|
41.6
|
|
|
Leadership
|
130
|
46.1
|
19
|
26.4
|
91
|
51.1
|
|
|
Managing a team
|
119
|
42.2
|
20
|
27.8
|
85
|
47.8
|
|
|
Peer teaching
|
93
|
33
|
9
|
12.5
|
70
|
39.3
|
|
|
Team work
|
184
|
65.2
|
33
|
45.8
|
126
|
70.8
|
|
|
Prioritisation
|
87
|
30.9
|
17
|
23.6
|
60
|
33.7
|
|
|
Delegating responsibility
|
73
|
25.9
|
13
|
18.1
|
52
|
29.2
|
|
|
Partner coordination
|
84
|
29.8
|
15
|
20.8
|
60
|
33.7
|
|
|
Reflective practices
|
33
|
11.7
|
8
|
11.1
|
21
|
11.8
|
d
|
Training in social and communication skills
|
|
|
|
|
|
|
|
|
Basic scientific communication skills
|
244
|
86.5
|
48
|
66.7
|
166
|
93.3
|
|
|
Practical field communication skills
|
149
|
52.8
|
24
|
33.3
|
107
|
60.1
|
|
|
Media communication
|
136
|
48.2
|
24
|
33.3
|
94
|
52.8
|
|
|
Cultural competency
|
72
|
25.5
|
22
|
30.6
|
42
|
23.6
|
|
|
Participant consent
|
152
|
53.9
|
30
|
41.7
|
100
|
56.2
|
|
|
Stress management
|
60
|
21.3
|
9
|
12.5
|
43
|
24.2
|
|
|
Social media
|
32
|
11.3
|
5
|
6.9
|
22
|
12.4
|
|
|
Interview techniques
|
144
|
51.1
|
31
|
43.1
|
95
|
53.4
|
|
|
Ethics
|
169
|
59.9
|
40
|
55.6
|
111
|
62.4
|
|
|
Relationship building
|
62
|
22
|
14
|
19.4
|
38
|
21.3
|
E
|
Training in emergency response training
|
|
|
|
Role of the epidemiologist during emergency response
|
169
|
59.9
|
33
|
45.8
|
113
|
63.5
|
|
|
Epidemiology of public health disasters
|
166
|
58.9
|
32
|
44.4
|
114
|
64
|
|
|
Humanitarian principles
|
67
|
23.8
|
18
|
25
|
42
|
23.6
|
|
|
Principles of escalation / scaling a response
|
45
|
16
|
9
|
12.5
|
30
|
16.9
|
|
|
Methods of data collection in an emergency
|
147
|
52.1
|
31
|
43.1
|
96
|
53.9
|
|
|
Ethics during emergencies
|
82
|
29.1
|
18
|
25
|
53
|
29.8
|
|
|
IMS - Incident Management System
|
73
|
25.9
|
14
|
19.4
|
46
|
25.8
|
|
|
EOC role- Emergency Operations Centre
|
93
|
33
|
17
|
23.6
|
63
|
35.4
|
|
|
IHR - International Health Regulations
|
121
|
42.9
|
15
|
20.8
|
87
|
48.9
|
|
|
HeRAMS: Health Resources Availability Monitoring System
|
11
|
3.9
|
1
|
1.4
|
8
|
4.5
|
|
|
EWARS: Early Warning, Alert and Response System (EWARS in a box)
|
79
|
28
|
12
|
16.7
|
58
|
32.6
|
|
|
Personal safety (use of PPE - personal protective equipment)
|
130
|
46.1
|
26
|
36.1
|
88
|
49.4
|
|
|
Border control (POE - point of entry)
|
46
|
16.3
|
8
|
11.1
|
30
|
16.9
|
FETP: Field Epidemiology Training Programme
When commenting on outbreak and surveillance training gaps and challenges, respondents reported the need for additional opportunities for knowledge consolidation and skill development (Box 1). Respondents also stated that the teaching needed to be grounded within the political and social context of outbreak and surveillance (Box 1). Training in alternate surveillance techniques such as syndromic and community based surveillance was discussed as lacking and respondents requested more training in different types of response such as to environmental and chemical and radiological disasters (Box 1).
Box 1: Outbreak and surveillance training gaps reported by epidemiology emergency response survey respondents, 2019-2020
Application
|
“I feel we were given enough knowledge, but did not apply it in practice.”
|
|
[training] “was mostly based around field epidemiology in stable, developing world settings. It's mostly related to the work of government departments.”
|
|
“I believe that I wanted to have more opportunities to apply in practice what I learned theoretically.”
|
|
“While we acquire lots of knowledge, the practical competencies could be more developed by being in the field during the training program”
|
|
“The knowledge and skills learnt were more geared toward outbreak response … Even then, looking back they were somewhat outdated and didn't necessarily reflect the political culture within which outbreaks occur.“
|
Knowledge
|
[I wanted training] “related to chemical, radiological and explosive emergencies”
|
|
Data analysis
Training on estimation of population size during emergencies was reported by only 29.4% (n=83) of respondents, this was similar for both FETP (n=52, 29.2%) and non-FETP (n=20, 27.8%) respondents. Almost 28% (n=78) of respondents had received training in managing complex datasets (Table 3b).
Thirty-six percent (n=101) of respondents reported receiving training in needs assessments, with 53.9% (n=152) trained in risk assessments. Training in survey development and implementation of specialised surveys, such as nutrition and mortality surveys, were uncommonly reported by respondents (18.4% n=52, and 29.8% n=84 respectively), as were analytical techniques such as transmission trees (12.8% n=36) and spatial analysis (25.2% n=71) (Table 3b).
Epi Info was the most commonly reported statistical package taught (72.7% n=205), followed by Microsoft Excel (66.3% n=187) and Stata (43.6% n=123) (Table 3b). There was a difference between FETP and non-FETP graduates regarding reported training in statistical packages; 83.7% (n=149) of FETP respondents compared to 43.1% (n=31) non-FETP respondents reported learning Epi Info. Excel training was reported by 73.6% (n=131) of FETPs compared to 48.6% (n=35) of non-FETP respondents.
When asked where they believed there were gaps in their epidemiology training in regards to data analysis, respondents listed training in data analysis and managing complex data skills; specifically, R statistical software training, population denominator estimation, spatial analysis, and mapping skill development.
Leadership and management
Survey questions relating to leadership and management training had varying responses. Sixty-five percent (n=184) of respondents reported teamwork was part of their epidemiology training, and 56.4% (n=159) reported learning evidence based decision-making. Responses to the remaining eight items in the leadership and management module indicated that most training programs did not include training in leadership and management skills, with under 50% of respondents saying they learnt these skills during their training, with training in reflective practices reported by only 11.7% (n=33) of respondents (Table 3c).
FETP respondents reported a higher percentage of training in all leadership categories compared to non-FETP, especially in mentoring and peer teaching (Table 3c). Within each category in this section, males reported much higher rates of learning, with the exception of peer teaching. Of note, 45.9% (n=62) of male respondents reported learning mentoring, compared to 24.3% (n=35) of female respondents, 61.5% (n=83) of males compared to 31.3% (n=45) of females reported learning leadership, and 34.1% (n=46) of males and 17.4% (n=25) of females reported learning to delegate responsibility during their training (Table 4).
Table 4: Reported training in leadership, comparison of epidemiology emergency response survey by gender, 2019-2020 (n=282)
Topic
|
Female
n=144 (%)
|
Male
n = 135 (%)
|
Evidence based decision making
|
77 (53.5%)
|
80 (59.3%)
|
Mentoring
|
35 (24.3%)
|
62 (45.9%)
|
Leadership
|
45 (31.3%)
|
83 (61.5%)
|
Managing a team
|
45 (31.3%)
|
72 (53.3%)
|
Peer teaching
|
51 (35.4%)
|
42 (31.1%)
|
Team work
|
89 (61.8%)
|
92 (68.1%)
|
Prioritisation
|
38 (26.4%)
|
47 (34.8%)
|
Delegating responsibility
|
25 (17.4%)
|
46 (34.1%)
|
Partner coordination
|
37 (25.7%)
|
45 (33.3%)
|
Social and communication
Training in basic scientific communication such as report writing and presentation preparation was common amongst respondents (n=244, 86.5%). Training in other communication techniques was less frequently reported; including training in practical communication in the field (n=149, 52.8%), media communication (n=136, 48.2%), cultural competence (n=72, 25.5%), and social media communication (n=32, 11.3%) (Table 3d). Training in stress management and relationship building were reported by just over 20% (n=60 and n=62 respectively). Interview techniques, consent, and practical ethical approaches to field work were reported by just above half of the respondents (Table 3d). With the exception of cultural competency, non-FETPs reported less training than FETPs to each question in this section (Table 3d).
Answers to open-ended questions asking respondents about social and communication training needs, highlighted recognition for the need for further training in in this area (Box 2). Further training in the use of traditional media and social media were commonly stated as essential training for epidemiologists (Box 2). Respondents also stated that training with a focus on cultural, political, and contextual understanding was needed, as were training on qualitative research methods, stress management, and prioritisation (Box 2).
Box 2: Social and communication training gaps reported by epidemiology emergency response survey respondents, 2019-2020
Communication
|
“I think a really valuable skill that should be taught in epidemiology is how to influence others with the data story. This isn't about most fancy, complicated analysis, but about working out what's important in the data for decision-making.”
|
Social science and anthropological skills
|
“My training as an anthropologist and social scientist significantly enhanced my skills as an epidemiologist. These are new concepts and under recognized and underused”
|
“I will welcome more knowledge in behavioural change and anthropology during the training”
|
Emergency response
Fourteen emergency response training items were listed in the survey, half (n=7) of which were reported by less than 30% of respondents each (Table 3e). Non-FETP respondents reported less training than FETP graduates in each of these emergency response categories (Table 3e).
When respondents were asked whether they believed emergency response training should be a core component of applied epidemiology training, almost 75% (n=211) replied yes, and 18% (n=50) suggested it should be optional.
Despite relatively low proportions of respondents having formally studied the listed emergency response topics, 64% (n=181) agreed or strongly agreed that their epidemiology training gave them the required knowledge to work as an epidemiologist during emergency response (Figure 3), and 65% (n=172) believed they had learnt the required skills for epidemiology emergency response (Figure 4). FETP respondents were more likely to answer positively to these questions than non-FETP (Figures 3 and 4).
When asked what was missing from their epidemiology training, respondents suggested emergency response training. Specifically, respondents asked for training on the epidemiology role during emergency response, who should respond to emergencies and what characteristics were needed, emergency response epidemiology methods, humanitarian principles, as well as teaching on the emergency response structure (Box 3).
Box 3: Emergency response training gaps reported by epidemiology emergency response survey respondents, 2019-2020
Emergency response
|
“Being fit for the field i.e. not everyone who has completed the program should be in the field.”
|
“Specific things like bioterrorism and natural disasters and hurricane response”
|
|
“Critical skills to data analysis and collection during an emergency, rarely having a denominator, working with dirty data, working with MoH's [Ministry of Health] without statistical packages.”
|
“Did not learn enough about the different approaches and methods that are/should be used in an emergency setting vs a regular ongoing surveillance or outbreak response setting.”
|
“Thinking systems in the middle of an emergency”
|
“A session on the realities of an emergency situation would be useful.”
|
“There was minimal relevant to emergency response or low resource settings.”
|
Response structure
|
“How humanitarian responses are structured - what is happening around you in such a response and concrete feedback about where epi skills and information can serve those components.”
|
|
“There were no emergency response topics covered in my epi training… no mention of IHR [International Health Regulations]”
|
Role
|
“Role of Field Epidemiologist during Humanitarian crisis still confuses me”
|
|
“Even at the advanced level and despite being "on the ground", does not have the capacity of those trained in the roles of the epidemiologist in emergency situations or health crises, in rapid interventions.”
|
“In a situation with an environmental disaster (e.g. air pollution), the epidemiologist has no preparation on his role in such an event. Other areas: Mass casualty, major water contamination, exposure to chemicals due to explosions etc... responders are prepared, but the epidemiologist is not.”
|