Public Health Exam and Credential are the Culmination of a Decades-Long Process

By Alex McEllistrem-Evenson, Editor, Health Workforce News

“The public health workforce is not easily defined or measured,” states Dr. Jean Moore, director of the New York Center for Workforce Studies, in a 2009 article. According to Moore’s review of health workforce issues within public health, “well-prepared public health professionals are essential to an effective public health system in the United States,” yet “the lack of clear definitions and good data make it difficult to fully assess … the adequacy of their skills and competencies in relation to their roles and responsibilities.”

As a field, public health casts one of the broadest nets in health, and the massive scope of these roles and responsibilities is mind-boggling, ranging from highly technical work in biostatistics and epidemiology to developing marketing campaigns for public health initiatives such as tobacco cessation and hand-washing. This is, perhaps, a large reason why the field has only recently developed and approved a means by which to address the concerns that Morre and others have cited about ensuring skill and competency levels.

The Certified in Public Health (CPH) Exam – developed, administered, and evaluated by the National Board of Public Health Examiners (NBPHE) – is now in its third year of existence, and is making significant strides towards widespread adoption.

“This is the only core-credentialing exam for public health professionals,” states Molly M. Eggleston, Deputy Executive Director of the NBPHE. “It’s the only one that requires a graduate-level degree. And the CPH covers our entire field. CPH professionals demonstrate that we can both function at all levels of the social-ecological model and understand the unique population-based prevention perspective that is ours as public health professionals.”

This exam and certification process has been a long time coming. “The dialogue about establishing national standards for public health professionals has been going on for decades,” Eggleston states. “There have been Institute of Medicine reports and recommendations from Surgeon Generals that the public health field really needed to take steps to set standards and professionalize itself. The stars aligned in 2005 when the [NBPHE] board was formed.”

Members of the NBPHE are proud of what they’ve accomplished thus far, and for good reason. Standardizing an assessment of public health knowledge is an incredibly difficult task. To describe the CPH exam as comprehensive, even in the context of a field as broadly defined as public health, would be an understatement.

The CPH exam covers five “core areas” of knowledge – Biostatistics, Environmental Health Sciences, Epidemiology, Health Policy and Management, and Social and Behavioral Sciences – as well as seven “cross-cutting areas” – Communication and Informatics, Diversity and Culture, Leadership, Public Health Biology, Professionalism, Programs Planning, and Systems Thinking. “The CPH examination is the only standardized test regarding public health knowledge worldwide,” states Dr. Terry Dwelle, North Dakota State Health Officer and Chair of the NBPHE and its Testing Committee, in a ND Health Department video interview.

According to Eggleston, “these core areas and the cross-cutting competencies were [originally] articulated by the Association of Schools of Public Health in their Masters in Public Health competency set,” a document which is essentially “a checklist of things that we ought to be able to do once we graduate with a graduate level degree in public health.”

Although this competency set is recognized by the Council for Education in Public Health (CEPH), Eggleston clarifies that public health schools and programs are not required to use it at the present time; however, “a lot of schools and programs have voluntarily adopted this competency set to guide their curriculum. You’ll see in the schools – which tend to be larger and have more resources than the programs – they’ll have a department in each one of these areas. So within a school of public health you’ll have a department of Biostatistics, a department of Environmental and Occupational Health, and so on.”

Public Health professionals “should all have a core understanding of all of these” areas, states Eggleston. “Epidemiology is really our core science; we all need to know fundamentally about how that works. We do tend to specialize to the extent that when we go to school we generally take a degree from a department,” she adds. “All of these areas of knowledge are needed by all of us working in the field of public health at a fundamental understanding level. It’s the basis for our further specialization.”

he most obvious negative repercussions of lacking formal standards for certification within public health or any health profession has to do with workforce quality. Particularly in a field with such a broad scope, a given public health position might require a high degree of competency in one fundamental area, providing room for figurative “rust” to develop in others over time. However, NBPHE analysis has revealed no statistically-significant differences in performance on the exam related to age or date of graduation. “More seasoned professionals do as well on the exam as well as those who are fresh out of their graduate training in public health,” states Eggleston.

Although obtaining CPH certification is voluntary at this time, there appears to be increasing support to change this. “We are seeing increasing evidence of institutionalization of the CPH credential,” states Eggleston. “We have a growing list of employers who are supporting the exam process: funding their employees’ registration fees and continuing education requirements, and preferentially recruiting and hiring those employees who are CPH.”

“This voluntary examination is being accepted and valued by the institutions that are involved in public health and protecting the public,” Eggleston continues. “The exam has met or exceeded all psychometric benchmarks set for it. This is a reliable, valid exam that accurately measures people’s knowledge of the core competencies in public health.”

The process of obtaining a CPH credential has received testimonials at the individual level as well. According to Dwelle, who obtained the CPH credential for himself decades after completing his formal education, preparing for the exam “does a number of things for the individual. Even in the preparation process,” he adds, “it stimulates us to prepare and actually review the core materials that are necessary to take that examination” and in a larger sense, “to engage in a lifelong learning process making sure that we are doing what’s necessary to keep our skills and competencies in our profession where they should be.” As with the certification processes in most health care professions, the NBPHE does require those who pass the CPH exam to maintain their certification through continuing education, requiring “50 hours of continuing education every two years,” and “a re-assessment experience every 10 years.”

Although the primary intentions of the exam are to establish a means of validating the competency of the public health workforce and to encourage existing professionals to improve and maintain their skill-sets, Eggleston acknowledges that an additional welcomed side-benefit is publicity for the profession as a whole. The increased recognition of the CPH Exam, in her opinion, “elevates public health to be on par with all other health professionals that have a licensure, certification or credential,” and may enable the public “to appreciate the essential services of public health.” This development couldn’t come at a more opportune time in Eggleston’s view, as the exam’s roll-out coincides with national marketing and branding efforts for the profession.

The contributions of public health initiatives are significant. “Most of the years of life that we’ve gained, in terms of the increased longevity of the US population, are attributable to public health interventions,” asserts Eggleston. “Clean air, clean water, immunizations, recognition of tobacco as a health hazard—these are all public health initiatives.”

That being said, public health often goes unheralded. In Eggleston’s opinion, one reason for this is the time it takes for public health work to have a demonstrable positive effect. “You often get the return on the investment in the longer term,” she states, comparing immunization efforts within public health – which are preventative in nature and operate over the course of a lifetime – to the way a primary care physician can dramatically resolve a life-threatening allergic reaction in an instant, with a shot of epinephrine.

It is within this context that the potential impact of the NBPHE’s work over the last five years becomes clear. Along with the formal recognition of a credential comes an inherent degree of trust. When faced with an illness or allergic reaction, we allow primary care physicians to treat us because we recognize that they have a common knowledge base. Threats to public health may be more difficult to recognize, but the understanding that effectively treating these maladies necessitates mastery of such a broad base of knowledge may result in a needed understanding that public health, too, is a primary intervention.