Master of Public Health Concentrations in Global Health in 2020: Preparing Culturally Competent Professionals to Address Health Disparities in the Context of Globalization

Background

Global health emerged as an academic discipline at the start of the 21st century as the global HIV epidemic raised awareness about the health threats posed by globalization and challenged the global community to address ethical issues like inequalities in access to HIV medications (Bateman et al., 2001). While international health typically involved binational cooperation models in which high-income countries supported health interventions in selected low- and middle-income countries, global health has a grander vision of using interdisciplinary tools and global cooperation to promote health equity within and across nations (Koplan et al., 2009).

Because global health in its current form is a relatively new field of study, research, and practice, the specific knowledge, skills, and abilities that are essential for global health practitioners are still being identified and refined. The graduate-level global health competency frameworks developed by educators, employers, and other stakeholders in North America, Europe, Australia, and partner countries, including low- and middle-income countries, emphasize the importance of knowledge about the burden of disease and the determinants of health; proficiencies related to policy development, analytic methods, and project management; and soft skills related to collaboration and professionalism (Sawleshwarkar & Negin, 2017). Educational pathways focused on preparing global health practitioners also generally emphasize the aptitudes required for participating in, developing, and leading equitable and ethical partnerships (Adams et al., 2016). However, voluntary recommendations like these are not required to be incorporated into the curricula and concentration-specific competencies of MPH degree programs.

Three competency models are of particular relevance to global public health education in the United States. The first was released in 2011 by the Association of Schools of Public Health (ASPH), which was founded in 1953 to facilitate communication among schools of public health housed within universities in the United States. The 2011 ASPH global health competency model for master’s level programs in public health featured seven domains: capacity strengthening, collaborating and partnering, ethics and professionalism, health equity and social justice, program management, sociocultural and political awareness, and strategic analysis (ASPH, 2011).

A broader set of global health competencies that expanded the 2011 ASPH model was released in 2014 by the Consortium of Universities for Global Health (CUGH), which was founded in 2008 to support the work of universities (especially those with medical schools) and other academic institutions and partners engaged in global health education and training, research, and practice. The CUGH competencies are not specific to medicine or public health. Instead, they feature 11 domains related to interprofessional practice (Jogerst et al., 2015; Wilson et al., 2014).

As more programs in public health became accredited by the Council on Education for Public Health (CEPH), ASPH was renamed the Association of Schools and Programs of Public Health (ASPPH). ASPPH now serves as the membership organization for CEPH-accredited schools and programs. Most of the CEPH-accredited master of public health (MPH) programs are in the United States, but CEPH also accredits schools and programs in Canada, Grenada, Hong Kong, Israel, Lebanon, Mexico, and Taiwan. Under the 2016 CEPH accreditation criteria, all MPH degree programs must demonstrate that their students master 12 foundational public health knowledge objectives plus 22 foundational competencies. These 34 foundational items encompass globalization, comparative health systems, health policy, program planning and management, the socioeconomic and environmental determinants of health, major causes of morbidity and mortality, qualitative and quantitative research methods, leadership, communication, and professionalism. All these areas are directly relevant to global health practice.

Concentration-specific competencies that complement the foundational ones enable public health students to gain additional knowledge and skills in a selected area of applied public health practice. In July 2018, ASPPH released new recommended competencies for MPH concentrations in global health. The ASPPH global health competencies are not stand-alone items. They are designed to add depth that builds on the foundational CEPH knowledge areas and competencies. The six ASPPH competencies for global public health practice emphasize (1) the roles and relationships of global health entities, (2) ethical approaches to global health practice, (3) monitoring and evaluation techniques for global public health programs, (4) interventions responsive to the social determinants of health, (5) workforce development for capacity strengthening, and (6) self-reflection, cultural humility, and lifelong learning (ASPPH, 2018). These items were developed in consultation with national and international stakeholders, and they draw on many of the existing ASPH and CUGH domains. An ASPPH tool kit provides implementation resources for MPH degree programs that voluntarily choose to adopt all or part of the ASPPH competency model.

There is no expectation that any of these sets of global health competencies will be adopted without modification by MPH programs offering concentrations in global health. Instead, all these documents are meant to be resources for programs as they engage in curricular planning and consider how best to prepare their own students for practice in local, regional, national, and transnational settings. Each CEPH-accredited MPH degree program has made its own determinations about which five or more concentration-specific competencies they deem to be most suitable for their own programs. There is no standard set of competencies for MPH global health concentrations. However, our analysis shows that most programs have selected competencies that align with a similar set of themes.

Purpose/Aims

The concentration-specific competencies being used by MPH degree programs for their concentrations in global health during the 2019-2020 academic year provide valuable information about the current state of global health education and the ways that rising leaders in public health practice are preparing to address health disparities. Understanding trends in professional education is beneficial for academic planning purposes as well as for supporting links between and among the academic sector and employers in the public and private sectors. Some programs have concentration-specific competencies that mix one or several of the ASPH, CUGH, and ASPPH domains or competencies with additional items that are of special relevance to the populations served by their students and alumni. Others have distinctive sets of competencies for their global health concentrations that do not appear to draw on the ASPH, CUGH, or ASPPH recommendations. Together, the concentration-specific competencies in use by CEPH-accredited MPH programs highlight the core knowledge and skills areas for global health practice that have emerged in recent years as the field has evolved and matured. The goal of this analysis was to examine the foci of the global health concentrations of MPH degree programs in 2019-2020. Our analysis of program websites, curricula, and competencies provides insight about how academic public health education programs are currently conceiving of global health as a field of graduate study and practice.

Method

Qualitative Coding

A preliminary code was independently assigned to each concentration-specific competency by each of the coauthors in March 2019. These initial codes were used to create a codebook, and all coauthors then used that codebook to conduct additional rounds of coding of the curriculum. The few discrepancies in the coding of the competencies were resolved through discussion and consensus. We grouped the codes into initial categories using an emergent process rather than an a priori approach, and then identified the themes expressed by the categories. We used a similar process to code the program descriptions, identify categories and themes for those codes, and achieve consensus about which quotations best illustrated recurrent themes.

After we developed definitions for the categories and themes reflected by concentration-specific competencies, it became apparent that many of the themes aligned with domains within the ASPH, CUGH, and/or ASPPH competencies. The coauthors used a consensus method to align the ASPH and CUGH competency domains with the six ASPPH competencies and then to assign each of our competency categories to one of those six domains. The final domains and associated categories are shown in Table 1. In January 2020, the coauthors used the final codebook to recheck the codes for the competencies and program descriptions of all global health MPH concentrations being offered during the 2019-2020 academic year.

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Table 1

Competency Areas for MPH Concentrations in Global Health During the 2019-2020 Academic Year

Domain	Subthemes	ASPPH 2018	CUGH 2015	ASPH 2011
Global health systems	• Agencies/organizations	Analyze the roles, relationships, and resources of the entities influencing global health (1)	Globalization of health and health care (2); sociocultural and political awareness (10)	Sociocultural and political awareness (6)
	• Globalization
	• Global priorities/SDGs
	• Comparative health systems
Ethics	• Health equity/human rights	Apply ethical approaches in global health research and practice (2)	Ethics (6); health equity and social justice (8)	Ethical reasoning and professional practice (3); health equity and social justice (4)
	• Ethical practice
Program management	• Monitoring and evaluation	Apply monitoring and evaluation techniques to global health programs, policies, and outcomes (3)	Program management (9)	Program management (5)
	• Planning and implementation
	• Policies/regulations
Strategic analysis	• Interventions	Propose sustainable and evidence-based multisectoral interventions, considering the social determinants of health specific to the local area (4)	Global burden of disease (1); Social and environmental determinants of health (3); strategic analysis (11)	Strategic analysis (7)
	• Burden of disease (morbidity and mortality)
	• Determinants of health (socioeconomic and environmental)
	• Research methods
Collaboration	• Partnerships	Design sustainable workforce development strategies for resource-limited settings (5)	Capacity strengthening (4)	Capacity strengthening (1)
Leadership and culture	• Cultural skills	Display critical self-reflection, cultural humility, and ongoing learning in global health (6)	Collaboration, partnering, and communication (5); Professional practice (7)	Collaboration and partnering (2)
	• Leadership
	• Self-reflection

Note. MPH = Master of Public Health; SDG = Sustainable Development Goals; ASPPH = Association of Schools and Programs of Public Health; CUGH = Consortium of Universities for Global Health.

Nearly all of the included MPH programs had already adopted the 22 foundational competencies required for accreditation or reaccreditation by CEPH under their 2016 criteria. The few programs that were still in the process of updating their curricula to align with the foundational competencies did not have core competencies that specifically mentioned global health, and when their core competencies covered topics that are relevant to global health, such as health systems and strategic analysis, the overlap was similar to the way that the 34 current CEPH foundational knowledge objectives and competencies are generally relevant to applied global health practice. We therefore coded only concentration-specific competencies for the included programs rather than coding both foundational and concentration competencies (see Supplemental Appendix).

Results

Thirty-two of the 189 institutions offering CEPH-accredited MPH degrees as of December 2019 met our eligibility criteria, including 27 offering concentrations in Global Health plus programs offering concentrations in Global Public Health (Rutgers), Global Health Practice (University of South Florida), Global Health Equity (Loyola University Chicago), Global Health and Health Disparities (Colorado State University), and International Health and Development (Tulane). In total, 17% (32 of 189) of the MPH programs accredited by CEPH as of the end of 2019 offered a concentration in general global health. Of the 34 universities with MPH programs in “applicant status” with CEPH as of December 2019, five included global health concentrations in their applications, including four offering a concentration in Global Health and one offering a concentration in Global and Community Health (Marshall University). In total, 17% (37 of 223) of the MPH programs accredited or in applicant status with CEPH offered a global health concentration. Of these 37 programs, 35 were in the United States, one in Canada, and one in Grenada.

All of the 37 included programs had existing global health concentration-specific competencies that align with aspects of at least three of the six ASPPH domains, with 26 overlapping with four or more and 13 overlapping with five or more (Table 2). Twenty-nine of the programs had at least one concentration-specific competency related to global health systems (ASPPH No. 1), including 18 with at least one competency focusing on agencies and organizations, nine highlighting globalization, seven featuring global priorities and initiatives such as the Sustainable Development Goals, and six examining comparative health systems. Some of these areas of global health systems may have been infrequently featured among the concentration-specific competencies because all MPH students must be able to “explain how globalization affects global burdens of disease” (CEPH Foundational Public Health Knowledge Area No. 11) and to “compare the organization, structure, and function of health care, public health, and regulatory systems across national and international settings” (CEPH Foundational Competency No. 8; CEPH, 2016).

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Table 2

Many of the Competencies for MPH Concentrations in Global Health Being Used During the 2019-2020 Academic Year Align With the Six Competencies Recommended by ASPPH in July 2018

University	1: Global health systems	2: Ethics	3: Program management	4: Strategic analysis	5: Collaboration	6: Leadership and culture
Brown University			•	•		•
California State University, San Marcos	•		•	•		•
Case Western Reserve University	•	•		•	•
Colorado State University	•	•		•
Drexel University	•	•	•	•	•
Emory University		•		•		•
George Mason University		•	•	•		•
Harvard University		•	•	•		•
Liberty University	•		•	•		•
Loma Linda University	•		•	•	•	•
Loyola University Chicago	•	•			•	•
Marshall University	•	•	•	•		•
Mount Sinai Icahn School of Medicine	•	•	•			•
New York University	•			•		•
Northwestern University	•	•	•		•	•
Oregon State University	•			•	•
Pennsylvania State University	•	•		•
Rutgers, The State University of New Jersey		•	•	•		•
Saint Catherine University	•	•	•	•	•	•
Saint George’s University		•		•	•	•
Saint Louis University	•		•			•
Southern New Hampshire University		•	•	•
Syracuse University	•	•		•	•	•
Touro University California	•	•	•	•	•	•
Tulane University	•	•	•	•		•
Uniformed Services University of the Health Sciences	•	•	•		•
University of Alberta	•	•	•		•
University of Cincinnati	•	•	•		•
University of Maryland at Baltimore	•	•	•	•	•	•
University of North Carolina, Chapel Hill	•	•	•		•	•
University of Pennsylvania	•	•	•	•		•
University of South Florida	•	•	•	•	•	•
University of Southern California	•				•	•
University of Washington	•		•	•
University of West Florida			•	•	•	•
Vanderbilt University	•		•	•	•	•
Washington University in St. Louis	•	•		•

Note. MPH = Master of Public Health; ASPPH = Association of Schools and Programs of Public Health.

Twenty-six programs had at least one concentration-specific competency related to ethics (ASPPH No. 2), including 18 covering aspects of health equity and human rights and 12 emphasizing ethical practice. While all MPH students must “discuss the means by which structural bias, social inequities, and racism undermine health and create challenges to achieving health equity at organizational, community, and societal levels” (CEPH Foundational Competency No. 6), professionals working in global health or with diverse local populations benefit from additional knowledge and skills pertaining to health equity (CEPH, 2016).

Twenty-six of the global health MPH concentrations had at least one concentration-specific competency on program management (ASPPH No. 3), including 16 with concentration-specific competencies focused on monitoring and evaluation, 13 focused on planning and implementation, and seven focused on policies and regulations. All MPH students must be able to “assess population needs, assets, and capacities” (CEPH Foundational Competency No. 6), “design a population-based policy, program, project, or intervention” (No. 9), “explain basic principles and tools of budget and resource management” (No. 10), and “select methods to evaluate public health programs” (No. 11; CEPH, 2016). Professionals working in international and multicultural settings must be able to apply these program management skills in resource-limited settings while working with diverse partners.

Twenty-eight of the MPH concentrations in global health covered at least one aspect of strategic analysis (ASPPH No. 4), including 17 critically examining interventions, 15 featuring the burden from various causes of morbidity and mortality, eight emphasizing the socioeconomic and/or environmental determinants of health, and six covering research methods. The 12 Foundational Public Health Knowledge objectives mandated by CEPH include the ability to “list major causes of morbidity and mortality in the U.S.” (No. 4) and explain the biological and genetic (No. 8), behavioral and psychological (No. 9), social, political, and economic (No. 10), and ecological (No. 12) factors that affect public health (CEPH, 2016). They also require knowledge of quantitative and qualitative methods (No. 3) and the science of primary, secondary, and tertiary prevention (No. 5). The concentration-specific competencies focus on understanding the burden of disease, risk factors, and interventions in global context.

Nineteen programs featured at least one concentration-specific competency related to collaboration and partnerships (ASPPH No. 5). All MPH students are expected to be able to “propose strategies to identify stakeholders and build coalitions and partnerships for influencing public health outcomes” (CEPH Foundational Competency No. 13) and “perform effectively on interprofessional teams” (CEPH, 2016). Global public health workers are expected to be able to work with an even greater diversity of partners, including participating in multinational, multilingual, multidisciplinary, and multisectoral teams.

Twenty-six of the global health concentrations had at least one concentration-specific competency focused on leadership and culture (ASPPH No. 6), including 14 promoting cultural skills, 11 emphasizing leadership, and eight requiring self-reflection. All MPH students are expected to “apply awareness of cultural values and practices to the design or implementation of public health policies or programs” (CEPH Foundational Competency No. 8) and to “describe the importance of cultural competence in communicating public health content” (No. 20; CEPH, 2016). All MPH students are also expected to demonstrate other facets of cultural competence, such as the ability to discuss structural bias and social inequalities (No. 6), build coalitions and partnerships (No. 13), advocate for diverse populations (No. 14), and select communication strategies for different audiences (No. 18), as well as applying leadership principles (No. 16; CEPH, 2016). The global health concentration competencies emphasize additional dimensions of the cultural, leadership, communication, and professional skills and personal qualities that are required for highly effective global public health practice.

Our coding and analysis of the program descriptions for MPH concentrations in global health revealed four key themes: globalization, low-income countries, social justice and equity, and culture and diversity (Table 3). These are not mutually exclusive categories. Instead, they can be envisioned as two scales: one for population (disparities–globalization) and one for practice (equity–diversity; Figure 1).

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Table 3

Examples of the Language Used to Describe the Aspects of Global Health Practice That Are Featured by Master of Public Health Programs With Concentrations in Global Health

Theme	Definition	Sample concentration purpose statements
Globalization	Global health is about health concerns that cross borders and affect countries of all income levels	“Health problems must be considered from a truly international perspective and implicit in that is the understanding that the health situation of one population affects other populations as well. Hence, without a healthy global community there is no healthy local or regional community . . . Our curriculum reflects the current realities of health around the world and reinforces the links between countries at different stages of economic development.” (Touro University California)
		“The track is designed for students interested in global health challenges and initiatives as they apply both globally and locally.” (Pennsylvania State University)
		“Engage and critically evaluate key challenges, policies, and processes as they affect the health of populations in a global context across national and sector boundaries.” (University of Cincinnati)
Low-income countries	Global health preferentially addresses health challenges in low-income countries and disadvantaged populations	“Promote comprehensive, long-term, and equitable health development, particularly in low-income nations.” (Oregon State University)
		“The curriculum focuses on assessment and intervention strategies useful in resolving health problems of primarily undeveloped countries.” (University of South Florida)
		“Global health addresses the worldwide health needs of people living in developing countries and resource-poor immigrant communities here in the United States.” (Saint Louis University)
Social justice and equity	Global health is about people working together to address social injustice and the underlying causes of and health inequalities	“The global health concentration seeks to improve health and achieve equity in health for all people worldwide. Students develop an understanding of the history, context, and impact of colonial health, tropical medicine, international health and global health, as well as the agencies and relationships that interact to address historical and ongoing global health issues.” (Case Western Reserve University)
		“(Global health) focuses on domestic and international health inequalities and is not about crossing borders but bridging health inequalities with scientific evidence of etiology and prevention.” (Brown University)
		“Become a leader in the field of public health by applying strategic principles of ethical reasoning and professional practice to advance health equity and social justice around the world.” (New York University)
Culture and diversity	Global health is about the cultural competencies that individuals must develop in order to serve diverse populations effectively	“The global health concentration provides students with the skills to advance the health and well-being of populations in diverse global settings . . . to develop and analyze public health programs that are aligned with local cultures, contexts, and resources.” (University of North Carolina, Chapel Hill)
		“The MPH degree in global health prepares committed professionals who are both technically competent and cross-culturally skilled in creating and facilitating sustainable health and development programs in diverse settings and populations. The program enables graduates to contribute to a better quality of life for all people—especially those who are vulnerable, underserved, marginalized, and disadvantaged.” (Loma Linda University)
		“Learn to work in a wide variety of settings with diverse populations, both domestically and abroad.” (Icahn School of Medicine at Mt. Sinai)

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Figure 1.

Two Dimensions of Population-Level and Practice-Emphasis Foci for Master of Public Health Concentrations in Global Health

The scale for population has one end emphasizing health in low-income countries and the other targeting the effects of globalization on countries of all income levels. A few programs have an international health focus that prioritizes health concerns that occur only or primarily in the world’s lowest income countries, but most have a more expansive view of the scope of global health. Some programs describe themselves as emphasizing globalization-related health issues that affect countries across the income spectrum and demand a coordinated global response. Some programs use a hybrid approach that examines how globalization affects all populations while paying special attention to the ways that globalization affects the health of disadvantaged and marginalized populations, such as low-income communities, refugees, and people experiencing humanitarian crises.

The other scale is for the practice focus, with one end addressing the socioeconomic and other inequalities that affect population health and the other end featuring the development of culturally competent practitioners who are prepared to work with diverse communities locally or in other settings. For this scale, the pole for social justice and equity is about changing attitudes and practices at the population level while the pole for culture and diversity is about equipping individual practitioners. Some programs have a special emphasis on one of these areas, but most can be classified as being at the center of the scale and seeking to ensure that their graduates understand the societal factors that generate, perpetuate, and exacerbate health disparities in the communities they serve and are equipped with the individual-level cultural knowledge, awareness, and skills to be effective collaborators, communicators, and leaders in diverse practice settings.

Many of the most prevalent themes that emerged from the concentration-specific competencies align with the four dimensions of global public health education that we identified from the program descriptions. The items within the global health systems domain, such as agencies and organizations, global priorities, and globalization, align with the globalization pole in Figure 1. The ethics domain, which features competencies related to health equity and human rights, aligns with the equity and social justice pole. The strategic analysis domain provides the tools for recognizing and addressing the health concerns of disadvantaged populations. The items within the leadership and culture domain align with the culture and diversity pole on the practice axis of the figure.

Discussion

The number of universities and colleges hosting global health institutes, centers, departments, and educational programs has expanded rapidly over the past 20 years (Matheson et al., 2014). Several global health competency models have sought to provide a structure for the educational demands and trends in this emerging field (Sawleshwarkar & Negin, 2017). The 37 CEPH-accredited and applicant MPH degree programs offering concentrations in global health during the 2019-2020 academic year have concentration-specific competencies that complement the foundational public health competencies from CEPH and align well with the global health domains covered by the ASPH, CUGH, and ASPPH recommendations. The program descriptions and competencies for global health MPH concentrations provide insight into how global health is developing and maturing as academic discipline.

Implications for Practice

MPH concentrations in global health are offered by nearly one in six CEPH-accredited MPH programs. These educational programs emphasize that global health practice is not limited to work in low-income countries. Global health MPH programs prepare practitioners to work in resource-limited settings anywhere in the world—including in their home communities—and to recognize and address emerging transnational concerns linked to globalization. Global health is built on a foundation of equity and social justice, and it is led by culturally skilled practitioners who capably contribute to and lead diverse partnerships. Our analysis shows that MPH degree concentrations in global health are already covering many of the domains recommended by ASPPH in 2018, while maintaining unique emphases that align with distinctive institutional missions and values. Consistent with the existing frameworks for global health competencies, MPH concentrations in global health aim to prepare students with the theoretical, ethical, technical, analytical, practical, and leadership skills needed to serve diverse populations effectively.

Supplemental Material