Management in Health, Vol 15, No 2 (2011)

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EuroHealth Group, Denmark;


Professor Gl ERGOR, MD, MPH

Dokuz Eyll University, Turkey;



Celal Bayar University,Turkey;



Marmara University, Turkey;


Belgin NAL, MD

Dokuz Eyll University, Turkey;



Ministry of Health, Turkey;



Field Epidemiology and Training Programmes are intended to strengthen the public health capacity within Ministries of Health by developing the human resource infrastructure within countries. The success of these programmes depends in a large part upon Ministry of Health involvement in the development process. Participation of the Ministry of Health in the development of the training programme is essential because of their knowledge of the health system and the pre-existing skills of their staff who are generally the training participants. Incorporating local stakeholders such as universities into the training programmes is also desirable in the early stages of programme development. The involvement universities helps to institutionalize the programme by creating ties with existing learning institutions, allows development of local language training materials, makes local mentoring of trainees possible, and enhances the sustainability of the programmes. This paper outlines the initial steps in the development process in Turkey of a Field Epidemiology and Training Programmes under the Strengthening of the Epidemiological Surveillance and Control of Communicable Diseases System phase I and II.



Keywords: field epidemiology, training, human resurces management



Human resources are a critical component to a high-functioning the health sector. Management and development of those resources is vital to the quality of services delivered on the individual level and to public health. Field epidemiology training programmes have become a key resource for public health workforce development in countries across the globe. High quality field epidemiologists are needed to strengthen public health capabilities and infrastructure to address the public health needs of countries. These training programmes are intended to train epidemiologists in the practical application of epidemiologic methods to the health concerns of their countries. Various models of field-based training programs exist, e.g. the Epidemic Intelligence Service of the U.S. Centers for Disease Control and Prevention, Field Epidemiology Training Programs (FETPs), Public Health Schools Without Walls (PHSWOWs) and the European Programme for Intervention Epidemiology Training (EPIET), but each country has to adapt the training programme to the needs of their workforce. (1)


The Epidemiological Surveillance and Control of Communicable Diseases System in Turkey (ESCCDS) project began in 2005. One of the needs that the project was designed to address was the absence of a Field Epidemiology Training Programme (FETP) which limited the Ministry of Health's ability to investigate and respond to outbreaks which hindered the implementation of the 2005 International Health Regulations (1) (2). In Turkey, there is no official job classification for epidemiologists in the Ministry of Health. Ministry of Health personnel at both the national and provincial level have medical degrees and their job classification is as medical staff. There are academic programs in epidemiology available at schools of public health in the universities, but the programs are geared towards academic research rather than applied field work. Since Ministry of Health staff are required investigate outbreaks of disease but are not required to have academic training in epidemiology, the need for training was apparent. The first phase of the project focused on institution and capacity building, including the initiation of the training programme. The second phase of the project, which began in 2007, focused on refining the training programme and identifying methods to create a sustainable program in the future.


Training Methodology

The curriculum was developed in ESCCDS I. It was modeled on the European Programme for Intervention Epidemiology Training (EPIET) Fellowship, a FETP administered by the European Centre for Disease Control and Prevention. The programme consisted of a three-week introductory epidemiology course and was followed by five one week single topic modules. When possible, standardized training materials from EPIET and TEPHINET were used during the training modules. In addition to the courses, participants were divided into groups and conducted operational research projects under the mentorship of international technical consultants. During the transition to the second project, a review of the training program under ESCCDS I was conducted with the Ministry of Health. Based on this review, it was determined that locally based trainers and mentors would enhance the quality of the training programme. A faculty member from Dokuz Eyll University in Izmir recruited to be epidemiology key expert for the second phase of the project and, in turn, identified three local mentors. In addition, the training materials and topics were revised based on needs identified during the first phase.


The revisions to the training program were made through collaboration between the project team leader, the epidemiology training coordinator and the epidemiology key expert. As a team they decided the training content, schedule, external expert selection, and evaluation methodology. In addition, the group oversaw the progress of the operational research studies being conducted by the training participants. The team also worked with international consultants to develop a roadmap for bringing the Turkish program in line with Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) standards.


Implementation of the training program

At the initiation of ESCCDSI it was decided, as the program was funded by the European Commission, if a training program was to be implemented the EPIET model would be used because that is the format used by the European Centres for Disease Control. Under that model, a three-week intensive introduction to epidemiology course is taken at the beginning of the program and followed by five single topic modules. Project staff undertook an informal, primarily verbal needs assessment to determine what topics and skills the training program should cover. In this process, Ministry of Health staff were asked to select training modules from a list of those offered by EPIET with the exception of adult education. Adult education was added to the standard curriculum because it is anticipated that the participants will become the primary trainers and mentors under a future FETP. During ESCCDS II the same modules were offered the second training cohort and two additional modules were developed at the request of the Ministry of Health for the first cohort (Table 1).


Table 1. Curriculum content of the training program for cohort one and cohort two. Modules highlighted in grey were added under ESCCDS II


Cohort One

Cohort Two

Introduction to epidemiology (3 weeks)



Operational research (1 week)



Training of trainers (1 week)



Epidemiologic and statistical software (1 week)



HealthMapper (1 week)



Public health emergency preparedness and response (1 week)



Data analysis: Advanced methods and literature review (1 week)



Advanced outbreak investigation (1 week)




During ESCCDS I, trainees were selected by Ministry of Health and included a mix of personnel from the Ministry, provincial health directorates, and the military health system. After completing the introductory course and the adult education module, the first cohort of trainees conducted basic epidemiology, surveillance and public health in-service courses for provincial health directorate personnel. The participants in the in-service courses became the pool of potential trainees under the second phase of the project. The participants in the in-service course were asked if they would be interested in becoming members of the second cohort of trainees. The Ministry of Health selected the second cohort from the list of volunteers.

Operational research projects were another aspect of the training programme. Under ESCCDS I, the research topics were selected by project staff and Ministry of Health. There were three topics selected, typhoid, tuberculosis, and brucellosis. The trainees were broken into three groups of approximately ten and assigned at least one international expert during the research protocol module. During the module the project teams worked with the international experts to develop their proposals and research methodology. After the end of the module, the project teams were expected to conduct research projects with assistance from their international mentors and project staff and write up a final report. Some barriers to this approach were encountered. One barrier was that it was difficult for the project teams to meet since they were scattered throughout the country and could not get time away from their normal duties. In addition, the international mentors were unable to return to the country to meet with the groups and could only communicate by e-mail or phone, which was difficult since some of the project team members have limited English and much of the communication was complex and technical, thus requiring translation. During the second project some modifications to the operational research component were made. In the introductory epidemiology course for both projects, participants were asked to research a topic and create a presentation. For the second cohort of trainees, instead of selecting any topic, they were asked to select a potential research topic in their province or area of work. The list was submitted to the Ministry of Health and reviewed and priority projects were selected. The participants were divided into seven groups of three to seven people and from the list of topics selected by Ministry of Health, seven were chosen by the participants for their operational research projects (Table 2).


Each group was assigned a local mentor to assist them as they conducted their research. These mentors also conducted the training modules and thus were able to meet with the groups for a week during the training modules. These changes addressed many of the barriers to conducting the operational research projects during ESCCDS I. However, lack of time to do the research project6s due to still having to complete normal duties remained.


Table 2. ESCCDS II operational research projects

Evaluation of Adverse Events after Immunization Surveillance System in 2004-2007

Evaluation of case reporting and case finding activities in communicable diseases and developing

a standardized model for reporting

Gastro-intestinal Disease Outbreak investigation in Konya

Strengthening hepatitis B surveillance in Mersin and Hatay provinces

Early warning systems and threshold setting in communicable disease surveillance

Evaluation of measles surveillance in Diyarbakır in 2005-2007, according to Measles Elimination

Program Surveillance Criteria.

Knowledge, Attitudes and Practices study (KAP) of Communicable Disease Surveillance among

secondary health care personnel in Mardin and Diyarbakır.




During the two project phases (2005 - early 2008) 47 (26 from phase I and 21 from phase II) staff from the Republic of Turkey Ministry of Health participated in the training program. Overall the training program was well received by participants as reflected in the evaluation reports. Participants appreciated both the teaching content, the teaching methods and felt that they were developing essential skills to investigate outbreaks. The EPIET format was well accepted by participants. The combination of theoretical modules with field operational research was considered very beneficial as it allowed them to apply the techniques they learned during the training modules. The progress of the training participants was quantitatively measured as well, and notable improvement was seen between pre-test and post test scores at the end of each module (3) The decision to have local, university-based mentors greatly enhanced the training programme. It allowed frequent and timely communication between the training participants and the mentor in Turkish, which created

stronger ties between mentor and mentee than was possible with mentors based outside of the country. In addition, the university-based mentors were familiar with local pedagogic methods that participants were familiar with. This allowed them to present complex technical information more effectively. Another benefit to having local trainers and mentors was the ability to quickly revise and adapt training materials without having to wait for translation. It also served to strengthen ties between academia and the civil service which can lead to further collaboration on public health research and interventions in the future. The Ministry of Health was as supportive of the FETP as the training participants. The Ministry of Health provided a staff member to act as a permanent liaison between the project team and the university-based epidemiology key expert and who was intimately involved in the development of the training curriculum. The input from the Ministry of Health helped to ensure that the programme would meet the needs of participants and helped foster ownership of the programme by the Ministry of Health. One difficulty encountered during the projects was that the Ministry of Health staff, both the liaison and the trainees, as well as the university-based training staff were still full time employees with their organizations and still had to fulfil all of their normal duties in addition to the training program. This made devoting time to the programme very difficult.






As the development of the FETP progresses in Turkey, the need to make permanent, dedicated FETP training and management positions will become critical to the programme's success and sustainability. In addition, a job category for field epidemiologists within the Ministry of Health must be created, possibly with higher remuneration, to encourage staff to join the FETP. A third project funded by the European Commission is planned under which the Turkish programme will continue to develop. The third project includes implementing the necessary regulations to allow trainees to have their work time devoted to the training programme, rather than as an additional task, thus creating a full time two-year applied training programme.

These changes are essential steps towards creating a sustainable programme that can contribute to the betterment of public health in Turkey.




1. European Commission. National, Multi-Beneficiary, Cross-Border and other Programmes - Financing Memo-randa & Project Fiches. European Commission Website. [Online] 2004. [Cited: June 1, 2011.] Communicable%20diseases.pdf.

2. World Health Organization. International Health Regulations; World Health Organization. [Online] 2008. [Cited: 4 30, 2011.]; 2008/9789241580410_eng.pdf.

3. Euro Health Group, SMI, UNICON, SIT. Technical Assistance for the Establishment of Epidemiological Surveillance and Control of Communicable Diseases System (ESCCDS) in Turkey - Phase II Draft Final Report. s.l. : Unpublished, 2009.






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