The Core Competencies for Public Health in Canada: Opportunities and Recommendations for Modernization.

CONTEXT: The 2008 Public Health Agency of Canada's (PHAC's) "Core Competencies for Public Health in Canada" (the "Canadian core competencies") outline the skills, attitudes, and knowledge essential for the practice of public health. The core competencies represent an important part of public health practice, workforce development, and education in Canada and internationally. However, the core competencies are considered outdated and are facing calls for review, expansion, and revision. OBJECTIVE: To examine the literature on public health competencies to identify opportunities and recommendations for consideration when reviewing and updating the Canadian core competencies. METHODS: This narrative literature review included 4 components: 3 literature searches conducted between 2021 and 2022 using similar search strategies, as well as an analysis of competency frameworks from comparable jurisdictions. The 3 searches were conducted in collaboration with the Health Library to identify core competency-relevant scholarly and gray literature published in English since 2007. Reference lists of sources identified were also reviewed. During the data extraction process, one researcher screened each source, extracted competency-relevant information, and categorized these data into key findings. RESULTS: After identifying 2392 scholarly and gray literature sources, 166 competency-relevant sources were included in the review. Findings from these sources were synthesized into 3 main areas: (1) competency framework methodology and structure; (2) competencies to add; and (3) competencies to modify. DISCUSSION: These findings demonstrate that updates to Canada's core competencies are needed and overdue. Recommendations to support this process include establishing a formal governance structure for the competencies' regular review, revision, and implementation, as well as ensuring that priority topics applicable across all competency categories are integrated as overarching themes. Limitations of the evidence include the potential lack of applicability and generalizability to the Canadian context, as well as biases associated with the narrative literature review methodology.

The Governance of Core Competencies for Public Health: A Rapid Review of the Literature.

Core competencies for public health (CCPH) define the knowledge, skills, and attitudes required of a public health workforce. Although numerous sets of CCPH have been established, few studies have systematically examined the governance of competency development, review, and monitoring, which is critical to their implementation and impact. This rapid review included 42 articles. The findings identified examples of collaboration and community engagement in governing activities (e.g., using the Delphi method to develop CCPH) and different ways of approaching CCPH review and revision (e.g., every 3 years). Insights on monitoring and resource management were scarce. Preliminary lessons emerging from the findings point towards the need for systems, structures, and processes that support ongoing reviews, revisions, and monitoring of CCPH.

Integrating Public Health Into Undergraduate Medicine in North America: A Systematic Review.

The coronavirus disease 2019 (COVID-19) pandemic has served as a stark reminder of the importance of foundational public health training for all physicians. However, the most effective way to incorporate these concepts into undergraduate medical education remains unclear. Here, we characterize the literature regarding the effectiveness of public health integration into undergraduate medical education in North America. We systematically searched MEDLINE, Embase, Cochrane Central, and Education Resources Information Center (ERIC) in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines for North American peer-reviewed literature, published from 01/01/2000 to 30/08/2021, that described outcomes of integrating public health training within an undergraduate medical curriculum. Results were qualitatively synthesized into key themes. A total of 38 studies, involving interventions across 43 medical schools, were included. Studies reported on a combination of public (n=13), global (n=9), population (n=9), community (n=6), and epidemiological (n=1) health interventions, and either implemented one-off workshops, electives, or international experiences (n=19); a longitudinal theme or long-term enrichment pathway (n=14); or a case-based learning curriculum (n=8). The majority (81.5%, 31/38) of integrations were self-described as successful and, of studies reporting on feasibility, most (94.1%, 16/17) were indicated as feasible. The definition of what constituted such success, however, was unclear. Innovative examples included the use of simulation workshops and mobile-optimized media content. Key challenges were noted, however, in securing adequate funding and buy-in from administrative leadership. Robust community partnerships and iterative cycles of implementation of the intervention were critical factors to success. In summary, foundational public health components can be effectively integrated into medical school curricula and would benefit from adequate resourcing, innovation, community partnerships, and continuous improvement.

Prioritization of public health financing, organization, and workforce transformation: a Delphi study in Canada.

BACKGROUND: The increased scrutiny on public health brought upon by the ongoing COVID-19 pandemic provides a strong impetus for a renewal of public health systems. This paper seeks to understand priorities of public health decision-makers for reforms to public health financing, organization, interventions, and workforce. METHODS: We used an online 3-round real-time Delphi method of reaching consensus on priorities for public health systems reform. Participants were recruited among individuals holding senior roles in Canadian public health institutions, ministries of health and regional health authorities. In Round 1, participants were asked to rate 9 propositions related to public health financing, organization, workforce, and interventions. Participants were also asked to contribute up to three further ideas in relation to these topics in open-ended format. In Rounds 2 and 3, participants re-appraised their ratings in the view of the group's ratings in the previous round. RESULTS: Eighty-six public health senior decision-makers from various public health organizations across Canada were invited to participate. Of these, 25/86 completed Round 1 (29% response rate), 19/25 completed Round 2 (76% retention rate) and 18/19 completed Round 3 (95% retention rate). Consensus (defined as more than 70% of importance rating) was achieved for 6 out of 9 propositions at the end of the third round. In only one case, the consensus was that the proposition was not important. Proposition rated consensually important relate to targeted public health budget, time frame for spending this budget, and the specialization of public health structures. Both interventions related and not related to the COVID-19 pandemic were judged important. Open-ended comments further highlighted priorities for renewal in public health governance and public health information management systems. CONCLUSION: Consensus emerged rapidly among Canadian public health decision-makers on prioritizing public health budget and time frame for spending. Ensuring that public health services beyond COVID-19 and communicable disease are maintained and enhanced is also of central importance. Future research shall explore potential trade-offs between these priorities.

Centralization and integration of public health systems: Perspectives of public health leaders on factors facilitating and impeding COVID-19 responses in three Canadian provinces.

The extent to which power, resources, and responsibilities for public health are centralized or decentralized within a jurisdiction and how public health functions are integrated or coordinated with health care services may shape pandemic responses. However, little is known about the impacts of centralization and integration on public health system responses to the COVID-19 pandemic. We examine how public health leaders perceive centralization and integration facilitated and impeded effective COVID-19 responses in three Canadian provinces. We conducted a comparative case study involving semi-structured interviews with 58 public health system leaders in three Canadian provinces with varying degrees of centralization and integration. Greater public health system centralization and integration was seen by public health leaders to facilitate more rapidly initiated and well-coordinated provincial COVID-19 responses. Decentralization may have enabled locally tailored responses in the context of limited provincial leadership. Opacity in provincial decision-making processes, jurisdictional ambiguity impacting Indigenous communities, and ineffectual public health investments were impediments across jurisdictions and thus appear to be less impacted by centralization and integration. Our study generates novel insights about potential structural facilitators and impediments of effective COVID-19 pandemic responses during the second year of the pandemic. Findings highlight key areas for future research to inform system design that support leaders to manage large-scale public health emergencies.

"We cobble together a storyline of system performance using a diversity of things": a qualitative study of perspectives on public health performance measurement in Canada.

BACKGROUND: There have been longstanding calls for public health systems transformations in many countries, including Canada. Core to these calls has been strengthening performance measurement. While advancements have been made in performance measurement for certain sectors of the health care system (primarily focused on acute and primary health care), effective use of indicators for measuring public health systems performance are lacking. This study describes the current state, anticipated challenges, and future directions in the development and implementation of a public health performance measurement system for Canada. METHODS: We conducted a qualitative study using semi-structured interviews with public health leaders (n = 9) between July and August 2021. Public health leaders included researchers, government staff, and former medical officers of health who were purposively selected due to their expertise and experience with performance measurement with relevance to public health systems in Canada. Thematic analysis included both a deductive approach for themes consistent with the conceptual framework and an inductive approach to allow new themes to emerge from the data. RESULTS: Conceptual, methodological, contextual, and infrastructure challenges were highlighted by participants in designing a performance measurement system for public health. Specifically, six major themes evolved that encompass 1) the mission and purpose of public health systems, including challenges inherent in measuring the functions and services of public health; 2) the macro context, including the impacts of chronic underinvestment and one-time funding injections on the ability to sustain a measurement system; 3) the organizational structure/governance of public health systems including multiple forms across Canada and underdevelopment of information technology systems; 4) accountability approaches to performance measurement and management; and 5) timing and unobservability in public health indicators. These challenges require dedicated investment, strong leadership, and political will from the federal and provincial/territorial governments. CONCLUSION: Unprecedented attention on public health due to the coronavirus disease 2019 pandemic has highlighted opportunities for system improvements, such as addressing the lack of a performance measurement system. This study provides actionable knowledge on conceptual, methodological, contextual, and infrastructure challenges needed to design and build a pan-Canadian performance measurement system for public health.

Partner notification by family physicians for sexually transmitted infections: Facilitators and barriers.

OBJECTIVE: To explore Canadian FPs' experiences with, perceived barriers to, and perceived facilitators of FP-initiated partner notification (PN) for HIV and other sexually transmitted infections (STIs), as well as to inform the development of tools that might enhance this work. DESIGN: Online survey. SETTING: British Columbia. PARTICIPANTS: A total of 146 FPs recruited through the Divisions of Family Practice community-based networks of FPs throughout the province. MAIN OUTCOME MEASURES: Family physicians' current STI and PN practices, opinions regarding FP-initiated PN, perceived barriers to and facilitators of FP-initiated PN, and preferred PN resources. RESULTS: More than 90% of FPs had diagnosed an STI within the past year, and most (60.3% to 96.6%, depending on the STI) told patients to inform their partners. Two-thirds (66.4%) felt that PN should not be done by FPs, and fewer than 10% reported contacting partners. Reported barriers included inaccurate or incomplete lists of partners (67.1%), poor compensation (54.1%), and insufficient time (54.1%). Facilitators chosen by respondents included another health professional assigned to follow up with PN (77.4%) and improved remuneration (74.7%). Electronic PN tools directed at patients (eg, PN slips) were favoured over resources directed at providers. CONCLUSION: Family physicians regularly manage STIs and currently take part in PN primarily through educating index cases. However, most do not feel that PN should be conducted by FPs, and most believe that FP-initiated PN would require additional personnel, remuneration, and legal guidance.

Lessons from management of syphilis in Nunavut, Canada, 2012-2020.

Background: Nunavut, part of Inuit Nunangat, is a geographically vast territory in northern Canada, with a population of over 38,000 people. Most (85%) of the population identify as Inuit. Nunavut has experienced a significant rise in heterosexual infectious syphilis cases since 2012. Management of communicable diseases, including syphilis, is challenging due to high staff turnover and long delays in specimen transport times. Social determinants of health are also an important contributor. The aim of this study is to describe the epidemiology and program elements for infectious syphilis from 2012-2020 and to highlight beneficial interventions. Methods: Syphilis is a notifiable disease in Nunavut with all cases reported to the Territorial Department of Health. Cases were staged by a medical consultant. Data were analyzed and released in public reports as part of the public health program. Results: From 2012 to 2020, 655 infectious syphilis cases were reported, with 53% of reported cases among females. Infection rates were highest in 20 to 39-year-olds. There was significant variability in reported cases over this time period by geographic region, with the majority of infectious cases reported from the Kivalliq region. Despite 48 reported cases in pregnancy, no confirmed congenital syphilis cases were identified. Program staff identified strengths of the response as well as ongoing needs, such as plain language resources available in multiple languages. Conclusion: Despite the logistical challenges with syphilis management in the territory, the overall outcomes have been positive, with no confirmed congenital cases identified. We attribute this to a coordinated effort by multiple partners including key actions by public health nurses and community health representatives.

Molecular Characterization and Antimicrobial Resistance in Neisseria gonorrhoeae, Nunavut Region of Inuit Nunangat, Canada, 2018-2019.

We assessed antimicrobial resistance (AMR) in Neisseria gonorrhoeae in Nunavut, Canada, using remnant gonorrhea nucleic acid amplification test-positive urine specimens. This study confirms the feasibility of conducting N. gonorrhoeae AMR surveillance and highlights the diversity of gonococcal sequence types and geographic variation of AMR patterns in the territory.

Facilitators and Barriers to Expedited Partner Therapy: Results From a Survey of Family Physicians.

BACKGROUND: Expedited partner therapy (EPT) can prevent transmission of sexually transmitted infections (STIs) and reinfection of the index patient. We surveyed family physicians (FPs) in British Columbia to understand their perceptions of barriers and facilitators to EPT use and explored how perceptions varied by demographic and practice characteristics. METHODS: Survey participants were recruited through the Divisions of Family Practice, which include greater than 90% of FPs in British Columbia. Common barriers and facilitators for EPT were identified using descriptive statistics. The association between each EPT barrier and facilitator and demographic and practice characteristics were tested using χ test. RESULTS: One hundred eighty-one FPs started the survey, of which 146 (80.7%) answered 10 questions or more and were analyzed. Overall, inaccurate information about sex partners (88 [60.3%] of 146) and medicolegal concerns (87 [59.6%] of 146) were the most common barriers reported. Family physicians in nonurban settings were more likely to identify insufficient time as a barrier compared with FPs in urban settings (P < 0.01). The most common facilitators were having a health care professional for follow-up after prescribing EPT (110 [75.3%] of 146), improved remuneration (93 [63.7%] of 146), clear clinical guidelines around EPT (87/146, 59.6%), and having a legal framework (92 [63.0%] of 146). Family physicians practicing for less than 9 years (the median) were more likely to identify the latter as facilitating EPT compared with FPs practicing for 9 years or longer (P < 0.05). CONCLUSIONS: Ensuring patients have access to a health care professional for follow-up, improved remuneration, and development of clinical guidelines and a legal framework can support the implementation of EPT. Tools catered to different practice types and contexts may help increase EPT use.

Building managed primary care practice networks to deliver better clinical care: a qualitative semi-structured interview study.

BACKGROUND: Primary care practices are increasingly working in larger groups. In 2009, all 36 primary care practices in the London borough of Tower Hamlets were grouped geographically into eight managed practice networks to improve the quality of care they delivered. Quantitative evaluation has shown improved clinical outcomes. AIM: To provide insight into the process of network implementation, including the aims, facilitating factors, and barriers, from both the clinical and managerial perspectives. DESIGN AND SETTING: A qualitative study of network implementation in the London borough of Tower Hamlets, which serves a socially disadvantaged and ethnically diverse population. METHOD: Nineteen semi-structured interviews were carried out with doctors, nurses, and managers, and were informed by existing literature on integrated care and GP networks. Interviews were recorded and transcribed, and thematic analysis used to analyse emerging themes. RESULTS: Interviewees agreed that networks improved clinical care and reduced variation in practice performance. Network implementation was facilitated by the balance struck between 'a given structure' and network autonomy to adopt local solutions. Improved use of data, including patient recall and peer performance indicators, were viewed as critical key factors. Targeted investment provided the necessary resources to achieve this. Barriers to implementing networks included differences in practice culture, a reluctance to share data, and increased workload. CONCLUSION: Commissioners and providers were positive about the implementation of GP networks as a way to improve the quality of clinical care in Tower Hamlets. The issues that arose may be of relevance to other areas implementing similar quality improvement programmes at scale.