Volume 58, Supplement 1, 1998
of the American Association
of Public Health Dentistry
114 Journal of Public Health Dentistry
The Development of Competencies for Specialists in Dental Public Health
Jane A. Weintraub, DDS, MPH
This paper describes the process of developing new competency statements and performance indicators for the specialty of dental public health. These competencies help define the specialty and provide a base for educational curricula and the specialty board examination. The process included a survey of four target groups: all board members, all directors or co-directors of advanced education programs in dental public health, people who had become diplomates in the last three years, and all students currently enrolled in dental public health programs. Many constituencies were represented at the workshop, conducted in May 1997, to develop the competency document. After the workshop, the document underwent a series of review activities. [J Public Health Dent 1998; 58 (Suppl 1):114-18]
Key Words: dental public health, dental education, dental specialty, curriculum, competency-based education.
Rationale for Developing New and Revised Competencies
At the 1997 annual meeting of the American Association of Public Health Dentistry (AAPHD), participants celebrated the organization's 60th birthday. Many goals and missions of the specialty of dental public health have remained the same during these 60 years; however, disease patterns, health care delivery systems and resources change, and the advancement of science and technology continues. The desire of our specialty to keep pace with these changes and advances also continues. In 1974 the first set of "behavioral objectives" for the specialty of dental public health was developed at a workshop in Boone, NC (1). These objectives helped define our specialty and provided a base for educational curricula and the specialty board examination. These objectives served well for 14 years. In 1988, these objectives were revised at a workshop in Bethesda, MD, and became "competency objectives" (2). As intended, they helped guide the practice of dental public health in the
1990s. In 1996, the impetus for revising the competency objectives came from several sources. The American Board of Dental Public Health (ABDPH) listed the following reasons in its recommendation to the American Association of Public Health Dentistry to initiate this process:
1. The last revision of the competency objectives was completed in 1988 and the board perceived the objectives to be out of date.
2. The proliferation of knowledge is placing an increasing burden on our educational programs. It is becoming more difficult for programs to provide, and for students to gain, sufficient expertise in all of the existing 165 objectives, as well as in new and emerging areas.
3. Educational programs have changed, so there are differences between programs that primarily educate researchers and those that educate public health practitioners.
4. The accreditation standards were last substantially revised in 1985, with minor revisions in 1988. The US Department of Education, one of the accrediting bodies for the American Dental Association's (ADA) Commission on Dental Accreditation, has new requirements. The ADA has requested all specialties to revise their standards to come into compliance. Although the standards used for accreditation are contained in a document separate from the competency objectives, it is appropriate for the curriculum section of the standards to reflect what the profession recommends as its core set of competencies.
The ADA does not require the specialties to have a set of competency objectives. Dental public health has taken a leadership role in this activity. It is the only dental specialty with this type of document. As Mecklenburg described in his keynote address at the 1988 workshop, the document was particularly useful in the mid-1980s when preparing the application to the ADA for the re-recognition of dental public health as a specialty (3).
Dr. Weintraub is project director and Lee Hysan Professor of Oral Epidemiology and Dental Public Health, University of California at San Francisco, School of Dentistry, Department of Dental Public Health and Hygiene, 707 Parnassus Avenue, PO Box 0754, San Francisco, CA 941430754. E-mail: email@example.com. Planning Committee: Drs. Eric Bothwell, Brian Burt, Joseph Doherty, Judith Jones, Jayanth Kumar, Reginald Louie, Linda Niessen, Gary Rozier, and Steven Silverstein. Reprints will be available from the AAPHD National Office. This project was supported by the US Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, and the AAPHD.
Vol. 58, Suppl. 1, 1998
In the spring of 1996, Dr. Robert (Skip) Collins, president of the AAPHD, asked me to direct this process. I did so with assistance from colleagues and staff at the University of California, San Francisco School of Dentistry (UCSF), the AAPHD national office, and an AAPHD planning committee. In addition to AAPHD's own financial contributions, the AAPHD was awarded a $50,000 procurement from US Health Resources and Services Administration, Bureau of Health Professions. Government Project Officer Dr. Kathy Hayes provided invaluable assistance throughout this process. This report will describe the process of developing these new competency statements.
The government contract required that at least four members of the planning committee be board certified as specialists in dental public health. A planning committee was appointed in consultation with the government project officer. The planning committee consisted of Drs. Eric Bothwell, Brian Burt, Joseph Doherty, Judith Jones, Jayanth Kumar, Reginald Louie, Linda Niessen, Gary Rozier, and Steven Silverstein. Dr. Collins also took an active role in this process. An electronic mail list for our group was established at the University of Michigan by Dr. Burt to facilitate communication. Dr. Bothwell served as the liaison to the Public Health Functions Steering Committee and Working Group Subcommittee on Workforce, Training, and Education Competency based Curriculum Group, which was meeting monthly in the Washington, DC, area.
During the 1996 AAPHD annual meeting in Orlando, several meetings were conducted to discuss the development of this process. I met with the planning committee, with the residency directors, and with anyone who wanted to attend a round table discussion on this topic. These meetings helped clarify needed preworkshop activities. We discussed philosophical and logistical issues, and agreed that a preworkshop survey of specific targeted groups should be conducted. A subgroup of the planning committee
Seated, 1 to r: Rebecca King, Kathy Hayes (HRSA project officer), Myron Allukian, Jane Weintraub (project director), Brian Burt, Alex White. Diagonally, back to front, l to r: Stuart Lockwood, Skip Collins, James Leake, Linda Kaste, Scott Tomar, Stephen Corbin (partially hidden), Barbara Gooch, John King, Steven Levy (partially hidden), Aljernon Bolden, Robert Dumbaugh (partially hidden), Scott Navarro, David Alexander, Catherine Horan (ADA speaker, partially hidden), Jayanth Kumar (mostly hidden), Reginald Louie, Ray Kuthy, James Sutherland (mostly hidden), Gary Rozier, Chester Douglass, Jed Hand, Sena Narendran, Bruce Brehm, Ira Parker, Steven Silverstein, Barbara Gerbert, Joseph Doherty.
Project Director Jane Weintraub leads a discussion during the workshop.
met during another meeting in Atlanta and selected participants for the workshop. Selecting participants was not an easy task because our specialty is blessed with a wealth of talent. Our contract specified that certain organizations and constituencies be represented, including: dental public health educators; members of the ABDPH; practitioners of dental public health national, state, and local programs; practitioners of allied dental health fields; experts in managed care issues, dental public health residents; community representatives, particularly from settings with large numbers of vulnerable populations; and a public health practitioner(s) from a nondental field. Not all participants initially selected were able to attend. The list of participants is shown in the Appendix.
Prior to the workshop, a survey (to be described) was conducted among four target groups and homework assignments were given to workshop participants. For homework, each participant was asked to review the competency objectives in the topical area to which he or she had been assigned, and indicate which items should be kept, deleted, or revised. Respondents were also asked to list the skills currently needed by an entry-level practitioner. Responses to the homework and survey were collated in advance and distributed to the workshop group leaders. Results of the survey were presented during the first plenary session of the workshop.
Preworkshop Survey Methods
The purpose of the survey was to evaluate the current competency objectives and to assess the need for changing the objectives and related aspects of the educational and certification process. The survey instrument was pretested in part at the residency directors' meeting in Orlando, and in more complete form among local dental public health and UCSF colleagues. The survey instrument was e-mailed or faxed to four target groups: all board members, all directors or codirectors of advanced education programs in dental public health, people who had become diplomates in the last three years, and all students currently enrolled in dental public health programs either part time or full time. My staff assistant removed the identifiers before giving me the surveys. Two mailings were conducted. After the second mailing, the members of the planning committee were each assigned several nonrespondents to personally contact to increase the response rate.
The overall response rate was 48 of 68 (71%). Although there are only six board members, seven respondents indicated that they were board members. Thus, the response rate for this category could be considered either 100 percent or 117 percent. Surveys were sent to 23 program directors, of whom three are also board members. Of the 20 not already counted, the response rate was 65 percent. If the three
Journal of Public Health Dentistry
Group 1-Health Policy, Program Management and Administration (1 to r, first row): John King, Rebecca King, Robert Dumbaugh, Reginald Louie; second row: Bruce Brehm, Stephen Corbin. Not pictured: Rhys Jones.
Group II-Research Methods (1 to r, first row): Barbara Gooch, Linda Kaste, Barbara Gerbert, Gary Rozier; second row: Scott Tomar, Ray Kuthy, Jayanth Kumar. Not pictured: Stuart Gansky, John Stamm.
board members are included, the response rate was 74 percent. The survey was sent to 21 new diplomates, of whom five are program directors. Of the 16 not already counted, the response rate was 63 percent, but 71 percent if the program directors are included. Of the 26 current students contacted, 69 percent responded. There were 19 workshop participants who met the criteria for one or more of the target groups and were sent surveys. The response rate among this group was 100 percent. Unfortunately, people not invited to the workshop were less likely to respond.
Some of the highlights of the survey results were:
• All board members favored the current mix of general and specific competency objectives, compared with 40-46 percent of the other three target groups.
• All groups favored the current format of four topical areas, overall 79 percent.
• Only 43 percent of board members favored separating minimum core competencies from more advanced skills, compared with 70-89 percent of the other groups.
• All board members favored having the same objectives for everyone without special focus tracks, compared with 17-50 percent of the other groups.
• Program directors (92%) were
most likely to support changing the eligibility criteria for certification; students, least likely (47%).
• The responses presented in Figure 1 were culled from two questions. Responses were not prioritized. The question from the survey asked about the skills, knowledge, or abilities respondents thought will be most needed by dental public health practitioners in the future. The homework question asked respondents to list the skills needed by an entry-level practitioner today. Many of the skills needed are difficult to teach. Students need mentors and field experiences where they can observe appropriate role models demonstrating many of these skills and abilities.
• The program directors were asked, "How do you use the competency objectives in guiding and developing the curriculum for your residents?" My favorite response was: "They are the Bible." Examples of other responses were: "as a self-test to determine what the resident knows;' "as a diagnostic tool for developing the residency plan," and "part of curriculum development."
• The good news was that most students (89%) reported they were very likely or likely to take the board exam in the future. Only one person indicated that he or she was unlikely and one person did not answer the question.
Skills, Knowledge, or Abilities Most Needed by Dental Public Health Practitioners
Knowledge of clinical dentistry and public health
Leadership abilities Communication skills, both oral and written
Ability to work effectively with a multidisciplinary team
Coalition and constituency building Advocacy skills
Negotiation abilities Political savvy Problem solving Computers, technology, informatics Marketing
Use of media in health promotion Research skills
Administrative skills Assessment, policy development, assurance
Delivery systems, financing mechanisms Evidence-based dentistry Grantsmanship Fundraising
Passion and integrity
Vol. 58, Suppl. 1, 1998
The workshop was conducted May 3-6, 1997, in San Mateo, CA, a community near the San Francisco airport. To lay the foundation for the meeting, several speakers addressed the participants at the first plenary session. After Dr. Skip Collins provided the welcome and introductions, I described the rationale for the workshop, the workshop planning process, results of the preworkshop survey, and presented my recommendations. Dr. Catherine Horan, manager, Advanced Specialty Education Programs for the ADA, presented background information regarding the new Department of Education requirements. These requirements provide the impetus for all specialties to revise their accreditation standards. The new standards will focus on outcomes assessment.
Dr. Bruno Petruccelli, chair, Council of Residency Directors, represented the American College of Preventive Medicine (ACPM). The ACPM has developed competency statements and performance indicators for their specialties. He described the process used by the ACPM to develop their competencies and the issues and challenges that they faced. The issues were all very relevant to dental public health and the document developed subsequently became a model for our deliberations. Dr. David Chambers, associate dean, University of the Pacific School of Dentistry, led the workshop participants through a discussion of what competencies are and how they can be evaluated, described the stages in professional growth from novice to expert, and showed us how to write competencies in a standardized format. After some lively discussion, the group agreed that we would develop competencies expected of a beginning practitioner after completing a two-year advanced education program in dental public health. The next two days were spent alternating between small work groups led by the work group chairs (Rebecca King, Gary Rozier, Brian Burt, Linda Niessen, and Alex White) and plenary sessions. Initially, the 43 participants were divided among four work groups that corresponded to the four topical areas of the 1988 competency objectives (see Appendix).
Some reconfiguring of the work groups took place, as it became evident that the final document was going to differ substantially from the list of 1988 objectives. The 1988 set lists 165 items that are primarily knowledge based and will continue to serve as a useful document, especially for program directors and residents. The new version provides a relatively short list of 10 competencies in behavioral terms that integrate skill, understanding and values and describe what a graduate of a dental public health program can (and preferably get paid to) do! The competency statements are presented in general terms with specific performance indicators to illustrate the range and depth expected in the competency.
Most of the 1988 competency objectives begin with one of the following eight verbs: describe, define, discuss, explain, identify, list, compare, or understand. The new competency statements all begin with more action-oriented verbs. The new statements place more emphasis on collaboration, advocacy, and monitoring and surveillance activities than did the prior objectives. Both documents emphasize program planning, implementation, evaluation and management, health promotion and disease prevention activities, critical evaluation of the scientific literature, and research methods. The competency development process forced the group to concentrate on the goals in the previous document listing competency objectives and to focus on stating what specialists in public health dentistry should be able to do after completing an advanced education program in dental public health. Although the product that emerged was different from what might have been anticipated given the results of the preworkshop survey, a consensus was reached by participants before the end of the workshop.
Group III-Oral Health Promotion and Disease Prevention (I to r, first row): James Leake, Maritza Cabezas, Brian Burt, Jed Hand; second row: Steven Levy, Bruno Petrucelli, David Alexander, Stuart Lockwood. Not pictured: Candace Jones.
Group IV-Oral Health Services Delivery System (I to r, first row): Steven Silverstein, Skip Collins, Alex White, Chester Douglass; second row: Aljernon Bolden, Scott Navarro, Myron Allukian, Sena Narendran, James Sutherland, Ira Parker. Not pictured: Linda Niessen.
Journal of Public Health Dentistry
The draft report was distributed in sequential phases to the planning committee, workshop participants, and key stake holders-such as residency directors-for feedback and comments. Revisions, edits, and comments were incorporated at each phase. An announcement was placed on the electronic mail dental public health list server and referred readers to the AAPHD homepage on the Internet. A final draft was presented to the AAPHD Executive Council at the 1997 annual meeting in Washington, DC. After a few minor edits, the document was approved. Additional information was provided during a round table discussion at the meeting. The document is on the AAPHD homepage. Reprints will be disseminated to key dental and public health organizations and other colleagues.
The new competency statements are a consensus of what is expected of graduates of two- year advanced education programs in dental public health. It is recognized that all students may not have the opportunity to achieve all of these competencies while in training. Consequently, these competencies are not identical to accreditation curriculum standards. Practitioners are expected to develop these skills after graduation as part of a lifelong learning process. These contemporary competency statements help us define the specialty of dental public health and will serve as a guide
to colleagues in other fields, educators, policy makers, employers, and future specialists.
1. Hughes JT. Behavioral objectives for dental public health. J Public Health Dent 1978; 38:100-7.
2. Competency objectives for dental public health. J Public Health Dent 1990; 50:33844.
3. Mecklenburg R Keynote address. Creating a future for dental public health. J Public Health Dent 1990; 50:334-7.
Appendix: Dental Public Health Competency Objectives Workshop Participants
Jane Weintraub, project director
Joseph Doherty, AAPHD National Office
Helen Doherty, AAPHD National Office
Kathy Hayes, HRSA project officer
Catherine Horan, ADA, speaker
David Chambers, University of the Pacific, speaker
Cynthia Klock, Marin County Head Start, community representative
Ricardo Salinas, UCSF staff
Group I: Health Policy, Program Management and Administration
Rebecca King, Chair
Bruce Brehm, recorder, dental public health resident
Group II: Research Methods
Gary Rozier, chair
Barbara Gooch, recorder, dental public health resident
Group III: Oral Health Promotion and Disease Prevention
Brian Burt, chair
Maritza Cabezas, recorder, dental public health resident
Bruno Petrucelli, Preventive Medicine Representative
Group IV: Oral Health Services Delivery System
Linda Niessen, co-chair Alex White, co-chair
James Sutherland, recorder, dental public health resident
Robert (Skip) Collins
Vol. 58, Suppl. 1, 1998 119
Preamble to the Competency Statements for Dental Public Health
Competency statements for dental public health, and the performance indicators by which they can be measured, were developed at a workshop in San Mateo, CA, on May 4-6, 1997. This is the third in a series of such workshops conducted by the American Association of Public Health Dentistry and the American Board of Dental Public Health, which set up the knowledge and practice base by which the specialty is recognized. The first such workshop was held at Boone, NC, in 1974 (1), and the second at Bethesda, MD, in 1988 (2). Social and technological change and the evolution of the specialty make periodic revisions essential.
Dental public health is defined by the American Board of Dental Public Health as:
... the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs, as well as the prevention and control of dental diseases on a community basis.
This population-based approach to professional practice is quite different from the approach required for individual patient care in private practice, though both forms of practice are integral parts of the dental profession. Accordingly, dental public health practice demands an additional body of knowledge and a set of skills beyond those obtained in an undergraduate dental education.
Some fundamental aspects of dental public health practice are not readily encompassed in a competency statement, and these can be considered part of the framework in which the competency statements are set. These fundamental attributes of the dental public health specialist include:
• Being a dentist. The scientific background and clinical skills to diagnose, prevent, and manage oral diseases and conditions inherent in a dental education provide the underlying foundation for advanced knowledge of dental public health.
• Demonstration of public health values, which essentially means a view of health issues as they affect a population rather than an individual, with particular emphasis on prevention, the environment in its broadest sense, and service to the community. Public health dentists usually work collaboratively as part of a multidisciplinary team of public health professionals and community representatives.
• Leadership characteristics, e.g., influencing health policies and practice through research, education, and advocacy; articulating a vision for the organization; negotiating and resolving conflicts; and preparing the next generation of public health dentists.
• Subscribing to the code of ethics set down by the American Dental Association and the American Public Health Association. [A code of ethics for the American Association of Public Health Dentistry is being developed. An interim association policy was approved at the 1997 annual meeting and is included in this issue of the JPHD, pp 123-4.1
The format for these competency statements is based on those developed by the American College of Preventive Medicine for residents in Preventive Medicine (3). As such, the competency statements are presented in general terms with accompanying specific performance indicators to illustrate the range and depth expected in the competency.
Competency means being able to function in context, and the term is used most often to describe the skills, understanding, and professional values of the beginning practitioner (4). Competency is a level reached by the person who is initially a novice, and who, after training and experience, reaches the level where he or she can
be certified as competent. It is a major landmark in professional development, but not the final point in the journey. That comes with proficiency, and the ultimate status of expert after many years of experience and professional growth. Competency in most areas of dental public health is seen as the point reached after students in advanced dental education programs complete two years of postgraduate education in the specialty requirements of dental public health. In that sense, these expectations comprise a "floor" rather than a "ceiling," a basic collection of the minimum knowledge, skills, and values needed for an entry level specialist to practice dental public health. It is understood that new practitioners may not have performed every competency at the level indicated while in training. However, it is expected that the practitioner will progress beyond the status of competency as his or her career continues, at least in certain areas.
The previous set of competency objectives (2) for dental public health specialty certification developed at the Bethesda workshop looks quite different from this current set. The previous objectives are essentially areas of knowledge that comprehensively cover just about everything that a public health dentist needs to know, but are not all "competencies" per se. By no means are they outdated, and they will continue to be used by advanced education directors as a guide for curriculum development. Many of those areas of knowledge have been incorporated into the current document.
There are two principal changes between the new competency statements and the previous set. First, the new competencies are stated in behavioral terms; they are intended to define what dental public health practitioners can do as opposed to what they know or understand. These competencies describe skills or abilities that are measurable or observable. Second, performance indicators have been added. Performance indicators are examples of the types of outcomes or categories of evidence to be collected and are used as a basis for judging competency attainment (3).
The competencies are the result of an attempt to achieve a consensus on the level of performance to be expected of all dental public health specialists at the completion of their educational program. They can help define the specialty to potential employers, to potential applicants for specialty certification, and to colleagues in the health professions. These competency statements form the basis by which the curriculum content of the "Standards for Advanced Specialty Education Programs" can be developed and applied. Specialty education programs in dental public health are accredited by the American Dental Associations Commission on Dental Accreditation in accordance with their degree of adherence to standards. The standards specify aspects of program administration, evaluation, facilities, and resources, as well as curriculum required for accreditation. The competencies are used by educational and residency program directors, faculty, and students to establish curricula, and by graduates of these programs as they prepare to take their examinations leading to specialty certification accorded by the American Board of Dental Public Health.
1. Hughes JT. Behavioral objectives for dental public health. J Public Health Dent 1978; 38:100-7.
2. Competency objectives for dental public health. J Public Health Dent 1990; 50:33844.
3. Lane DS, Ross V. Final report. Improving training of preventive medicine residents through the development and evaluation of competencies. Washington, DC: US Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, 1993, HRSA contract f192-468(P).
4. Chambers DW, Gerrow JD. Manual for developing and formatting competency statements. J Dent Educ 1994; 58:361-6.
Vol. 58, Suppl. 1, 1998
Dental Public Health Competencies
A specialist in dental public health will:
I. Plan oral health programs for populations.
Establishing goals and setting priorities.
Assessing oral health status, needs, and demands, and their determinants in a community (see Competencies VI, IX, X).
Understanding the natural history of oral diseases and conditions.
Assembling, reviewing, analyzing, and interpreting existing data, including census, vital statistics, scientific literature, oral health care/public health, and relevant legal documents (see IX).
Assessing quality of data, noting strengths and limitations (see IX).
Compiling all types of resource inventories (e.g., economic, personnel, legal, political, social).
Developing program plans (such as for prevention and service delivery, etc.).
a. Identifying problem or potential problem.
b. Setting goals, objectives, and priorities.
c. Identifying target population.
d. Assessing current system (public and private components), incl. organizational structure and its relevance to decision-making process.
e. Determining demand for program.
f. Analyzing alternative interventions (see IX).
g. Selecting best practices and interventions that take into account cultural differences (see 11, VII-6, IX).
h. Determining procedures, policies, and implementation plans.
i. Identifying and analyzing liability issues and developing risk-reduction strategies.
j. Developing budget and financing to ensure access for needed services.
k. Determining timeline.
l. Developing plans for monitoring and evaluation (see V, VI).
Collaborating with community partners and constituency building (see 11-4, 11-9, III-1, VII, VIII-4). II.
II.Select interventions and strategies for the prevention and control of oral diseases and promotion of oral health
This competency reflects:
1. Using a comprehensive knowledge of the efficacy, effectiveness, and efficiency of the various interventions to select interventions and strategies to prevent and control oral diseases. Balancing costs and possible risks against benefits of potential interventions (see V, IX).
2. Understanding national, state, local health objectives.
3. Integrating knowledge of health determinants when selecting interventions.
4. Identifying the role of cultural, social, and behavioral factors, practices, and issues in determining disease initiation and progression, disease prevention, health promoting behavior, and oral health service organization and delivery.
5. Advocating for oral health policies (see VIII).
6. Providing information on maintaining and improving oral health at the community and individual level (see VII).
7. Communicating with groups and individuals on oral health issues (see VII).
8. Serving as a resource for professional and community groups concerning evidence for the effectiveness of preventive and treatment interventions and the rationale for their use (see VII).
9. Collaborating with other health professionals, agencies, and private groups in disease prevention and health promotion activities. Examples include tobacco cessation, community water fluoridation, and early childhood caries prevention programs (see 1-5,114, III-1, VII, VIII4).