Public health education at China’s higher education institutions: a time-series analysis from 1998 to 2012

Public health education at China’s higher education institutions: a time-series analysis from... Background: Although China’s modern education for public health was developing over the past 60 years, there is a lack of authoritative statistics and analyses on the nation’s development of education for public health at higher education institutions (HEIs). Few quantitative studies on this topic have been published in domestic and international peer-reviewed journals. To address this knowledge gap, we aimed to use national data to quantitatively analyse the scale, structure, and changes of public health education in China’s HEIs, and to compare the changes of public health education with those of other health science disciplines. Methods: This study uses previously unreleased national data provided by the Ministry of Education of China that includes the number of health professional students by school and major. The data, which spans from 1998 to 2012, are descriptively analyzed. Results: The number of HEIs for public health education per 100 million population increased from 7.2 in 1998 to 11.3 in 2012. The total enrolment, number of students, and number of graduates increased at rates of 7.3, 7.4, and 5.8% per year, respectively. The percentage of junior college students dropped drastically from 24.0 to 8.4% from 1998 to 2012. During that same period, the number of undergraduates, master and doctorate students increased. Undergraduates accounted for the majority of public health graduates (63.1%) in 2012, and master and doctorate students increased by 10.0 and 5.1 times, respectively, from 1998 to 2012. The relative percentage of public health enrollment, students, and graduates to all health education disciplines dropped from about 6.0% percent in 1998 to around 2% in 2012. Conclusions: The overall scale of public health education has clearly expanded, though at a slower pace than many other health science disciplines in China. The increase of public health graduates helped to address the previous shortage of public health professionals. Gradually adopting a modern model of education, public health education in China has undergone notable changes that may be informative to other developing countries though it still faces a complex situation in terms of graduates’ adherence to public health, student recruitment, teaching and training, program planning and reform. Keywords: China, Public health, Education, Scale of education, Structure of education, Human resources for health * Correspondence: qmeng@bjmu.edu.cn School of Public Health & China Center for Health Development Studies, Peking University, Mailbox 505, 38 Xueyuan Road, Haidian, Beijing 100083, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hou et al. BMC Public Health (2018) 18:679 Page 2 of 8 Background The scope of education for public health has contin- Socioeconomic development and changes in lifestyle ued to evolve and expand in China. From the 1950s to behaviors lead to increasing demands for preventive 1970s, the Chinese model of public health education was medicine and public health services. As the World adopted from the former Soviet Union, placing emphasis Health Organization pointed out in its report, ‘Life in on sanitation and hygiene. During this era, many medical st the 21 century: a vision for all’,there is a shift to focus universities and colleges established departments of hygiene on preventive medicine in effort to improve and maintain or, as it was later called, preventive medicine. Public health baseline health [1]. In China, non-infectious chronic dis- education mainly consisted of five core disciplines: food eases (NCDs) have become a serious health threat, and and nutrition, environment health, labor health, radiation are recognized as a severe public health problem. National health, and school health [10, 12, 13]. Beginning in the data showed that one in five people in China have been 1980s, departments of preventative medicine began found- diagnosed with at least one chronic disease, and deaths ing schools of public health [14]. New disciplines were also caused by chronic diseases comprise an estimated 80% of established, based on western models, which included epi- total mortality [2, 3]. This chronic disease burden consti- demiology, health statistics, social medicine, and health pol- tuted 70% of total disease burden in 2005 [2, 3]. While the icy and management. In 2002 and 2003, the outbreak and incidence rates of infectious diseases dropped drastically spread of SARS not only raised people’s attention to public in recent years, infectious diseases continue to be major health and infectious diseases prevention, but also led to a threats to the health of the Chinese people [4]. The strong call for the education and training of health profes- outbreaks and onslaught of Severe Acute Respiratory sionals to tackle public health emergencies [15]. In the past Syndrome (SARS), avian flu, and HIV/AIDS provides few years, globalization and the aging population triggered evidence that the threat of infectious disease is a prevalent the establishment of some new disciplines, including global issue. Also, aside from challenges from both chronic and health and elderly health [16]. infectious diseases, China faces other public health issues Sorted by levels of education attainment, public health such as a rapid aging population, smoking, environment education programs at China’s higher education institutions pollution, obesity, and other health disorders [5–7]. In (HEIs) can be classified into four types: 3-year junior col- order to meet these challenges, competent public health lege (i.e. Da Zhuan), 4- or 5-year undergraduate/bachelor, professionals are urgently needed by the Chinese society. 3-year master, and 3-year doctorate programs. Master However, there is still a shortage of public health profes- and doctorate education belongs to graduate education, sionals in China [8, 9]. For example, the number of health of which the focus has shifted from academic education professionals for disease prevention and control is around (e.g. PhD degree programs) to professional education 14 per 100,000 people in China, which is only one-fifth of (e.g. Master of Public Health degree programs) [10]. A that of the United States [10]. The number of health profes- number of the most competitive universities also offer sionals at China’s Centers for Disease Prevention and Con- 7-year combined undergraduate-master programs, and trol (CDCs) decreased from 157,000 in 2005 to 147,000 in 5-year combined master-doctorate programs. The Master 2011 [11]. Nearly half of China’s public health professionals of Public Health (MPH) program was initialized in 2002 have graduated from secondary schools with a vocational [17]. As of 2010, there were 24 universities that were autho- degree (i.e. Zhong Zhuan), adding to concerns regarding rized to admit MPH students, with an annual enrollment of the public health professionals’ level of education [8]. about 1500. The annual enrollment of undergraduate, mas- Therefore, China’s public health education system is faced ter, and doctorate public health students were about 7000, with the task of coping with increasing demands for its 1500, and 300 to 400, respectively [18]. public health workforce. China’s public health workforce exceeds 0.8 million As the most populous country and largest producer of people [19]. Modern education for public health has health professionals in the world, China has a vast and been developing for more than 60 years in the country. complex system of health professional education [3]. Be- Nationally, China is estimated to have the largest num- cause the Chinese government adopted a prevention-first ber of public health schools in the world, totaling 72 in policy to guide its health efforts, public health has been an 2008 [20]. To the best of our knowledge, there is a lack indispensable component of health professional education of authoritative statistics and analyses on the nationwide in the country. When the People’s Republic of China was development of education for public health. Only a few founded in 1949, public health, formerly called “hygiene”, quantitative studies on this topic were published in both was one of the only four undergraduate majors for health domestic and international peer-reviewed journals. To professionals, and remained as a core major though the address this knowledge gap, we aimed to use national official list of majors was revised several times. Since data to conduct a quantitative analysis of the scale and then, public health and preventative medicine have been structure of education for public health at China’s HEIs first-level disciplines in education of health professionals. and their changes. By connecting the results of data Hou et al. BMC Public Health (2018) 18:679 Page 3 of 8 analysis with existing research and the most recent 11.3 per 100 million population between 1998 and 2012. Chinese health-professional education reform, we also The number of HEIs providing junior college programs discuss policy suggestions and implications for the re- decreased slightly, from 50 programs in 1998 to 49 pro- form of public health education in China and other de- grams in 2012. By contrast, HEIs with doctorate-level veloping countries. public health education programs more than doubled For China’s higher education, the year 1998 was im- during the same timeframe. HEIs with either under- portant because several educational policies were im- graduate or master programs totaled 97 and 70 in 2012, plemented by the central government around this year, and both programs increased enrollment by more than which posed lasting and varied effects on education of 80% since 1998. health professionals. These policies include numeric ex- During 1998 to 2012, education for public health was pansion of enrollment, further development of private averaging an annual growth rate of 7.3% for enrollment, education institutions, and university mergers [3]. There- 7.4% for the number of students, and 5.8% for the number fore, our research question in this paper focused on: 1) of graduates. In other words, the number of public health how the overall scale and structure of public health educa- enrollment, students, and graduates increased by 2.7, 2.7, tion had changed since 1998, and 2) how public health and 2.2 times, respectively (Table 1,Fig. 2). However, when education had performed when compared with other compared to other health professional education, the rela- health science disciplines from 1998 to 2012. tive percentage of public health education decreased, indi- cating a greater increase in enrollment for other health Methods disciplines than public health. Specifically, the relative per- Data used in this study are previously unreleased national centage of public health enrollment, students, and gradu- data provided by the Ministry of Education (MOE) of ates to all health education disciplines dropped from about China, which include the numbers of health professional 6.0% percent in 1998 to around 2% in 2012 (Table 1). students by school and major. The datasets were gener- As shown in Fig. 3, public health enrollment increased ated from yearly statistical forms that each higher educa- at a rate of 7.3% per year, which was much lower than tion institution submitted to local education authorities the other health-related disciplines such as nursing and the MOE [3]. The data, spanning from 1998 to 2012, (31.9%), integrated Chinese western medicine (28.9%), were analyzed by descriptive analysis. stomatology (21.8%), and pharmacy (17.8%). Our analysis of the MOE dataset was focused on higher education institutions (HEIs) that offer education for public Structure of education health, with at least one program in the first-level discipline: The number of public health undergraduate, master, and public health and preventive medicine. These programs are doctorate students increased from 1998 to 2012, with an offered through junior college, bachelor, master, or doctor- average growth rate of 8.0, 16.2, and 15.9%, respectively. ate degrees. Meanwhile, the percentage of junior college students China’s HEIs can be grouped into two types: regular decreased from 24.0 to 8.4%. Undergraduate students HEIs and HEIs for adults. Typically, the former admits consistently outnumbered the other types of students, high-school graduates as full-time students by the national accounting for about 70% of public health students in college entrance examination, while the latter provides these years (Table 2). adults with higher education on a part-time basis through In 1998, junior college graduates accounted for distance education or select on-campus courses. Regular nearly half (46.4%) of public health graduates and the HEIs may best represent China’s higher education of health percentage dropped to 14.4% in 2012. Undergraduate professionals because they are dominant in the educational graduates accounted for the majority of graduates system and all top HEIs are regular ones. Furthermore, a with 63.1% in 2012, while master and doctorate grad- person who wishes to study health science at HEIs for uates respectively increased by 10.0 and 5.1 times adults should be an in-service health professional or have from 1998to 2012 (Table 3). obtained a license for practice [21], making it difficult to es- timate the effects of education output on the development of health workforce. Therefore, only regular HEIs are in- Discussion cluded in our analysis. This study provides important information regarding the overall scale and changes of the public health education Results at China’s HEIs between 1998 and 2012. We found that Overall scale and its changes the number of public health education institutions, enroll- As shown in Fig. 1, the number of HEIs offering public ment, students, and graduates generally increased over the health education programs has increased from 90 to 153 years. The expansion of public health education has played institutions or from 7.2 per 100 million population to apositiveroleinaddressingthe deficit of the public health Hou et al. BMC Public Health (2018) 18:679 Page 4 of 8 Fig. 1 Number of higher education institutions that offered education for public health workforce. Indeed, the number of public health workers in But, while the overall scale of public health education China increased from 533,000 in 2005 to 667,000 in 2012 expanded, it occurred at a slower pace than many other [22]. From this study, we can also support that the decrease health science disciplines. At one of the most competi- in junior college enrollment and increased enrollment in tive universities in China, doctorate students admitted undergraduate, master, and doctoral programs directly into public health and preventive medicine programs affected the education attainment composition of pub- only increased 5.3% from 2008 to 2011, which was sub- lic health professionals. By 2012, 28.7% of public health stantially lower than the average 14.1% increase for all practitioners had a higher educational attainment beyond disciplines within the university. Also, the enrollment undergraduate level [23]. In China’s CDCs, this percentage quota at the university was considered to be insufficient grew from 15.5% in 2005 to 30.7% in 2010 [11]. for the public health and preventive medicine programs [24]. Although China plans to increase the public health workforce to 1.2 million by 2020, the country has yet Table 1 Number and relative percentage of public health to establish a national-level plan to regulate the in- education enrollment, students and graduates creased scale of public health education [22]. Several Year Enrollment Student Graduate important issues, such as the gap between supply and a a a N% N% N% demand for the public health workforce, are still wai- 1998 4854 5.9 18,739 6.2 4209 6.4 ting to be well studied. Another remaining question 1999 6221 5.3 20,808 5.9 4437 6.7 concerns how best to increase the overall scale of public health education. 2000 9138 5.7 26,237 5.8 4181 6.4 A majority of public health graduates are employed by 2001 5052 2.7 18,167 3.2 2853 4.1 CDCs, institutes of health inspection, or hospitals [25, 26]. 2002 5462 2.5 20,419 2.9 3183 3.7 Nevertheless, some scholars believed there might be an 2003 5912 2.1 21,801 2.5 3537 2.9 oversupply of public health graduates since many public 2004 7808 2.4 26,413 2.6 4530 2.7 health graduates also commonly found jobs outside the 2005 8061 2.2 28,481 2.4 4656 2.2 healthcare system [27]. The School of Public Health (SPH) of Fudan University, widely known as one of the best SPHs 2006 9158 2.2 32,518 2.4 5666 2.1 in China, reported that nearly one third of its undergradu- 2007 9572 2.4 34,972 2.4 5734 1.8 ate graduates in 2008 were employed by enterprises that 2008 11,157 2.6 39,906 2.5 6231 1.6 were unrelated to any type of health field or science [28]. 2009 11,743 2.4 43,040 2.5 7995 1.9 The most frequently cited factors for this phenomenon 2010 12,079 2.3 45,662 2.5 9058 1.9 were associated with remuneration, geographic locations, 2011 12,374 2.1 47,500 2.4 9090 1.9 and career advancement [28, 29]. According to a later study on the same school, some master and doctorate graduates 2012 13,048 2.2 50,949 2.4 9268 1.8 a also were employed by enterprises. Between 2009 and 2013, Relative percentages compared to total number of enrollees, students, and graduates for all health-related disciplines the proportion of finding a job at enterprises ranged from Hou et al. BMC Public Health (2018) 18:679 Page 5 of 8 Fig. 2 Number of public health education enrollment, students and graduates: 1998–2012 11.8 to 20.5% for master graduates and 0 to 19.4% for doc- health student were unwilling to find a job in public torate graduates [30]. health after graduation [31]. Furthermore, the education Another issue was that many students were often per- for public health students in China lags behind due to suaded or assigned to study public health. According to outdated curriculum and teaching materials [18], excessive a nationwide survey of 1197 public health undergraduate focus on teaching biomedical sciences [8], insufficient or students, those who chose to study public health as their low quality practical training in the public health sector first preference only accounted for 26.9% of the entire [6, 32]. Finally, although it is essential to equip future phy- surveyed students, which starkly contrast against the sicians with the knowledge of disease prevention and sup- preferences for students who chose to study medicine port their ability to deal with public health emergencies (75.0%). Due to a large proportion of students that were [33], insufficient attention was given to teaching public dissatisfied with their majors, these students were more health and building public health competencies in the likely to find a job that is not related to health science. medical education in China, leaving medical students with The survey also found that about one in five public poor awareness of disease prevention and creating a public health and preventive medicine 7.3 basic medicine 7.3 forensic medicine 7.9 medical techniques 9.5 clinical medicine 9.5 traditional Chinese medicine 9.8 chinese pharmacy 17.2 pharmacy 17.8 stomatology 21.8 integrated Chinese and westerm medicine 28.9 nursing 31.9 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Fig. 3 Average growth rate of enrollment: 1998–2012 Hou et al. BMC Public Health (2018) 18:679 Page 6 of 8 Table 2 Number of public health students by educational levels: 1998–2012 Year Junior college Undergraduate Master Doctorate Total 1998 4503(24.0) 13,334(71.2) 754(4.0) 148(0.8) 18,739(100.0) 1999 4676(22.5) 15,059(72.4) 891(4.3) 182(0.9) 20,808(100.0) 2000 6674(25.4) 18,165(69.2) 1158(4.4) 240(0.9) 26,237(100.0) 2001 2362(13.0) 14,357(79.0) 1147(6.3) 301(1.7) 18,167(100.0) 2002 2686(13.2) 15,900(77.9) 1485(7.3) 348(1.7) 20,419(100.0) 2003 2851(13.1) 16,684(76.5) 1827(8.4) 439(2.0) 21,801(100.0) 2004 4078(15.4) 19,584(74.1) 2209(8.4) 542(2.1) 26,413(100.0) 2005 3119(11.0) 22,000(77.2) 2687(9.4) 675(2.4) 28,481(100.0) 2006 3685(11.3) 24,879(76.5) 3181(9.8) 773(2.4) 32,518(100.0) 2007 3963(11.3) 26,432(75.6) 3735(10.7) 842(2.4) 34,972(100.0) 2008 4967(12.4) 29,652(74.3) 4319(10.8) 968(2.4) 39,906(100.0) 2009 4783(11.1) 32,419(75.3) 4885(11.3) 953(2.2) 43,040(100.0) 2010 4474(9.8) 34,698(76.0) 5406(11.8) 1084(2.4) 45,662(100.0) 2011 4111(8.7) 36,240(76.3) 6057(12.8) 1092(2.3) 47,500(100.0) 2012 4277(8.4) 39,362(77.3) 6144(12.1) 1166(2.3) 50,949(100.0) Percentage in parenthesis deficiency in training for these students on infectious dis- in highest demand, and to improve the quality of those eases and population health topics [34, 35]. graduates. A number of measures were suggested to Therefore, education for public health in China faces a strengthen the reform: establishing a balancing mechan- complex situation, with much work still be done, especially ism between the supply and demand of health profes- with the introduction of a new national health-professional sionals to optimize the scale and structure of education, education reform. In 2017, the State Council called for a prioritizing standardized education to improve the quality close correlation between the education of health profes- of graduates, and improving incentive policies for health sionals and Chinese health system’s demand for health pro- professionals. In the first health professional education fessionals. This emphasizes a major aim of the education policy issued by the General Office of the State Council reform: to increase the supply of those health professionals since the founding of the People’sRepublicofChina in Table 3 Number of public health graduates by educational levels: 1998–2012 Year Junior college Undergraduate Master Doctorate Total 1998 1954(46.4) 2024(48.1) 184(4.4) 47(1.1) 4209(100.0) 1999 1889(42.6) 2293(51.7) 218(4.9) 37(0.8) 4437(100.0) 2000 1597(38.2) 2321(55.5) 231(5.5) 32(0.8) 4181(100.0) 2001 620(21.7) 1944(68.1) 225(7.9) 64(2.2) 2853(100.0) 2002 476(15.0) 2364(74.3) 289(9.1) 54(1.7) 3183(100.0) 2003 749(21.2) 2308(65.3) 397(11.2) 83(2.3) 3537(100.0) 2004 968(21.4) 2964(65.4) 482(10.6) 116(2.6) 4530(100.0) 2005 760(16.3) 3198(68.7) 568(12.2) 130(2.8) 4656(100.0) 2006 1280(22.6) 3536(62.4) 692(12.2) 158(2.8) 5666(100.0) 2007 1037(18.1) 3618(63.1) 902(15.7) 177(3.1) 5734(100.0) 2008 1394(22.4) 3654(58.6) 1012(16.2) 171(2.7) 6231(100.0) 2009 1400(17.5) 5094(63.7) 1293(16.2) 208(2.6) 7995(100.0) 2010 1743(19.2) 5689(62.8) 1402(15.5) 224(2.5) 9058(100.0) 2011 1315(14.5) 6010(66.1) 1501(16.5) 264(2.9) 9090(100.0) 2012 1331(14.4) 5848(63.1) 1848(19.9) 241(2.6) 9268(100.0) Percentage in parenthesis Hou et al. BMC Public Health (2018) 18:679 Page 7 of 8 1949, public health professionals are listed as one of the Funding China Academy of Engineering (2013-XZ-21-3, 2014-ZD-09) and China Medical health professionals that are scarce and urgently needed Board (11–083). China Academy of Engineering and China Medical Board were by the Chinese society, indicating a need to continue not involved in design of the study and collection, analysis, and interpretation expanding the overall scale of public health education of data and in writing the manuscript. [36]. In the near future, concrete actions may be needed Availability of data and materials to accelerate the reform progress in education for public The dataset generated and analysed during the current study are not publicly health. To optimize the overall scale of education, it may available because it is the asset of the Ministry of Education of People’s Republic of China and the authors are not authorized to share it to the public. be necessary to plan and reform public health education Researchers who are interested in the dataset for academic purpose may by developing evidence-based research and policy-making. contact JH: houjianlin@bjmu.edu.cn. Meanwhile, it is also important to take measures to recruit Authors’ contribution students who are more likely to stay in public health. In QM and ZW designed the study. JH, YL, NW conducted the data analysis and addition to improving the public health curriculum, produced the first draft under the guidance of QM and ZW. LX and SS made China’s HEIs may consider providing MD (Doctor of substantial contributions to interpreting data and revising the manuscript critically. All authors participated in editing of the final manuscript, read and Medicine)- MPH (Master of Public Health) dual degree approved the final manuscript. programs. Considering the magnitude of China’s public health Ethics approval and consent to participate Not applicable. Permission was obtained from the Ministry of Education of workforce and education, the country has great potential People’s Republic of China to access the data. to serve as a role model for other developing countries in public health education and regulation. Gradually Competing interests The author(s) declare that they have no competing interests. adopting a modern model of education, public health education in China has undergone notable changes that Publisher’sNote may be informative to other developing countries. Changes Springer Nature remains neutral with regard to jurisdictional claims in includeexpanding scaletoaddress theshortageofpublic published maps and institutional affiliations. health workers, adjusting educational levels to improve Author details education attainment composition, and diversifying dis- Institute of Medical Education & National Center of Health Professions ciplines and programs to support specialized public 2 Education Development, Peking University, Beijing 100083, China. School of health professionals. With the implementation of the new Public Health, Peking University, Beijing 100083, China. China Center for Health Development Studies, Peking University, Beijing 100083, China. Office reform and its continuous efforts to improve the supply of of Education, Peking University Health Science Center, Beijing 100083, China. the public health workforce, China is capable of continu- 5 6 University of Hawaii-Mānoa, Honolulu, HI 96822-2319, USA. Jishuitan ing to contribute significantly to the international arena of Hospital, Beijing 100035, China. School of Public Health & China Center for Health Development Studies, Peking University, Mailbox 505, 38 Xueyuan public health education. Road, Haidian, Beijing 100083, China. Received: 21 February 2018 Accepted: 24 May 2018 Conclusions While the number of public health students at HEIs has been growing over the past couple of years and could References 1. World Health Organization. Life in the 21st century: a vision for all.1998. potentially begin to address China’s need for public http://www.who.int/whr/1998/media_centre/en/. Accessed 16 Jan 2018. health professionals, it is expanding at a slower pace 2. Fu H, Li Y, Peng WX, Gao JL, Qiang HH, Dai JM, et al. To curb the "blowout" when compared to other health science disciplines. Also, of chronic diseases, China should change the traditional disease-oriented thinking mode first. Fudan Univ. 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Public health education at China’s higher education institutions: a time-series analysis from 1998 to 2012

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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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Abstract

Background: Although China’s modern education for public health was developing over the past 60 years, there is a lack of authoritative statistics and analyses on the nation’s development of education for public health at higher education institutions (HEIs). Few quantitative studies on this topic have been published in domestic and international peer-reviewed journals. To address this knowledge gap, we aimed to use national data to quantitatively analyse the scale, structure, and changes of public health education in China’s HEIs, and to compare the changes of public health education with those of other health science disciplines. Methods: This study uses previously unreleased national data provided by the Ministry of Education of China that includes the number of health professional students by school and major. The data, which spans from 1998 to 2012, are descriptively analyzed. Results: The number of HEIs for public health education per 100 million population increased from 7.2 in 1998 to 11.3 in 2012. The total enrolment, number of students, and number of graduates increased at rates of 7.3, 7.4, and 5.8% per year, respectively. The percentage of junior college students dropped drastically from 24.0 to 8.4% from 1998 to 2012. During that same period, the number of undergraduates, master and doctorate students increased. Undergraduates accounted for the majority of public health graduates (63.1%) in 2012, and master and doctorate students increased by 10.0 and 5.1 times, respectively, from 1998 to 2012. The relative percentage of public health enrollment, students, and graduates to all health education disciplines dropped from about 6.0% percent in 1998 to around 2% in 2012. Conclusions: The overall scale of public health education has clearly expanded, though at a slower pace than many other health science disciplines in China. The increase of public health graduates helped to address the previous shortage of public health professionals. Gradually adopting a modern model of education, public health education in China has undergone notable changes that may be informative to other developing countries though it still faces a complex situation in terms of graduates’ adherence to public health, student recruitment, teaching and training, program planning and reform. Keywords: China, Public health, Education, Scale of education, Structure of education, Human resources for health * Correspondence: qmeng@bjmu.edu.cn School of Public Health & China Center for Health Development Studies, Peking University, Mailbox 505, 38 Xueyuan Road, Haidian, Beijing 100083, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hou et al. BMC Public Health (2018) 18:679 Page 2 of 8 Background The scope of education for public health has contin- Socioeconomic development and changes in lifestyle ued to evolve and expand in China. From the 1950s to behaviors lead to increasing demands for preventive 1970s, the Chinese model of public health education was medicine and public health services. As the World adopted from the former Soviet Union, placing emphasis Health Organization pointed out in its report, ‘Life in on sanitation and hygiene. During this era, many medical st the 21 century: a vision for all’,there is a shift to focus universities and colleges established departments of hygiene on preventive medicine in effort to improve and maintain or, as it was later called, preventive medicine. Public health baseline health [1]. In China, non-infectious chronic dis- education mainly consisted of five core disciplines: food eases (NCDs) have become a serious health threat, and and nutrition, environment health, labor health, radiation are recognized as a severe public health problem. National health, and school health [10, 12, 13]. Beginning in the data showed that one in five people in China have been 1980s, departments of preventative medicine began found- diagnosed with at least one chronic disease, and deaths ing schools of public health [14]. New disciplines were also caused by chronic diseases comprise an estimated 80% of established, based on western models, which included epi- total mortality [2, 3]. This chronic disease burden consti- demiology, health statistics, social medicine, and health pol- tuted 70% of total disease burden in 2005 [2, 3]. While the icy and management. In 2002 and 2003, the outbreak and incidence rates of infectious diseases dropped drastically spread of SARS not only raised people’s attention to public in recent years, infectious diseases continue to be major health and infectious diseases prevention, but also led to a threats to the health of the Chinese people [4]. The strong call for the education and training of health profes- outbreaks and onslaught of Severe Acute Respiratory sionals to tackle public health emergencies [15]. In the past Syndrome (SARS), avian flu, and HIV/AIDS provides few years, globalization and the aging population triggered evidence that the threat of infectious disease is a prevalent the establishment of some new disciplines, including global issue. Also, aside from challenges from both chronic and health and elderly health [16]. infectious diseases, China faces other public health issues Sorted by levels of education attainment, public health such as a rapid aging population, smoking, environment education programs at China’s higher education institutions pollution, obesity, and other health disorders [5–7]. In (HEIs) can be classified into four types: 3-year junior col- order to meet these challenges, competent public health lege (i.e. Da Zhuan), 4- or 5-year undergraduate/bachelor, professionals are urgently needed by the Chinese society. 3-year master, and 3-year doctorate programs. Master However, there is still a shortage of public health profes- and doctorate education belongs to graduate education, sionals in China [8, 9]. For example, the number of health of which the focus has shifted from academic education professionals for disease prevention and control is around (e.g. PhD degree programs) to professional education 14 per 100,000 people in China, which is only one-fifth of (e.g. Master of Public Health degree programs) [10]. A that of the United States [10]. The number of health profes- number of the most competitive universities also offer sionals at China’s Centers for Disease Prevention and Con- 7-year combined undergraduate-master programs, and trol (CDCs) decreased from 157,000 in 2005 to 147,000 in 5-year combined master-doctorate programs. The Master 2011 [11]. Nearly half of China’s public health professionals of Public Health (MPH) program was initialized in 2002 have graduated from secondary schools with a vocational [17]. As of 2010, there were 24 universities that were autho- degree (i.e. Zhong Zhuan), adding to concerns regarding rized to admit MPH students, with an annual enrollment of the public health professionals’ level of education [8]. about 1500. The annual enrollment of undergraduate, mas- Therefore, China’s public health education system is faced ter, and doctorate public health students were about 7000, with the task of coping with increasing demands for its 1500, and 300 to 400, respectively [18]. public health workforce. China’s public health workforce exceeds 0.8 million As the most populous country and largest producer of people [19]. Modern education for public health has health professionals in the world, China has a vast and been developing for more than 60 years in the country. complex system of health professional education [3]. Be- Nationally, China is estimated to have the largest num- cause the Chinese government adopted a prevention-first ber of public health schools in the world, totaling 72 in policy to guide its health efforts, public health has been an 2008 [20]. To the best of our knowledge, there is a lack indispensable component of health professional education of authoritative statistics and analyses on the nationwide in the country. When the People’s Republic of China was development of education for public health. Only a few founded in 1949, public health, formerly called “hygiene”, quantitative studies on this topic were published in both was one of the only four undergraduate majors for health domestic and international peer-reviewed journals. To professionals, and remained as a core major though the address this knowledge gap, we aimed to use national official list of majors was revised several times. Since data to conduct a quantitative analysis of the scale and then, public health and preventative medicine have been structure of education for public health at China’s HEIs first-level disciplines in education of health professionals. and their changes. By connecting the results of data Hou et al. BMC Public Health (2018) 18:679 Page 3 of 8 analysis with existing research and the most recent 11.3 per 100 million population between 1998 and 2012. Chinese health-professional education reform, we also The number of HEIs providing junior college programs discuss policy suggestions and implications for the re- decreased slightly, from 50 programs in 1998 to 49 pro- form of public health education in China and other de- grams in 2012. By contrast, HEIs with doctorate-level veloping countries. public health education programs more than doubled For China’s higher education, the year 1998 was im- during the same timeframe. HEIs with either under- portant because several educational policies were im- graduate or master programs totaled 97 and 70 in 2012, plemented by the central government around this year, and both programs increased enrollment by more than which posed lasting and varied effects on education of 80% since 1998. health professionals. These policies include numeric ex- During 1998 to 2012, education for public health was pansion of enrollment, further development of private averaging an annual growth rate of 7.3% for enrollment, education institutions, and university mergers [3]. There- 7.4% for the number of students, and 5.8% for the number fore, our research question in this paper focused on: 1) of graduates. In other words, the number of public health how the overall scale and structure of public health educa- enrollment, students, and graduates increased by 2.7, 2.7, tion had changed since 1998, and 2) how public health and 2.2 times, respectively (Table 1,Fig. 2). However, when education had performed when compared with other compared to other health professional education, the rela- health science disciplines from 1998 to 2012. tive percentage of public health education decreased, indi- cating a greater increase in enrollment for other health Methods disciplines than public health. Specifically, the relative per- Data used in this study are previously unreleased national centage of public health enrollment, students, and gradu- data provided by the Ministry of Education (MOE) of ates to all health education disciplines dropped from about China, which include the numbers of health professional 6.0% percent in 1998 to around 2% in 2012 (Table 1). students by school and major. The datasets were gener- As shown in Fig. 3, public health enrollment increased ated from yearly statistical forms that each higher educa- at a rate of 7.3% per year, which was much lower than tion institution submitted to local education authorities the other health-related disciplines such as nursing and the MOE [3]. The data, spanning from 1998 to 2012, (31.9%), integrated Chinese western medicine (28.9%), were analyzed by descriptive analysis. stomatology (21.8%), and pharmacy (17.8%). Our analysis of the MOE dataset was focused on higher education institutions (HEIs) that offer education for public Structure of education health, with at least one program in the first-level discipline: The number of public health undergraduate, master, and public health and preventive medicine. These programs are doctorate students increased from 1998 to 2012, with an offered through junior college, bachelor, master, or doctor- average growth rate of 8.0, 16.2, and 15.9%, respectively. ate degrees. Meanwhile, the percentage of junior college students China’s HEIs can be grouped into two types: regular decreased from 24.0 to 8.4%. Undergraduate students HEIs and HEIs for adults. Typically, the former admits consistently outnumbered the other types of students, high-school graduates as full-time students by the national accounting for about 70% of public health students in college entrance examination, while the latter provides these years (Table 2). adults with higher education on a part-time basis through In 1998, junior college graduates accounted for distance education or select on-campus courses. Regular nearly half (46.4%) of public health graduates and the HEIs may best represent China’s higher education of health percentage dropped to 14.4% in 2012. Undergraduate professionals because they are dominant in the educational graduates accounted for the majority of graduates system and all top HEIs are regular ones. Furthermore, a with 63.1% in 2012, while master and doctorate grad- person who wishes to study health science at HEIs for uates respectively increased by 10.0 and 5.1 times adults should be an in-service health professional or have from 1998to 2012 (Table 3). obtained a license for practice [21], making it difficult to es- timate the effects of education output on the development of health workforce. Therefore, only regular HEIs are in- Discussion cluded in our analysis. This study provides important information regarding the overall scale and changes of the public health education Results at China’s HEIs between 1998 and 2012. We found that Overall scale and its changes the number of public health education institutions, enroll- As shown in Fig. 1, the number of HEIs offering public ment, students, and graduates generally increased over the health education programs has increased from 90 to 153 years. The expansion of public health education has played institutions or from 7.2 per 100 million population to apositiveroleinaddressingthe deficit of the public health Hou et al. BMC Public Health (2018) 18:679 Page 4 of 8 Fig. 1 Number of higher education institutions that offered education for public health workforce. Indeed, the number of public health workers in But, while the overall scale of public health education China increased from 533,000 in 2005 to 667,000 in 2012 expanded, it occurred at a slower pace than many other [22]. From this study, we can also support that the decrease health science disciplines. At one of the most competi- in junior college enrollment and increased enrollment in tive universities in China, doctorate students admitted undergraduate, master, and doctoral programs directly into public health and preventive medicine programs affected the education attainment composition of pub- only increased 5.3% from 2008 to 2011, which was sub- lic health professionals. By 2012, 28.7% of public health stantially lower than the average 14.1% increase for all practitioners had a higher educational attainment beyond disciplines within the university. Also, the enrollment undergraduate level [23]. In China’s CDCs, this percentage quota at the university was considered to be insufficient grew from 15.5% in 2005 to 30.7% in 2010 [11]. for the public health and preventive medicine programs [24]. Although China plans to increase the public health workforce to 1.2 million by 2020, the country has yet Table 1 Number and relative percentage of public health to establish a national-level plan to regulate the in- education enrollment, students and graduates creased scale of public health education [22]. Several Year Enrollment Student Graduate important issues, such as the gap between supply and a a a N% N% N% demand for the public health workforce, are still wai- 1998 4854 5.9 18,739 6.2 4209 6.4 ting to be well studied. Another remaining question 1999 6221 5.3 20,808 5.9 4437 6.7 concerns how best to increase the overall scale of public health education. 2000 9138 5.7 26,237 5.8 4181 6.4 A majority of public health graduates are employed by 2001 5052 2.7 18,167 3.2 2853 4.1 CDCs, institutes of health inspection, or hospitals [25, 26]. 2002 5462 2.5 20,419 2.9 3183 3.7 Nevertheless, some scholars believed there might be an 2003 5912 2.1 21,801 2.5 3537 2.9 oversupply of public health graduates since many public 2004 7808 2.4 26,413 2.6 4530 2.7 health graduates also commonly found jobs outside the 2005 8061 2.2 28,481 2.4 4656 2.2 healthcare system [27]. The School of Public Health (SPH) of Fudan University, widely known as one of the best SPHs 2006 9158 2.2 32,518 2.4 5666 2.1 in China, reported that nearly one third of its undergradu- 2007 9572 2.4 34,972 2.4 5734 1.8 ate graduates in 2008 were employed by enterprises that 2008 11,157 2.6 39,906 2.5 6231 1.6 were unrelated to any type of health field or science [28]. 2009 11,743 2.4 43,040 2.5 7995 1.9 The most frequently cited factors for this phenomenon 2010 12,079 2.3 45,662 2.5 9058 1.9 were associated with remuneration, geographic locations, 2011 12,374 2.1 47,500 2.4 9090 1.9 and career advancement [28, 29]. According to a later study on the same school, some master and doctorate graduates 2012 13,048 2.2 50,949 2.4 9268 1.8 a also were employed by enterprises. Between 2009 and 2013, Relative percentages compared to total number of enrollees, students, and graduates for all health-related disciplines the proportion of finding a job at enterprises ranged from Hou et al. BMC Public Health (2018) 18:679 Page 5 of 8 Fig. 2 Number of public health education enrollment, students and graduates: 1998–2012 11.8 to 20.5% for master graduates and 0 to 19.4% for doc- health student were unwilling to find a job in public torate graduates [30]. health after graduation [31]. Furthermore, the education Another issue was that many students were often per- for public health students in China lags behind due to suaded or assigned to study public health. According to outdated curriculum and teaching materials [18], excessive a nationwide survey of 1197 public health undergraduate focus on teaching biomedical sciences [8], insufficient or students, those who chose to study public health as their low quality practical training in the public health sector first preference only accounted for 26.9% of the entire [6, 32]. Finally, although it is essential to equip future phy- surveyed students, which starkly contrast against the sicians with the knowledge of disease prevention and sup- preferences for students who chose to study medicine port their ability to deal with public health emergencies (75.0%). Due to a large proportion of students that were [33], insufficient attention was given to teaching public dissatisfied with their majors, these students were more health and building public health competencies in the likely to find a job that is not related to health science. medical education in China, leaving medical students with The survey also found that about one in five public poor awareness of disease prevention and creating a public health and preventive medicine 7.3 basic medicine 7.3 forensic medicine 7.9 medical techniques 9.5 clinical medicine 9.5 traditional Chinese medicine 9.8 chinese pharmacy 17.2 pharmacy 17.8 stomatology 21.8 integrated Chinese and westerm medicine 28.9 nursing 31.9 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Fig. 3 Average growth rate of enrollment: 1998–2012 Hou et al. BMC Public Health (2018) 18:679 Page 6 of 8 Table 2 Number of public health students by educational levels: 1998–2012 Year Junior college Undergraduate Master Doctorate Total 1998 4503(24.0) 13,334(71.2) 754(4.0) 148(0.8) 18,739(100.0) 1999 4676(22.5) 15,059(72.4) 891(4.3) 182(0.9) 20,808(100.0) 2000 6674(25.4) 18,165(69.2) 1158(4.4) 240(0.9) 26,237(100.0) 2001 2362(13.0) 14,357(79.0) 1147(6.3) 301(1.7) 18,167(100.0) 2002 2686(13.2) 15,900(77.9) 1485(7.3) 348(1.7) 20,419(100.0) 2003 2851(13.1) 16,684(76.5) 1827(8.4) 439(2.0) 21,801(100.0) 2004 4078(15.4) 19,584(74.1) 2209(8.4) 542(2.1) 26,413(100.0) 2005 3119(11.0) 22,000(77.2) 2687(9.4) 675(2.4) 28,481(100.0) 2006 3685(11.3) 24,879(76.5) 3181(9.8) 773(2.4) 32,518(100.0) 2007 3963(11.3) 26,432(75.6) 3735(10.7) 842(2.4) 34,972(100.0) 2008 4967(12.4) 29,652(74.3) 4319(10.8) 968(2.4) 39,906(100.0) 2009 4783(11.1) 32,419(75.3) 4885(11.3) 953(2.2) 43,040(100.0) 2010 4474(9.8) 34,698(76.0) 5406(11.8) 1084(2.4) 45,662(100.0) 2011 4111(8.7) 36,240(76.3) 6057(12.8) 1092(2.3) 47,500(100.0) 2012 4277(8.4) 39,362(77.3) 6144(12.1) 1166(2.3) 50,949(100.0) Percentage in parenthesis deficiency in training for these students on infectious dis- in highest demand, and to improve the quality of those eases and population health topics [34, 35]. graduates. A number of measures were suggested to Therefore, education for public health in China faces a strengthen the reform: establishing a balancing mechan- complex situation, with much work still be done, especially ism between the supply and demand of health profes- with the introduction of a new national health-professional sionals to optimize the scale and structure of education, education reform. In 2017, the State Council called for a prioritizing standardized education to improve the quality close correlation between the education of health profes- of graduates, and improving incentive policies for health sionals and Chinese health system’s demand for health pro- professionals. In the first health professional education fessionals. This emphasizes a major aim of the education policy issued by the General Office of the State Council reform: to increase the supply of those health professionals since the founding of the People’sRepublicofChina in Table 3 Number of public health graduates by educational levels: 1998–2012 Year Junior college Undergraduate Master Doctorate Total 1998 1954(46.4) 2024(48.1) 184(4.4) 47(1.1) 4209(100.0) 1999 1889(42.6) 2293(51.7) 218(4.9) 37(0.8) 4437(100.0) 2000 1597(38.2) 2321(55.5) 231(5.5) 32(0.8) 4181(100.0) 2001 620(21.7) 1944(68.1) 225(7.9) 64(2.2) 2853(100.0) 2002 476(15.0) 2364(74.3) 289(9.1) 54(1.7) 3183(100.0) 2003 749(21.2) 2308(65.3) 397(11.2) 83(2.3) 3537(100.0) 2004 968(21.4) 2964(65.4) 482(10.6) 116(2.6) 4530(100.0) 2005 760(16.3) 3198(68.7) 568(12.2) 130(2.8) 4656(100.0) 2006 1280(22.6) 3536(62.4) 692(12.2) 158(2.8) 5666(100.0) 2007 1037(18.1) 3618(63.1) 902(15.7) 177(3.1) 5734(100.0) 2008 1394(22.4) 3654(58.6) 1012(16.2) 171(2.7) 6231(100.0) 2009 1400(17.5) 5094(63.7) 1293(16.2) 208(2.6) 7995(100.0) 2010 1743(19.2) 5689(62.8) 1402(15.5) 224(2.5) 9058(100.0) 2011 1315(14.5) 6010(66.1) 1501(16.5) 264(2.9) 9090(100.0) 2012 1331(14.4) 5848(63.1) 1848(19.9) 241(2.6) 9268(100.0) Percentage in parenthesis Hou et al. BMC Public Health (2018) 18:679 Page 7 of 8 1949, public health professionals are listed as one of the Funding China Academy of Engineering (2013-XZ-21-3, 2014-ZD-09) and China Medical health professionals that are scarce and urgently needed Board (11–083). China Academy of Engineering and China Medical Board were by the Chinese society, indicating a need to continue not involved in design of the study and collection, analysis, and interpretation expanding the overall scale of public health education of data and in writing the manuscript. [36]. In the near future, concrete actions may be needed Availability of data and materials to accelerate the reform progress in education for public The dataset generated and analysed during the current study are not publicly health. To optimize the overall scale of education, it may available because it is the asset of the Ministry of Education of People’s Republic of China and the authors are not authorized to share it to the public. be necessary to plan and reform public health education Researchers who are interested in the dataset for academic purpose may by developing evidence-based research and policy-making. contact JH: houjianlin@bjmu.edu.cn. Meanwhile, it is also important to take measures to recruit Authors’ contribution students who are more likely to stay in public health. In QM and ZW designed the study. JH, YL, NW conducted the data analysis and addition to improving the public health curriculum, produced the first draft under the guidance of QM and ZW. LX and SS made China’s HEIs may consider providing MD (Doctor of substantial contributions to interpreting data and revising the manuscript critically. All authors participated in editing of the final manuscript, read and Medicine)- MPH (Master of Public Health) dual degree approved the final manuscript. programs. Considering the magnitude of China’s public health Ethics approval and consent to participate Not applicable. Permission was obtained from the Ministry of Education of workforce and education, the country has great potential People’s Republic of China to access the data. to serve as a role model for other developing countries in public health education and regulation. Gradually Competing interests The author(s) declare that they have no competing interests. adopting a modern model of education, public health education in China has undergone notable changes that Publisher’sNote may be informative to other developing countries. Changes Springer Nature remains neutral with regard to jurisdictional claims in includeexpanding scaletoaddress theshortageofpublic published maps and institutional affiliations. health workers, adjusting educational levels to improve Author details education attainment composition, and diversifying dis- Institute of Medical Education & National Center of Health Professions ciplines and programs to support specialized public 2 Education Development, Peking University, Beijing 100083, China. School of health professionals. With the implementation of the new Public Health, Peking University, Beijing 100083, China. China Center for Health Development Studies, Peking University, Beijing 100083, China. Office reform and its continuous efforts to improve the supply of of Education, Peking University Health Science Center, Beijing 100083, China. the public health workforce, China is capable of continu- 5 6 University of Hawaii-Mānoa, Honolulu, HI 96822-2319, USA. Jishuitan ing to contribute significantly to the international arena of Hospital, Beijing 100035, China. School of Public Health & China Center for Health Development Studies, Peking University, Mailbox 505, 38 Xueyuan public health education. Road, Haidian, Beijing 100083, China. Received: 21 February 2018 Accepted: 24 May 2018 Conclusions While the number of public health students at HEIs has been growing over the past couple of years and could References 1. World Health Organization. Life in the 21st century: a vision for all.1998. potentially begin to address China’s need for public http://www.who.int/whr/1998/media_centre/en/. Accessed 16 Jan 2018. health professionals, it is expanding at a slower pace 2. Fu H, Li Y, Peng WX, Gao JL, Qiang HH, Dai JM, et al. To curb the "blowout" when compared to other health science disciplines. Also, of chronic diseases, China should change the traditional disease-oriented thinking mode first. Fudan Univ. 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BMC Public HealthSpringer Journals

Published: May 31, 2018

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