Improving Conceptual Understanding of Veterinary Public Health Among Veterinary, Medical and Public Health Professionals

1. + Improving Conceptual Understanding of Veterinary Public Health Among Veterinary, Medical and Public Health Professionals Joann M. Lindenmayer, DVM, MPH Tufts Cummings School of Veterinary Medicine

2. Background • Public Health School (1988): veterinarians not considered members of the public health system • Epidemiology defined as the study of disease patterns in human populations • Courses on Environmental Health did not mention animals • Depending upon the year, few to no veterinary medical doctors in the class • Career services advice: “Go back to clinical practice.”

3. Background (continued) • 1988 to present: Increasing awareness of a role for veterinarians in the public health system • 1980s through today: Emerging and reemerging infectious diseases • 75% are zoonotic • September 11, 2000 and bioterrorist threats • Recurrent food security crises in subSaharan Africa • 2006: Hurricane Katrina and disaster and emergency preparedness and response • Increasing interest in the welfare of food animals

4. Background (continued) • But veterinarians are still missing from public health • practice • CDC: 88 veterinarians/~8500 member workforce (2006) • FDA: 47 veterinarians/~10,500 member workforce (2003) • World Bank: 2 veterinarians in the institution (2006) • FAO: 15 veterinarians in the institution (2006) • Not every state has a public health veterinarian • research • NIH: 69 veterinarians/~17,500 workforce (2003) • Of 44,000 grants awarded in 2003, 440 were awarded to veterinarian principal investigators • 22,000 of these grants involved animals • education • Veterinarians largely missing from faculty in schools and programs in public health and medicine • Curriculum in schools of medicine and public health rarely includes content related to animals and animal populations

5. The View from Veterinary Medicine • Hendrix CM, McClelland DL, and I Thompson. A punch list for changing veterinary medicine’s public image in the 21st century. JAVMA 2006; 228:506-510 • “Of approximately 1,400 conference attendees at the unveiling of Healthy People 2010 in Washington, DC, in January 2000, only six were veterinarians…One was a bona fide attendee.” • “Nevertheless, other health care professionals challenged those veterinarians in attendance with the question, “What are you [veterinarians] doing here?” and with the statement, “I thought veterinarians treated animals. I didn’t know they really had a role in public health.”

6. The View from Medicine • Kahn L. Confronting Zoonoses, Linking Human and Veterinary Medicine. EID 2006;12:556-561. • “In the clinical setting, input from both professions [medical and veterinary communities] would improve assessments of the risk-benefit ratios of pet ownership, particularly for pet owners who are immunocompromised.” • “In public health, human and animal disease surveillance systems are important in tracking and controlling zoonoses such as avian influenza virus.” • “Physician and veterinarians comparative medicine research teams should be promoted and encouraged to study zoonotic agent-host interactions.”

7. Where Do We Begin? • Public Health Practice • CDC: National Center for Zoonotic, Vector-Borne and Enteric Diseases (NCVBED) • Public Health Research • British Medical Journal 2005, volume 331 • Roth et al: Human health benefits from livestock vaccination for brucellosis: a case study • Mort et al: Psychosocial effects of the 2001 UK foot and mouth disease epidemic in a rural population: qualitative diary based study • Schelling et al: Synergy between public health and veterinary services to deliver human and animal health interventions in rural low income settings • NIH Roadmap’s interdisciplinary teams • Public Health Education • Schools and Programs in Public Health • Veterinary Medical Schools • Medical Schools?

8. The Beginning: Public Health Education • Tufts University School of Medicine – School of Veterinary Medicine Combined DVM-MPH Program • First DVM-MPH Program in the US • Administered by the Public Health and Family Medicine Program, Tufts University School of Medicine • 14/320 veterinary students currently enrolled (~5% of each class) • Challenge: encourage a shared approach to population health that includes medical and veterinary medical students alike • Cummings School of Veterinary Medicine DVM curriculum • Veterinary Public Health core course • ~300 students • Most will graduate into small animal medicine and surgery practice • Challenge: Integrate public health with veterinary medical practice at the local (community) level

9. What is Veterinary Public Health? • Veterinary Public Health is “the sum of all contributions to the complete physical, mental and social well-being of humans through an understanding and application of veterinary science.” World Health Organization • Does this definition give enough emphasis to the interdependence of the health of human and animal populations?

10. Interesting Themes for Veterinary Public Health at the Local Level • Ten Essential Public Health Services: a framework for improving the practice of public health • Based on a broad, inclusive view of the public health system • Sets targets and benchmarks at the national, state and local level • American College of Veterinary Preventive Medicine Model Curriculum (Fogelman)

11. Monitor health status Diagnose and investigate Inform, educate and empower Mobilize community partnerships Develop policies and plans Enforce laws and regulations Link to personal health services Assure competent workforce Evaluate health services Research for new insights Ten Essential Public Health Services

12. American College of Veterinary Preventive Medicine Model Curriculum • Food Safety • Environmental Health • Zoonoses • Foreign Animal Diseases • Epidemiology and Biostatistics • Community Health

13. What Do Public Health, Medical and Veterinary Medical Professionals Understand about Veterinary Public Health? Concept Mapping Tools

14. Background: Concept Maps • Graphical tools for organizing and representing knowledge • Alternative to structured questionnaires • Novak JD and Musonda D. A twelve year longitudinal study of science concept learning. American Educational Research Journal 1991; 28:117-153. • Follow and understand changes in children’s knowledge of science • Based on learning psychology of Ausubel and colleagues (Ausubel DP et al.[1978] Educational psychology: a cognitive view (2nd ed.). New York: Holt, Rinehart and Winston • Learning takes place by the assimilation of new concepts and propositions into existing concept and propositional frameworks held by the learner

15. Concept Maps: Elements • Concepts: perceived regularity in events or objects, or records of events or objects, designated by a label • Connecting lines: link two concepts • Linking words/phrases: specify the relationship between two concepts • Propositions: two or more concepts connected using linking words or phrases to form a meaningful statement

16. Concept Map: An Example Animal Health Depends on Human Health

17. Concept Maps: Features • Hierarchical • Constructed with reference to a focus question • Provides context for the particular knowledge domain • Cross links: creative links between knowledge domains • Specific examples of events or objects

18. Concept Maps: Applications • Represent expert knowledge • Identify learner misconceptions • Evaluate the learning process • Curriculum development • Learning tool • Conflict resolution • Articulate knowledge needed to solve problems • Represent baseline level of understanding of a topic • Program development

19. Background: VUE • Visual Understanding Environment • Development supported by Andrew Mellon Foundation grant to Tufts University Instructional Technology (UIT) Academic Technology (AT) Group • University-wide resource that provides consultations, collaborative partnerships and faculty development focusing on the use of instructional technology to support teaching and research initiatives • Connects concept maps and the ideas they represent to digital resources • Concept maps become content maps

20. Purpose • Use VUE to assess understanding of 4 stakeholder groups for their understanding of Veterinary Public Health • Medical school faculty • Veterinary Medical school faculty • Public health practitioners • The Public

21. Materials and Methods • Approved by T-NEMC Institutional Review Board • Pilot tested • Recruitment among members of 4 stakeholder groups: medical school faculty, veterinary medical school faculty, public health practitioners, public • Convenience sample of 5 participants in each group • Still recruiting members of the public

22. Materials and Methods • Study elements • Preinterview questionnaire about professional and personal (i.e., as animal owner) experience with veterinarians from TCSVM and elsewhere • Concept mapping session • “What are the first four words, concepts or ideas that come you mind when you hear the words ‘Veterinary Public Health?’” • Each session audio-taped to validate concept maps • “During the course of this session, has your thinking about Veterinary Public Health changed and if it has, how has it changed?”

23. Materials and Methods: Analysis • Nodes and relationships standardized by language • Nodes and relationships categorized • by topic • by essential public health service

24. Results

25. Frequency of Primary Node Topics, by Categories (n=60)

26. Unique Primary Node Topics • Social/psychological support • insufficient veterinary-medical interface • animal emergency response • Variety • Knowledge • public policy • Service • environment, climate, agents • pet ownership • disease management • Risks • Surveillance • investigation

27. Comments • Veterinary medical professionals always mentioned human and animal health together; public health and medical professionals always spoke of them separately • Only veterinarians mentioned research • Medical professionals did not mention prevention or education

28. Frequency of Essential Public Health Services, by Primary Node Categories • EPHS #3 (inform, educate) mentioned 4 times • EPHS #10 (research) mentioned 3 times • Only by veterinarians • EPHS #2 (diagnose, investigate) mentioned twice • EPHS #1 (monitor), #4 (mobilize community partnerships) and #5 (develop policies and plans) mentioned once • No other EPHS were mentioned

29. Frequency of EPHS Mentioned in Primary Nodes, by Stakeholder Group

30. Frequency of EPHS Mentioned in Secondary and Tertiary Nodes • Inform, educate (#3): 47 times • Develop policies and programs (#5): 35 times • Research (#10): 24 times • Diagnose and investigate (#2): 23 times • Monitor (#1): 13 times • Link to services (#7): 11 times • Mobilize (#4) and Evaluate (#9): once each • Not mentioned: #6 (regulate) and #8 (assure competent work force)

31. Frequency of EPHS Mentioned in 20, 30 Nodes, by Stakeholder Group

32. Comments • Public health professionals and veterinarians mentioned EPHS #3 (Diagnose and Investigate) and #3 (Inform and educate) far more than did physicians • Veterinarians mentioned linking to services far more than did any other group • Physicians and veterinarians mentioned research often, public health professionals not at all • Only veterinarians mentioned the word ‘anthropozoonosis’

33. Features of Individual Responses by Respondent Specialty: Public Health • Chronic disease epidemiologist (aging)/RD: social and psychological support, care of animals in agricultural systems, lack of veterinary medical-human medical integration • Laboratory director: zoonoses • Local public health practitioner: emergency response, bioterrorism, rodent and insect control, community relations • ID epidemiologist: surveillance, case definitions, need for better laboratory support, education of veterinarians for public health diseases • Chief epidemiologist: education of veterinarians in public health issues, team approach to outbreak investigations

34. Features of Individual Responses by Respondent Specialty: Medical School • Nephrologist: people’s behavior and society, how affected by perception of risk from animals and vice versa • Senior administrator: policy, virtual laboratories for research • ER physician with global experience: environment, climate, vectors, population shifts • Nutritionist: animals as commodities, people’s ethical responsibility for humane care • Cancer researcher: diseases, epidemiology, research, prevention strategies

35. Features of Individual Responses by Respondent Specialty: Veterinarians • Geneticist: genomic research and application of knowledge to diseases of potential public health importance, disconnect between basic and clinical research • Laboratory animal veterinarian: food supply, lab animals and their impact on development of treatments for people, responsible pet ownership • Hematologist, FIV researcher, practitioner: monitoring and protecting population health • Nephrologist: immune-suppressed clients, physicians’ lack of understanding of zoonotic diseases, especially international ones • Nutritionist: risk assessment and reduction in animal and human populations, animal role in chronic disease prevention, safe food handling for animals and humans

36. What is Veterinary Public Health? • There is little common understanding of Veterinary Public Health beyond ‘diseases’ • People define VPH by their specialty topics • Current definitions are not helpful • “I had never heard those two words put together in the same sentence.” • There is a need for a more coherent, better conceptual understanding of VPH • Combine the Ten Essential Public Health Services and the ACVPM Model Curriculum on Community Health

37. Next Steps • Complete the present project • Conceptual mapping sessions with members of the public • Additional analyses using other features of VUE • MergeMap • Use this to develop a strategic plan for Veterinary Public Health at Tufts University

38. "What has the study of biology taught you about the Creator, Dr. Haldane?"“If one could conclude as to the nature of the Creator from a study of his creation it would appear that God has a special fondness for stars and beetles.” J.B.S. Haldane, British geneticist and writer (1892-1964)