The Constructing of Field Epidemiologists in the Periphery of Communities of Practice: A Qualitative Investigation into Learning in Field Epidemiology Training Programs

Abstract

Field epidemiology addresses urgent health problems to quickly inform prevention and control interventions. Field epidemiologists use epidemiological tools to conduct surveillance and investigate outbreaks of disease to provide decision-makers with information to control and prevent diseases. For 75 years, field epidemiology training programs (FETPs) have been the primary training mechanism, with 100 programs operating globally today. Typically, FETPs feature a month-long course and one to two years of service-based, hands-on learning to build competence in public health surveillance and outbreak detection and investigation. Though studies often evaluate FETP outputs and outcomes, research into learning processes is limited. This thesis addresses that gap, exploring how learning occurs within FETPs through three questions: 1) What were the learning approaches in the foundational FETP? 2) What are the learning approaches in contemporary FETPs? 3) Where do principles and practices misalign in FETPs? To address the first question, a case study of the foundational FETP (the US Epidemic Intelligence Service) used inductive content analysis of published documents. It showed alignment with Knowles's andragogical principles, Kolb's experiential learning cycle, and Lave's and Wenger's legitimate peripheral participation in communities of practice, revealing a constructivist, humanist, and situated learning approach. For the second question, I co-designed a qualitative study with four contemporary FETPs: Australia, Japan, Mongolia, Taiwan. Data collection included participant observation and 47 in-depth interviews with six advisors and 19 trainees. Analysis followed Charmaz's grounded theory and Polkinghorne's narrative inquiry, synthesizing narratives into program-specific case stories and reviewing these for verisimilitude with each program's coresearcher. Cross-program comparisons revealed a common learning process in which trainees engaged the data, knowledge, people, and systems of public health contexts to revise or reinforce knowledge. Enabling factors included learning environments, trainee tenacity, and advisor stewardship. Routine work placements were the most robust learning environment, while courses contributed the least. Further analysis of advisor stewardship yielded three components: assigning trainee roles and responsibilities, "laying the groundwork" for trainee activities, and adaptive engagement. Modes of engagement comprised a six-scale spectrum ranging from hands-off to hands-on. Advisors aimed for gradual shifts toward hands-off modes, but they adapted to the culture, trainee characteristics and learning needs, task urgency and complexity, and advisor-to trainee ratios. These findings revealed misalignments between the global focus on curriculum design and the reality of learning through practice, as well as between advisors' desired and actual modes of engagement. This thesis provides contemporary evidence of FETP learning processes across diverse contexts, offering insights to inform evaluation and improve practice. It expands Lave and Wenger's legitimate peripheral participation in communities of practise by illustrating how FETP advisors balance legitimacy and peripherality to construct trainee competence while minimising public health risks. By illuminating the learning process in FETPs, this thesis addresses a critical gap in the literature, points to implementation pathways for building field epidemiology capacity, and advances the application of communities of practice theory in contemporary, globally relevant contexts. Its findings emphasize the importance of learning in context, learning environments, advisor stewardship, and trainee tenacity. It introduces a spectrum of adaptive modes of advisor engagement with trainees. Lastly, it presents concrete recommendations to enhance trainee learning based on the findings and identifies further directions for research to inform FETP practice and policy.