Abstract
Environmental health departments in the Caribbean continue to contend with environmental determinants of health related to an increasingly complex array of challenges, including climatic change, disasters, pollution, bioterrorism, and global pandemics. Building the human resource capacity to meet these challenges requires access to modernized, context-relevant training, especially for environmental health inspectors who interface with the public. This study focuses on the standardized Three-Step training program delivered by education institutions across the Caribbean, which is the primary training required by ministries of health for entry into the environmental health inspectorate. A total of 22 focus groups were completed in five countries—Barbados, Guyana, Jamaica, Saint Lucia, and Trinidad and Tobago—with 94 participants drawn from the education institutions delivering training and the inspectors who have received the training. Findings suggest: program strengths in core academic content; weaknesses in faculty experts to deliver advanced subjects; opportunities for enhancing field-training experiences in collaboration with ministries; and threats to program survival due to bottlenecks in public sector hiring that reduce the attractiveness of entering the profession. Interestingly, academic trainers and practitioners differ on the importance of certain knowledge sets, such as legal and court procedural skills and epidemiological data analysis. As ministries of health in these countries contemplate ways to modernize the inspectorates, these findings can guide how ministries and education institutions work together to modernize the Three-Step training program.
Points for practitioners
Environmental health inspectors interfacing with the public are well placed to contribute perspectives to the public health modernization discourse. Formal training programs must be periodically and frequently recalibrated to societal needs and the state of the art in subject area knowledge. Strengthening the local teaching institutions’ capacity to deliver relevant educational programs will translate into better-prepared frontline professionals. Formal training lags in integrating some emergent subject areas, such as climate change and environmental health determinants.
Keywords
Introduction
The modernization of public services in the Caribbean continues to be a challenge, with slow, uneven gains over the last decade. Across the various island nations, while public management systems may exhibit certain similarities of postcolonial parallels, successes in adopting, for example, features of new public management are largely dependent on heterogeneous government structures that have evolved, the ways that government systems operate, and the state of the economy, among other factors (Bissessar, 2002). This challenge is perhaps nowhere better exhibited than in the field of public health services (Jules and Fryer, 2016).
This study is concerned with the subgoal of the United Nations Sustainable Development Goal 3 (SDG3): “substantially increase health recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States.” The focus is on environmental health, which is the assessment and management of environmental influences on human health. This entails the study of food safety and hygiene, occupational health and safety, community health, the built environment, and pollution control. The World Health Organization (WHO, 2020) currently estimates that 23% of all global deaths could be attributed to environmental issues, such as air pollution, poor sanitation, exposure to radiation, and other environment-related causes.
Three major functions for environmental health practice are assessment, policy development, and assurance (CDC, 2011). Practice requires an understanding of the connection between environment and health to know what needs to be done to prevent some of the worst impacts of environmental exposures, as well as valuing ecosystem services to human health and welfare. Serious disruptions in fundamental ecological processes (e.g. the carbon and nitrogen cycles) have implications for agriculture and ecosystem productivity and pollution of sensitive water bodies, which, in turn, impact on human health (Shah et al., 2020; Shibata et al., 2015). Whether through monitoring and tracking efforts or through research, from the standpoint of prevention, it is important to consider the proximate causes of a problem and the root environmental causes.
The United States Agency for International Development (USAID) states that “the burden of disease associated with non-communicable chronic diseases is greater than the burden of disease associated with communicable diseases or injuries in Latin America and the Caribbean; however, it receives much less attention” (Meyer and Sullivan, 2012: 14). Achieving improvements in public environmental health through change in environmental determinants depends on the capacities of public environmental health departments, which are characterized as severely under-resourced in most developing countries (Ahmed et al., 2010). Multilateral agencies and governments alike are very concerned about building environmental health human resources. Typical mechanisms for doing this involve training workshops, sanctioned degree programs, and technical assistance.
In the Caribbean, economic development and urbanization have resulted in alarming increases in air, water, and waste pollution (Eliasson, 2015). Weather extremes associated with climate change are related to increased risk of heat-related mortality and changes in ranges of vector-borne diseases, alterations in agricultural productivity, and greater uncertainty in water supplies. Prevention of noncommunicable diseases is especially challenging for developing countries because these diseases are multifactorial and because the scarcity of local data makes prevention efforts highly dependent on international practices instead of approaches rooted in local culture, lifestyles, and climate (McMichael et al., 2006). Caribbean communities are among the most climate change-vulnerable populations, susceptible to warmer temperatures, rising sea levels, rainfall changes, and more severe extreme weather events, such as hurricanes and tropical storms (Mercer at al., 2012). Growing evidence points to the increased risk from heat stress, asthma, and vector, food, and waterborne diseases. Changing climate conditions can worsen the impacts of these diseases (Anyamba et al., 2012).
Globalization of trade, travel, and commercial activity means that localized infectious disease outbreaks have the potential to spread widely in short spaces of time to multiple communities. The current COVID-19 pandemic is but the latest in a continuous string of infection events over the last two decades that include the zoonotic-originated viruses H1NI and SARS (Filleul et al., 2010). Environmental health personnel have significant roles to play in early detection, monitoring, assessments, community engagement and awareness, reporting and surveillance, and deploying prevention strategies (Watts et al., 2017). To lose this perspective and only give attention, as is so prevalent, to the medical intercept of searching for cures is ineffective (Goel, 2020; Rao et al., 2011).
The Caribbean environmental health agenda was officially championed by the Caribbean Environmental Health Institute headquartered in Saint Lucia; however, lack of regional government support led to its dissolution by the early 2010s. After this, the vacuum of public health reform was left off the policy agenda until the Caribbean Public Health Agency (CARPHA) was formed in 2013 (Jules and Fryer, 2016). Implementing environmental health prevention strategies in the Caribbean is complex (CARPHA, 2019; Dulal et al., 2009) and few involved parties are experts, being unable to make persuasive arguments to policymakers in the executive, legislative, and judicial branches of government to prioritize environmental determinants of health (Aspinall, 2014). However, more recently, there has been growing support for health professionals to be incorporated in executive decision-making processes (Watts et al., 2017).
To meet evolving environmental health challenges requires a well-trained environmental health professional workforce (Kwesigabo et al., 2012). A fundamental component of building environmental health human resource capacity is high-quality academic training. Some 15 years ago, the Three-Step Program (3-Step) was launched. It was envisioned that a standardized academic program would serve to facilitate training a cadre of Caribbean Community (CARICOM) 1 and common market nationals as environmental health inspectors (EHIs). 2 Such a program would allow for the equivalency of qualifications that would permit a free movement of CARICOM nationals intraregionally. It is now necessary to assess 3-Step’s suitability for preparing EHIs to face today’s societal needs and emerging challenges. This is a necessary first step toward modernizing and improving the regional human resource capacity and moving toward SDG3.
EHIs in Caribbean public health services
Role and responsibilities
EHIs in the Caribbean, as in many other jurisdictions, represent the front line of government’s public health regulatory interface with the general public. Typically empowered through legislation such as a Public Health Act, EHIs are among few ranks of civil servants with power of entry and other monitoring and enforcement powers with which to carry out their legal duties (Soverall, 2015). EHIs monitor health and hygiene standards and investigate environmental health problems (Zhang et al., 2018). They are responsible for monitoring and enforcing health and hygiene legislation (Maceachen et al., 2016). They also investigate incidents such as pollution, noise, toxic contamination, pest infestation, waste disposal, and food poisoning (Ning et al., 2014). They are likely to spend time in the community they serve inspecting premises, collecting evidence from incidents, and providing advice. Other responsibilities include compiling reports, delivering training, investigating complaints, serving legal notices, providing evidence in court, and liaising with other organizations (see Table 1 3 ) (Pham et al., 2010).
Opportunities for promotion through the EHI ranks include within the local and central public health sector, and sometimes in other parts of government, such as health and safety agencies, customs and excise services, and environmental agencies (Campbell et al., 2011). Table 2 provides the current estimated numbers of EHI personnel in the five Caribbean countries studied.
Trained and experienced EHIs are also being co-opted from the public service by lucrative opportunities with hotel chains, building contractors, and manufacturing interests (Raj-Reichert, 2013). There degree and non-degree career routes are outlined in Figure 1.
3-Step
3-Step was launched with the intent of providing a standardized, relevant, high-quality academic training of EHIs. It was designed and sanctioned by the Pan American Health Organization (PAHO) along with five educational institutions in the Caribbean, who were then charged with providing the academic training for EHIs across all CARICOM countries. They are the Barbados Community College in Barbados, the Arthur Lewis Community College in Saint Lucia, The College of Science, Technology and Applied Arts of Trinidad & Tobago, the University of Technology in Jamaica, and the University of Guyana. The principal objective of 3-Step is the enhancement of environmental health education and facilitating the establishment of equivalency of qualifications to support free movement of professionals, enhance the caliber of professionals, and, in turn, strengthen the capacity of environmental health departments across the region (PAHO, 2005).
Graduates of 3-Step are trained as environmental health generalists across fields of environmental health, including food hygiene, vector control, health promotion/health education, epidemiology, microbiology, communicable disease control, technical drawing, building science, health legislation, health administration, water-quality control, wastewater management, and solid waste management. In the fourth year of the program, advanced subject specializations are available and are also provided post-degree as standalone professional certificates. Figure 2 summarizes the program components.
Methodology
Data collection
Five countries were assessed: Barbados, Jamaica, Saint Lucia, Guyana, and Trinidad and Tobago. Data collection was based primarily on a focus group methodology. The main purpose of focus group research is to draw upon respondents’ attitudes, feelings, beliefs, experiences, and reactions. Two groups of participants were identified for information gathering: training institution personnel and ministry of health personnel. Focus groups were completed in each country by the researcher and audio recorded with permission from participants (Kamphuis et al., 2010) (see Table 3). In total, four focus groups were held in each country (one each for 3-Step faculty, training institute administrators, environmental health professionals, and ministry administrators) plus one multi-country meeting for training institutions and one for ministries of health. In total, there were 22 focus groups with 94 participants. 4
Data collection proceeded in three phases, with each prior phase helping to frame the next. The first phase comprised of country-level focus groups with faculty and EHIs. Upon completion, the researcher reviewed notes taken with the focus groups to assist with directing questioning in phase two, where the administrator focus groups (health ministries and education institutions) were conducted. Similarly, the third phase comprising two multi-country focus groups was informed through review of both sets of research notes from phases one and two. All phases utilized a similar semi-structured questioning route developed to ensure consistency in questions across groups (Kamphuis et al., 2010). The questioning routes directed discourses into the strengths, weaknesses, opportunities, and threats (SWOT) analysis format (Aslan et al., 2014; Wazir et al., 2013). SWOT analysis is a management tool able to analyze the internal and external conditions and factors shaping 3-Step through the identification and analysis of its strengths and weaknesses, and the opportunities and threats to which it is exposed. Discourses were systematically structured for coverage of different aspects of 3-Step, with phase two spending more time on questions around future visions for program and environmental health practice. Phase three introduced additional probing questions to illicit, compare, and contrast insights between countries, institutions, and ministries.
Data analysis
Analyses were performed following the framework approach in which the EHI job specifications and 3-Step served as bases for inquiry and information was structured through SWOT analysis (Aslan et al., 2014). A preliminary list of “themes” was composed relating to these frameworks, and then relevant phrases in the transcripts were identified and examined by contrast comparisons. For each relevant phrase or idea recorded, a judgment was made on whether it fitted into one or more existing theme or under new themes. Phrases and ideas were coded by theme to reflect all the nuances in the data possible (Pope et al., 2000). Coding was completed by the researcher. To validate and reduce potential misinterpretations of the recorded comments, the audio was also sent to in-country researchers in each of the five study countries. They independently coded and their reports were compared to that of the researcher (Wong and Poon, 2010).
Themes were reviewed and the importance of each was assessed. More emphasis was given to comments that were discussed at great length, with great intensity, with great specificity by multiple participants, and across focus groups (Countouris et al., 2014). Commonalities, alignments, and patterns across focus groups in the SWOT rubric were matched, serving to triangulate and validate focus group information, adding to reliability of the information collected.
Results and analysis
Figure 3 summarizes results of the survey questionnaire. There is strong agreement between both EHIs and educators on importance of “monitoring and detection” and “inspection and assessment.” The largest gaps between both groups are on “design and deploy solutions” and “epidemiology and reporting,” where educators rate importance of these as more important than EHIs perceive them to be in their work routines, as well as “courts and legal,” where EHIs perceive this as far more important than educators perceive it to be for academic training.
Table 4 summarizes more survey results. There are statistically significant differences between educators and EHIs on the importance of foundation subjects of 3-Step. Educators perceive statistical training as more important while EHIs perceive legal, negotiations, and environmental risk subjects as more important to their roles compared to educators (Lefebvre et al., 2012). Regarding advanced certificates, there is no statistically significant difference in both groups’ perceptions that new certificates in climate change, pandemics, and air quality are needed. However, differences in perceptions are statistically significant for existing certificates in port security and disaster risk. Neither group disagrees that 3-Step faculty need strengthening or that there are not enough public sector career opportunities for EHIs, though there is as statistically significant difference between EHIs seeing the private sector as becoming more attractive than educators.
Results of qualitative analysis5
Education institutions’ perspectives
Strengths
Institutions have updated their programs independently. Overall, they have been revised to emphasize new communicable diseases and environmental determinants of global health. Updates have been institutionalized in all institutions except Guyana, and all plan future revision iterations. Jamaica plans on infusing indigenous elements of health into the program. Guyana will look at a substantial, well-organized, and well-executed six-month-long internship or attachment with the Ministry of Health as a requirement for graduation.
The ability of this cadre of EHIs to manage such a substantial workload of public reports and complaints relatively effectively suggests that their training is serving them well. This point has been made by high-level decision-makers and is seen as an indicator of the quality of EHI training. Administrators also reported that the public is generally satisfied with the performance of EHIs as complaints about EHIs are seldom received or escalated to government executive level.
Weaknesses
Institutions have limitations in confirming internship placements every year. This situation is particularly acute for the large Trinidad and Tobago program, especially for non-nationals, who must find internships in their home countries. Perhaps one of the most significant limitations to the program at present is accommodation of students in laboratories and for field assignments. To move the program forward, institutions require resources such as for improving library resources and laboratory facilities. In Guyana and Saint Lucia, lab space and time is borrowed from the public health laboratories, which themselves are not up to date. In Trinidad and Tobago, an arrangement has been struck with the University of the West Indies for the time being.
Programs suffer from a lack of permanent faculty and this is compensated for by hiring part-time faculty who may not be subject experts or may lack instructing experience. The program does not particularly address technical report writing or written communication. Graduates do not necessarily have enough competency in communicating with various audiences.
Opportunities
There is movement toward mixed-mode delivery of courses. The objective is not to move as much material online as possible, but rather to give students a variety of learning options, including face to face, blended, and a fully online. However, some faculty have concerns about maintaining online quality. Jamaica is investigating inclusion of online laboratories and online simulations as alternatives to in-person bench work.
As particular issues rise to the international agenda, there are opportunities for EHIs to contribute if invited and empowered to articulate the positions of Small Island Developing States (SIDS). They also need to be up to date on rising issues, such as persistent organic pollutants, international health regulations, disease surveillance, marine pollution, the Basel Convention, and others.
When the program started, the emphasis was on skills for monitoring activities and the demand for these graduates almost singularly came from the government sector. The science of environmental health has evolved and the demand is now also for modeling and building. These skills can serve the growing demand for environmental health professionals in industry to design, model, and build systems.
Threats
There are long waiting lists and significant bottlenecks in career movement for EHIs, resulting in, for example, a glut of personnel at lower ranks even when overqualified. This discourages retention of the workforce. In Guyana, hiring is done in batches only every three to four years, restricting employment opportunities.
The institutions have been hard pressed for resources over the last several years because of general economic decline. While government budget allocations to educational institutions have not generally been reduced, they have remained constant while operating costs have continued to go up. Additional grants and funding have been and will continue to be sought for specific expenses, such as laboratories and learning materials, from local, regional, and international partners.
Hiring and retaining core faculty is challenging. Traditionally, part-time faculty have included well-seasoned chief inspectors who hold advanced graduate qualifications but there are still gaps in deep expertise. Ratios of full-time to part-time faculty in 3-Step range from 3:2 in Jamaica to 3:7 in Guyana.
Academic advisory boards are absent or are being dismantled. Such boards, if intact, would have included multiple stakeholders tasked with guiding the evolution of training programs and bridging gaps in perspectives between programs and practitioners. All training institutions have these advisory boards documented but none of them are active. These boards have not been prioritized by education administrators seeking to cut costs, and even when they are periodically engaged, the time between engagements is such that they can provide only sporadic advice that may not lead to continuous improvements.
EHI perspectives
Strengths
The program instills an understanding and appreciation of the importance of EHIs in society, and the significant role for which they are preparing, through emphasis on the fact that EHIs are among the few officials that are empowered with right of entry to premises and also to conduct seize and destroy duties when required. Graduates are also able to interact with other ministries, including ministries of agriculture and environmental protection agencies. This is becoming more important as EHIs are required to serve on interministerial committees.
Training includes fundamental subjects, such as vector control and food safety, but also more advanced and relevant topics, including port security, where knowledge of topics such as international health regulations and sanitary and phyto-sanitary standards and regulations are required. There is strong emphasis on fieldwork and community engagement in the curriculum, though some institutions organize this more effectively than others. For example, Jamaica implements effectively a six-month fieldwork/internship at the end of the program, while Trinidad and Tobago secures a series of two-week field engagements for students throughout the program. Another “signature” of the Jamaica program is the strong emphasis on sampling and sample analysis; even though EHIs do very little analysis, they must understand how to perform sampling and how to interpret the results of sample analysis.
Graduates of the bachelor’s degree program are highly employable in the public and private sectors. Jamaica’s public health and allied government sector absorbs an estimated three in four graduates. Similarly, in Barbados and Guyana, almost all associate degree-level graduates are absorbed in the public sector, even if at lower rank than fits their qualification. In Jamaica, most of those stay in public sector employment, especially in the Ministry of Health, parishes, and municipalities. However, in more recent times, many have been finding employment within the private sector as well.
Weaknesses
The program overemphasizes the “technical” role of EHIs but there are often equal or more social and “non-technical” aspects to EHI responsibilities. EHIs have duties to the communities that are enshrined in law in CARICOM jurisdictions. They are also called upon to apply that technical knowledge to support policy. This is not a context where many EHIs feel confident since it is not a skill explicitly developed in the program.
The program does not prepare EHIs with legal and prosecutorial skills, legal procedures in court, principles such as conflict of interest, or how to represent themselves in court, as they often have to. EHIs working for local governments have to represent themselves in court as they prosecute public nuisance cases. Working at the parish level is becoming increasingly litigious. This aspect of EHIs’ regulatory role is not highlighted enough in the program. For example, EHIs have lost cases because they provided advice to a member of the public on a matter under the jurisdiction of that inspector, hence unknowingly promoting a conflict of interest.
The curriculum should not neglect “soft aspects” of EHI responsibilities. For example, members of the public often call in, or visit, EHIs to complain, vent, and seek advice. The 3-Step program does not train EHIs in listening, empathizing, and reassuring the public as much as they are skilled to find solutions to complaints. The “art of persuasion” or negotiations and conflict resolution should be taught in order to, for example, convince vulnerable communities of the need for action in disaster scenarios such as flooding.
The 3-Step program should train EHIs to have a broader understanding of environmental issues, risk management, and sustainability in order to contribute fully to ministerial initiatives and collaborations that they will be asked to become involved in. EHIs must already interact intimately with the environmental, water and sewage, and food and drugs agencies. At the advanced certificate level, the weakest concentration continues to be in environmental engineering (water/wastewater engineering) largely because teaching material is vastly outdated compared to modern engineering knowledge and practice. The program should teach the fundamentals of engineering systems and design in order to understand plant operations for various industrial processes and activities. Barbados and Trinidad and Tobago point out the weakness of new EHIs’ background in epidemiology even after completing the advanced certificate. New advanced concentrations, such as in port security, are needed to facilitate the changing societal context.
The bachelor’s level is not being taught by faculty with enough deep knowledge and expertise in the subject matter areas. The program is limited by the faculty expertise available. Stemming from this, students must enroll for courses based on what the university makes available due to faculty availability. New EHIs are therefore less academically prepared than expected, and considerable efforts must be made by environmental health departments to bring them “up to speed.” For example, 3-Step should train EHIs in how to conduct a site inspection and pre-site inspection preparation such as studying layouts of various sites, and to identify critical points in operations to pay attention to on site. Due to logistical challenges, in Trinidad and Tobago and Saint Lucia, the practicum is delivered at any time of the degree schedule, which is pedagogically illogical since the practicum should be completed only when all the core coursework has been satisfactorily completed.
Opportunities
There are some areas for EHI professional growth that can be included in the academic programs. One such opportunity is derived from ministries including EHIs in design of public health and allied policies, regulations, and standards. If EHIs receive more training in currently weak areas, such as epidemiology and statistical analyses and research, they will be able to contribute meaningfully in the policy realm. The Chief Health Inspector in Trinidad and Tobago noted that “working with demographic and census data and cross-referencing with epidemiology, data, and trends in order to devise strategic interventions—this should be a basic skill developed during the academic experience” (personal interview, November 2018).
Island life is changing socioculturally and environmental health training and practice needs to cater to such changes. One example is the large shift in community concentrations to coastal urban areas as agrarian lifestyles of the past fade. Another is the preponderance of lifestyle diseases. Academic programs must recognize that, for example, public complaints about indoor air quality are now everyday occurrences in environmental health departments. The governments of Guyana and Trinidad and Tobago have been placing continued emphasis and resources on disaster risk management and mitigation. There are several intersects with the roles and responsibilities of EHIs, including early warning systems and post-disaster response. Risk management approaches need strengthening in programs as public health discussions now note ecological risk due to climate change in environmental impact assessment and health risk assessment. EHIs are not taught to understand the connections between their competencies and ecology and environment. Economic change is also bringing new opportunities to the profession. As trade and commerce become larger parts of island economies, training is needed in border control, quarantine, and the health consequences of trade and the movement of goods as the economy grows.
The program should pay attention to introducing students to technology, technology applications, and solutions as they pertain to environmental health practice. Examples include use of advanced modeling and forecasting methods in epidemiology; advanced sampling techniques and equipment, and online and social media environments for awareness building and community engagement. There is the opportunity to harness new technological advances for health surveillance, monitoring, and forecasting but personnel must be trained in new skills, such as data entry, data analysis, data processing, and interpretation.
New advanced certifications are needed to coincide with areas of increasing public demand. These include the increasing demand for quality control personnel in the seafood industry, demand for environmental health and safety inspectors in private industrial facilities, and demand for skills in waste management and engineering. In Jamaica, policymakers have heightened interest in environmental health department inputs on chemicals management, as well as the ever-increasing complexity of enforcing occupational health and safety and air pollutant emissions in industry.
Threats
Students interested in environmental health are cautious about job prospects since there is less turnover in EHI ranks than other public sector areas. Many serving EHIs have 15–20 years of field experience. In some jurisdictions, such as Barbados, the Ministry of Health’s minimum requirement for employment as an EHI is an associate degree. In practice, most of the current EHIs hold a bachelor’s degree. Ideally, the ministry would like to hire EHIs who already hold bachelor’s degrees. To facilitate this, government human resource reforms will have to be passed since EHI salaries currently remain the same regardless of whether the person holds an associate or bachelor’s degree. It is also fairly commonplace now to have many environmental assistants pursuing or holding bachelor’s degrees but still in assistant posts. This is because of the slow turnover in the ranks and little new expansion in EHI-level positions.
In smaller jurisdictions, such as Saint Lucia and Guyana, recruitment to public sector EHI positions comes periodically every couple of years in batches and not continuously, making it therefore a less attractive course of study for students. Regional health authorities hire separately on a contractual basis, with less job security in such arrangements. Most CARICOM ministries of health have an established number of posts and that can only be changed through slow, bureaucratic processes (Soverall, 2015).
Discussion
There is a general consensus from all the ministries of health that 3-Step has been beneficial to building the environmental health units. Having credentialed EHIs gives the departments an additional degree of confidence, professionalism, and recognition. It also increases the standing of EHIs in the eyes of the public and among health sector peers.
Practitioners identified areas for 3-Step improvement in order to help build their capacity. While there are some recommendations that are specific to each of the five countries, there are some salient and common threads that suggest weaknesses or areas for improvement in the overall curriculum. The most relevant of these include an emphasis on the regulatory role of EHIs, including proper training in prosecution and making legal arguments, and in the performance of health risk assessments, which encompass environmental and ecological risk assessments. Another area is increasing the ability of EHIs to analyze epidemiology data and design studies and experiments. Third is the need for the curriculum to employ more opportunities to incorporate technology and technological applications and solutions in professional practice. Fourth is the need for EHIs to learn courtroom procedures, how to present cases and evidence in law, and how to represent themselves in the judicial system when called upon to do so. This is not only theoretical learning; rather, they should also be exposed to courts for practical learning.
Prior program revisions have not kept up with the job market. In Barbados, EHIs are trained in more advanced and relevant topics, including port security, where knowledge of topics such as international health regulations and sanitary and phyto-sanitary standards and regulations are required (Shah et al., 2019). However, the course on port health requires further depth in development to include new technological and protocol advances. In Trinidad and Tobago, a more advanced diploma is being designed for specialization in port security.
There is reason to infuse impact of climate change on environmental determinants of health, disaster risk assessments and management, and indoor air quality in the curriculum in very practical ways that enhance the understanding and skills of EHIs in addressing vector control, epidemiology, and other environmental health subjects. Other areas for improvement include emphasizing soft skills, risk management, and sustainability, as well as being aware of growing public demands for services, for example, in indoor air quality, emissions monitoring, and hazardous waste.
The most vociferously identified weakness of the program, with the exception of Jamaica, is the perceived erosion in the quality of the internship component over time. Just as subject-level content should now go through another standardization process, the important internship component of programs, which have also evolved, must be re-evaluated. Institutional conditions have resulted in internship/practicum approaches that, in some cases, may not be achieving desired learning outcomes, nor optimizing the learning potential of such arrangements. Quality control of this aspect of programs is urgently required. EHIs are well positioned to put this view forward since nearly all of the internship/practicum placements are within their units and others in the ministries of health. Educational institutions must ensure that advanced courses, that is, specialized and highly technical courses, are not taught be generalist faculty, part-time instructors, or even former EHIs. This is because the academic classroom environment will be the first place and sometimes even the only time in the EHIs’ careers that they will have the opportunity and time to be exposed to “deep experts” and learn from them.
Conclusions
Over the 15-year span from initiation of the program until now, program content has evolved and changed due to a number of academic reasons, such as the scientific advancement of subject fields, but also in response to the needs of practitioners and to cater to the needs of the market (students and society). If the original policy goal of the 3-Step program of standardization of qualifications across CARICOM is to be maintained, then it is time for educational administrators to again come to the table and negotiate a common program structure and content.
Theoretically, this will allow the region to achieve the level of standardization needed but, at the same time, allow for a measure of tailoring to country contexts and reserve a measure of autonomy for educational institutions to make independent decisions about content. Also, a regional standing committee comprising of representatives from the academic delivery institutions must be constituted to, among other functions, make periodic decisions on course and content substitutability and equivalency as the programs move forward in the future. A regional-level advisory board comprising ministries, training institutions, and multilateral agencies such as PAHO must be an integral part of the process, especially as even though EHIs were part of the consultations to develop the original program, their participation fell off immediately after. This means that over the time of implementation, the evolution of the programs was relatively devoid of official practitioner input in a structured way. This would have only increased the rift between academic programming and insights from practice.
Expansion of the program to other institutions in the Caribbean, as well as further embracing online modes of program delivery, will further help achieve the goal of enhancing the management of environmental health programs in CARICOM states and the caliber of persons working in the environmental health field across the region. Broadly, the program has been valuable for training EHIs. Benefits to environmental health units include: raising the professional standard of practice for units; strengthening EHI pride in service and confidence when dealing with the public; and providing a firm academic grounding for EHIs to deepen and expand through additional advanced training programs.
Lastly, in broader terms of tackling the challenges of Caribbean public health sector reform, this study highlights how a lack of attention to human resource development and systems serves to erode public standing of front-line professionals and impact their preparedness to meet increasing responsibilities. However, even so, it is also clear that common and impending drivers of environmental health such as climate change and global pandemics are causing policymakers and educators to reassess public health systems, performance, and regional investment in improvements.
Supplemental Material
sj-pdf-1-ras-10.1177_0020852321994914 - Supplemental material for Preparing public health at the front lines: effectiveness of training received by environmental health inspectors in the Caribbean
Supplemental material, sj-pdf-1-ras-10.1177_0020852321994914 for Preparing public health at the front lines: effectiveness of training received by environmental health inspectors in the Caribbean by Kalim U. Shah in International Review of Administrative Sciences
Footnotes
Acknowledgements
The Pan American Health Organization, Caribbean Office, assisted with organizing the focus group sessions. Thanks to the ministries of health and education institutions in Barbados, Guyana, Jamaica, Saint Lucia, and Trinidad and Tobago that participated in this study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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References
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