pmc950521321279J Public Health Manag PractJ Public Health Manag PractJournal of public health management and practice : JPHMP1078-46591550-5022407796881270388010.1097/PHH.0000000000002204HHSPA2127178ArticleBuilding Capacity in Public Health: Effects of the Pacific Public Health Fellowship Program in the US-Affiliated Pacific IslandsFrazierCassandra MartinMPHConcepción AcevedoJenifferPhDHolmesGaylePhDArgotsingerBrittanyMPHIrizarry-RamosJessicaPhD, MSRostamiSoulmazMPHColmanLauraPhD, MPHDeanHazel D.ScD, DrPHDauphinLeslie A.PhDNational Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce, Centers for Disease Control and Prevention, Atlanta, Georgia (Ms Frazier, Dr Concepcion Acevedo, Ms Argotsinger, Dr Irizarry-Ramos, Dr Colman, Dr Holmes, Dr Dean, and Dr Dauphin); and Pacific Island Health Officers Association, Honolulu, HI (Ms Rostami).Correspondence: Cassandra M. Frazier, MPH, Centers for Disease Control and Prevention, 2400 Century Parkway, Atlanta, Georgia, 30345 (bkx9@cdc.gov).3122025Nov-Dec20252110202515122025316982990Context:

Public health agencies require a competent, well-trained workforce to protect health and meet the specific needs of the communities served. In the US-Affiliated Pacific Islands (USAPI), geographic and educational barriers, and limited availability of culturally and linguistically appropriate training programs are unique challenges that contribute to public health workforce shortages.

Program and Implementation:

The Pacific Public Health Fellowship Program (PPHFP) was introduced through a partnership between the Centers for Diseases Control and Prevention and the Pacific Island Health Officers Association. It was designed to address barriers to public health workforce development and capacity in USAPI. Established in 2019, PPHFP is a 2-year, full-time training program designed for USAPI residents who are recent college graduates with interests in pursuing careers in public health. The program includes a competency-based training curriculum and field-based projects at participating host sites to address local public health challenges. PPHFP has expanded from 2 fellows in 2021 to 43 fellows in 2024, with each USAPI having hosted fellows.

Evaluation:

All 2021–2023 cohort respondents to the PPHFP exit survey have reported satisfaction with the program, increased knowledge and skills in public health, and readiness to enter the public health workforce. In addition, respondents reported that they have contributed to public health workforce capacity at their local host sites. In total, 16 of 17 graduates from these cohorts have been employed or continued their education in the public health field.

Discussion:

PPHFP is a successful approach to addressing unique public health workforce challenges in USAPI through recruitment, training, and placement of residents at local host sites. This fellowship program can serve as a model for enhancing public health workforce capacity in other regions and globally.

capacity buildingfellowshippublic health workforceIntroduction

A skilled and adaptable workforce is central to a strong public health system and is essential to advancing health and well-being of communities.1,2 However, barriers to maintaining a competent and ready public health workforce have been well documented.3,4 A need exists for building a stronger and more stable workforce that better reflects the community it serves.5 In addition, many new members of the governmental public health workforce lack formal academic training in public health (eg, bachelor’s or master’s degree), highlighting the need for more on-the-job training.5–7 Training programs such as internships and fellowships are proven models for fostering career trajectories for future public health professionals. These programs provide foundational knowledge and skill-building through developmental, on-the-job experiences.

Fellowship programs at the Centers for Disease Control and Prevention (CDC) are essential, offering valuable opportunities for professional growth, skill development, and career advancement.8,9 These programs provide practical experience enabling fellows to learn and apply knowledge in real-world settings. For example, CDC’s Public Health Associate Program (PHAP) is a 2-year training program that provides participants an opportunity to develop foundational public health skills through hands-on, field-based experiences. After completing the program, the majority of associates join the public health workforce, working in crucial roles to address emerging public health needs.10 Since its inception in 2007, approximately 1800 associates have participated in PHAP, gaining experiential learning while building capacity of public health agencies across the United States.11,12 However, PHAP’s reach and effects in the US-Affiliated Pacific Islands (USAPI) is limited by applicant eligibility requirements and the remoteness of host assignments. Only US citizens are eligible to participate in PHAP, which excludes citizens from the 3 freely associated states, the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau. Consequently, due to limited access to formal public health training, a need exists to cultivate a local workforce to address crucial health workforce shortages in the Pacific region.13 The University of Guam offers the only 4-year public health degree in USAPI, through its Bachelor of Health Science Program with a concentration in Public Health. For postgraduate training, students must seek opportunities outside the region, with the closest Master of Public Health programs located at the University of Hawai’i and Fiji National University.

To provide access to a local training program and offer a solution to the lack of advanced public health programs in USAPI, CDC partnered with the Pacific Island Health Officers Association (PIHOA) to develop the Pacific Public Health Fellowship Program (PPHFP). PIHOA is a nonprofit organization that seeks to improve the health and well-being of communities in USAPI. PIHOA is also a recipient of a cooperative agreement managed by CDC designed to improve the quality, performance, and sustainability of USAPI public health system through capacity-building.14 Modeled after PHAP, PPHFP represents the first cross-cutting fellowship program implemented in the Pacific Islands to address public health workforce gaps and prepare local professionals with the necessary skills to respond effectively to health concerns. This report describes PPHFP’s training efforts in the territories and freely associated states and summarizes its contributions to enhancing public health capacity in USAPI.

Program Description and Implementation

PPHFP is a 2-year training program initiated in 2019 to prepare recent college graduates from USAPI for successful careers in public and community health in their islands. To establish the program, PIHOA applied a human-centered design approach, prioritizing perspectives from community members and local public health practitioners and ensuring that it would be both relevant and sustainable.15 PIHOA conducted an environmental scan to assess human resources and local infrastructure to support the program. Focus groups and interviews conducted with 34 public health professionals from health departments, ministries of health, and academic institutions within USAPI identified common needs across the region, such as gaps in core competencies and formal education (eg, bachelor’s degree in public health). PIHOA conducted a pilot period to refine the program design within the USAPI context to ensure it aligned with local priorities. This groundwork enabled the program to begin building strong local partnerships and establish a foundation necessary for program implementation.

Fellow and host site selection

PPHFP is designed to train recent college graduates with a minimum of an associate’s degree who reside in the Pacific territories or freely associated states. To support their fulltime, two-year commitment to the program, fellows receive a living allowance in an amount determined by each USAPI jurisdiction. Eligible applicants must be US citizens or a resident from USAPI, including the freely associated states. Fellows are selected through an annual competitive recruitment and application process. Recruitment efforts include direct engagement with local health agencies, partnerships with universities and USAPI community colleges, social media campaigns, regional E-blast announcements, and informational webinars. Applicants must submit a completed application detailing their interest in a public health career, participate in an interview, and provide letters of recommendation. Once selected, PIHOA matches the fellow with a public health program within a department or ministry of health, referred to as a host site program. Host site programs provide fellows with hands-on public health experience, training, and mentorship. Public health programs must apply to become a host site program. To be selected, they must identify a qualified supervisor experienced in mentoring and demonstrate their capacity to provide training, professional development, and leadership throughout the fellowship. Host sites programs are selected with input from health leaders who consider local public health priorities and workforce needs.

Curriculum-based training

Fellows and host site supervisors collaborate to develop a work plan that outlines their learning goals, objectives, key projects, and anticipated deliverables during the 2-year fellowship. Fellows complete online and in-person trainings centered on Tier 1 (Front Line and Program Support Responsibilities) of the Core Competencies for Public Health Professionals.16,17 The Core Competencies encompass 9 public health domains, and 45 competencies aligned with the 10 essential public health services, such as Analytics and Assessment, Community Partnership, and Leadership and Systems Thinking. Examples of trainings include the Federal Emergency Management Agency’s Emergency Preparedness Course, the Public Health 101 Series offered through CDC TRAIN, and PIHOA’s Strengthening Health Interventions in the Pacific (SHIP) Post-Graduate Certificate in Field Epidemiology, accredited by the Fiji National University.18 Host site supervisors also participate in mentor enhancement training adapted from the Center for the Improvement of Mentored Experiences in Research curriculum.

Practice-based training

In addition to curriculum-based learning, fellows conduct field-based projects that address current, localized public health challenges within the jurisdiction. These projects focus on health-related concerns, including communicable diseases (eg, HIV/AIDS, viral hepatitis, tuberculosis (TB), and Hansen’s disease) and noncommunicable diseases (eg, maternal and child health, family planning, behavioral health, and disease surveillance and epidemiology). By working on these assigned projects, fellows can add to the local health agency’s capacity to address priority areas.

Fellows gain additional exposure to the broader public health system by engaging with the PIHOA Executive Board, which consists of Ministers, Directors, and Secretaries of Health for USAPI. The Executive Board offers perspective regarding the reach and sustainability of PPHFP and provides guidance about maximizing the program to build local workforce capacity within USAPI. Fellows participate in Executive Board meetings, exposing them to high-level health leadership practice and networking.

Program Management and EvaluationProgram administration and funding

The management of PPHFP is a coordinated effort between PIHOA and CDC. PIHOA oversees all administration of this multifaceted, cross-jurisdictional program. This includes securing and supporting host site programs, recruiting and onboarding fellows, coordinating curriculum and trainings, engaging with partners and aligning priorities with the PIHOA Executive Board, and promoting the program throughout the USAPI region. The program is centrally managed from PIHOA’s Guam office by a dedicated team. The PPHFP manager leads program planning, delivery, and evaluation and serves as the liaison between PIHOA, USAPI host sites, and CDC. Additional staff include a program administrator and several mentors who provide mentorship and support to fellows and host site supervisors ensuring programmatic expectations are met.

CDC’s investments in PPHFP reflect a cross-agency commitment to strengthening the public health workforce pipeline in the USAPI. During federal fiscal years 2019–2024, CDC invested a total of $6 964 972 in the program (Figure 1). CDC’s initial investment provided crucial resources to initiate the program and support its formation. Increases in program investments over time enabled the fellowship to overcome unique logistical and operational challenges of delivering capacity building efforts in remote settings with limited infrastructure, such as traveling fellows to training and professional development in the continental United States and across USAPI, participation in the field epidemiology certification program, and providing equipment and supplies to each fellow. Funding from the American Rescue Plan Act of 2021 created an opportunity to expand the fellowship program in response to the COVID-19 public health emergency by broadening the potential pool of eligible applicants from the initial bachelor’s degree requirement to associate’s degree or higher. This expansion further met the critical workforce needs in the USAPI.

Evaluation approach

A crucial focus for CDC and PIHOA is ensuring that investment in PPHFP results in a stronger, more capable public health workforce that meets the needs of USAPI populations (Figure 2). With input from a local evaluation advisory group, PIHOA established a 5-year monitoring and evaluation approach grounded in the program’s human-centered design, ensuring program accountability, continuous quality improvement, and progress toward programmatic growth. Like evaluations of other fellowship programs,19 PIHOA’s evaluation approach uses a mixed-method design that incorporates administrative data, surveys, and interviews to capture program aspects at different points in time. Analysis of program administrative data (eg, fellow workplans and progress reporting) determines whether the program is being delivered as intended and guides program refinement and improvement. To provide a qualitative gauge of each fellow’s competency and knowledge development, PIHOA uses multiple assessment tools including quarterly supervisor performance discussions, mentor feedback, and performance on capstone projects and oral presentations. Fellows and host site supervisors also complete a checklist to monitor the successful completion of required public health core competencies through training and hands-on experience.

To assess perspectives of value, satisfaction, and career readiness, midpoint and end of program questionnaires are administered online to fellows and host site supervisors. Fellows also participate in exit interviews after graduation to provide additional qualitative feedback and complete a questionnaire 1-year postgraduation to assess postgraduation employment. This comprehensive evaluation is currently underway to assess the program’s 5-year outcomes and overall impact. Findings from this evaluation will be disseminated in future publications. This evaluation activity was reviewed by CDC, deemed not research, and is being conducted consistent with applicable federal law and CDC policy.a

Fellowship Reach and Post-Employment

Initial insights from PIHOA’s evaluation efforts demonstrate exponential growth in program reach, resources, and accomplishments. Within 4 years, the program expanded from 2 fellows in 2021 to 43 fellows by end of 2024 (Figure 3). The geographic reach of fellows also increased. Two jurisdictions, Guam and the Commonwealth of the Northern Mariana Islands, served as host sites for cohort 1. By cohort 5, each USAPI jurisdiction has hosted fellows spanning populated and remote islands, including Tinian and Ebeye, while serving a population of approximately 500 000 people (Figure 4). Among the 43 fellows across cohorts 1–5, 86% were female. Thirty-five percent of fellows had a bachelor’s degree and 65% had an associate’s degree, with most academic concentrations primarily in public health, nursing, liberal arts, business and Micronesian studies.

At the time of reporting, 17 fellows from cohorts 1–3 had graduated from the program. As a condition of program completion, all graduated fellows met the program’s 45 core competencies as assessed and approved by the host site supervisor through the competency checklist. Based on exit surveys from cohorts 1–3,b moreover, 100% of fellows reported satisfaction with the program, increased knowledge and skills in public health, and readiness to enter the public health workforce. The fellows also reported that they were able to contribute to the team at their host site and would recommend the program to others considering a public health career. Among host site supervisors who participated in exit interviews, 100% reported satisfaction with the program. After graduation, 16 of the 17 fellows (94%) gained employment or furthered their education within the public health field. Twelve fellows were employed by their host sites in USAPI, including Palau, Marshall Islands, Guam, and the Federated States of Micronesia. They serve as public health emergency preparedness coordinators, laboratory technologists, disease investigation specialists, and public health nurses. One fellow became a health program specialist at a health agency in the continental United States. Three of the remaining fellows enrolled in college to pursue a bachelor’s degree with a concentration in public health.

Field-based Project Examples

Program successes and accomplishments can also be found within the individual participating territories and freely associated states. The following field-based project examples offer insight into the scope of the fellows’ contributions to addressing key public health priorities.

American Samoa

Fellows are contributing to the formation of the first-ever Maternal Mortality Review Committee (MMRC). This CDC initiative establishes a jurisdiction-led, multidisciplinary committee that identifies, reviews, and characterizes pregnancy-related deaths and identifies prevention opportunities. Their efforts laid the groundwork for the American Samoa Department of Health to become a recipient of CDC’s MMRC Grant. Fellows are also adapting CDC’s Hear Her Campaign. This program raises awareness about urgent maternal warning signs to prevent pregnancy-related deaths, including extending its reach to pregnant women with rheumatic heart disease.

Guam

Fellows are strengthening surveillance capacity for maternal and child health by spearheading the jurisdiction’s first MMRC; successfully coordinating Guam’s first Women’s Health Summit; collecting, analyzing, and reporting data regarding maternal and fetal morbidity; conducting surveys regarding prenatal care; and initiating outreach events. Other fellows have assisted with developing Guam’s first hepatitis B surveillance profile, creation of standard operating procedures for viral hepatitis surveillance and investigation, and development of viral hepatitis fact sheets for health care professionals.

Palau

A fellow participated in school-based data collection on vaping rates among young adolescents. Data were used to guide development of the current law banning e-cigarettes. This law prohibits the importation, use, possession, and sale of e-cigarettes in Palau. Other fellows gained hands-on experience in laboratory science, including testing for TB specimens, running antigen/GeneXpert for COVID-19 tests, analyzing and reporting laboratory antibiotics culture results, and developing standard operating procedures for serology tests for HIV, hepatitis, and sexually transmitted infections. Fellows are also supporting national efforts to combat antimicrobial resistance (AMR) by investigating repeat antibiotic prescriptions at the Palau Hospital Pharmacy. While working for the Community Health Centers, fellows led the creation of a billing and collection dashboard to track and address discrepancies for improved management and use of public health resources. They also created a social marketing plan for HPV vaccinations by assessing parents’ perceptions of the vaccine for young females to increase HPV vaccine uptake and assisted with efforts to formalize tele-health services.

The Republic of Marshall Islands

Fellows reestablished the Zone Nursing Program. The fellows, based in Majuro and Ebeye, received training to conduct a census-based community health profile of their respective islands. Each fellow mapped the profile of households in their assigned geographic zone. They reported the number of members, age, and other relevant information, conducted assessments of basic vital signs, and delivered health care services (eg, wound care dressing and childhood immunizations). Their outreach enabled the program to reach every household across their island, including some communities located in the neighboring islands, populations who typically cannot make it to health centers or hospitals. Further, the fellows analyzed health profile data to identify public health needs unique to their zone and created projects to address those individual zone needs. As a result, Republic of Marshall Islands plans to reinstate and sustain this zone nursing program.

Federated States of Micronesia

In Chuuk, fellows have participated in mass TB screening and treatment outreach across 3 outer islands and created TB contact investigation guidelines to improve treatment planning protocol. In Pohnpei, fellows introduced routine screening for TB among diabetes mellitus patients, as part of a cross-cutting communicable disease and noncommunicable disease collaboration. Other fellows conducted laboratory surveillance and analysis of AMR for outbreak prone diseases. Fellows hosted in Kosrae implemented a project to assess alcohol, tobacco, and drug-use among school students and designed and implemented education sessions for sexual and reproductive health. Fellows in Yap are proposing a mass sexually transmitted infections screening and treatment outreach for Yap and the outer islands while also working on laboratory strengthening for procurement, inventory and stockpiling processes, determining laboratory wastage, and updating the laboratory quality assurance manual.

These successes signify the fellows’ clear and notable contributions to advancing public health priorities in USAPI. They also underscore how the fellows contributed to USAPI’s capacity to implement activities aligned with CDC’s national priorities, including addressing the chronic disease epidemic, strengthening surveillance and laboratory capacity, protecting maternal health, combating antibiotic resistance, and decreasing the spread of vaccine-preventable diseases.20

Discussion

PPHFP strengthens efforts to address critical workforce shortage and public health workforce capacity in USAPI by building a pathway for local public health professionals. An essential factor in PPHFP’s success is leveraging CDC’s existing partnership with PIHOA. Since 1986, PIHOA has worked in the Pacific region to build capacity and find solutions to strengthen the public health workforce and close infrastructure gaps. PIHOA’s implementation of PPHFP further enhances USAPI public health workforce development initiatives. Its commitment to local communities in USAPI, coupled with a deep understanding of the unique challenges, needs, and opportunities, has been key to its effective fellowship management and coordination of host sites, mentors’ identification, fellows’ placement, and program promotion in the region.

The unique characteristics of USAPI necessitate a workforce development approach tailored to meet the specific and challenging needs of the islands.13 The USAPI are culturally and linguistically diverse, with more than a dozen languages spoken along with unique customs and traditional practices across the territories and freely associated states. Geographically, hundreds of remote islands and atolls are dispersed throughout the Pacific Ocean, leading to geographic isolation, dependency on external support for food and supplies, and increased health migration because of limited access to health care. The islands are susceptible to natural disasters, which increases associated public health risks.21 Additionally, health care workforce shortages are well documented, while limited educational opportunities beyond the associate’s degree-level are available.22 By selecting candidates with an associate’s degree or higher who come from and are familiar with the unique needs of USAPI, PPHFP proactively builds local capacity to protect USAPI from health and safety threats. The fellows understand the challenges, navigate sociocultural systems, and, through training and experiential learning, can identify and execute strategies that are tailored to these needs. As a result, the program strengthens USAPI’s public health workforce, infrastructure, and public health systems from within.

With 94% of graduated fellows entering USAPI public health workforce or continuing their education in public health, PPHFP is positioned to increase the number of local health professionals over time, cultivating a cadre equipped to use public health tools and strategies to meet the needs of USAPI. The fellows’ field training is deeply rooted in the communities they serve, which can help foster trust and enhance the influence of their work. Fellows can integrate their cultural perspectives into emergency response and preparedness efforts, public health program planning and implementation, and collaborate with local leaders and stakeholders, allowing for more effective and culturally relevant health interventions. This collaboration strengthens and extends the reach for CDC’s national health initiatives and services within USAPI. Additionally, high graduate retention indicates a return on CDC’s investment in USAPI capacity building efforts. Further, potential exists for program expansion in response to emerging needs and gaps of USAPI workforce by training existing health department staff early in their career who have not received formal public health training. As the program takes root in the broader work to strengthen the USAPI public health workforce, efforts are underway to address program sustainability. In the short term, the program continues to receive support from regional health partners and leadership. For the long-term, PIHOA is actively engaging with partners to explore opportunities for support to assist with program sustainability. These efforts will also be informed by the future findings of the evaluation which may include recommendations for sustainable pathways.

This report is the first description of the creation of an innovative fellowship program to build critical local workforce capacity in USAPI and summary of their contributions to local public health. One limitation of this report is limited evaluation data. At the time of reporting, only fellows from cohorts 1–3 had graduated from the fellowship resulting in a limited number of respondents to the end-of-program surveys. As more cohorts graduate, continued monitoring and evaluation can help further demonstrate effects of CDC’s cumulative investment, how well the program objectives are being achieved, opportunities for continual quality improvement, and contributions to population health outcomes.23

Acknowledgements:

The authors would like to express their gratitude to the Pacific Island Health Officers Association (PIHOA), particularly its Executive Board consisting of the Ministers, Secretaries, and Directors of Health from the US-Affiliated Pacific Islands for their endorsement and guidance throughout the implementation of the Pacific Public Health Fellowship Program. The authors also extend appreciation to Ms Emi Chutaro, MSc, Ms Janet Camacho, MSN, MPH, Ms Cerina Mariano, MPA, Ms Bernadette Schumann, MPA, Ms Jade Chennaux, BS, PGCFE from PIHOA and Dr Kristine Qureshi and Dr Yvette Paulino from the University of Guam for their dedicated efforts in the management, design and implementation of the program. Additionally, we are grateful for the technical assistance provided by Mr Kane Agan and Ms Megan Harbour from the Office of Island Affairs and the Partnership Resources Management Branch, respectively, in the Division of Partnership Support, National Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce, Centers for Disease Control and Prevention.

Funding:

This work was supported by the Centers for Disease Control and Prevention, OT21-2101: Strengthening the Public Health Systems and Services in the US-Affiliated Pacific Islands.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

The authors declare no conflicts of interest.

§ See, eg, 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.

At the time of this study, cohort 4 is in the second program year and cohort 5 began in Fall 2024.

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Total and Annual CDC Investments in the Pacific Public Health Fellowship Program, 2019–2024.

Pacific Public Health Fellowship Program Logic Model.

Annual and Cumulative Numbers of Pacific Public Health Fellowship Program Fellows, 2020–2024.

Number of Pacific Public Health Program Fellows, by the US-Affiliated Pacific Islands, 2020–2024 (N = 43 fellows).

Implications for Policy & Practice

PPHFP strengthens efforts to address critical workforce shortage in USAPI by building a pathway for local public health professionals. PPHFP fellows contribute to strengthening the public health workforce capacity in USAPI.

By providing hands-on training opportunities to persons who are from the Pacific Island region and are familiar with the unique social, geographic, and cultural environments, public health agencies that serve as PPHFP host sites can bolster efforts to address social and economic conditions that affect population health.

The findings from the study demonstrate that PPHFP can serve as a model for similar workforce development programs within the Pacific region, and globally. It provides insights and lessons for other regions looking to establish a new local pathway for public health professionals.

The collaborative development of PPHFP by CDC and PIHOA enabled an expansion into USAPI to address local needs and national priorities, effectively bridging external partners into the region. This partnership fosters an approach to public health interventions, where locally trained fellows are better positioned to implement and sustain health initiatives introduced or funded by external agencies, supporting long-term effects and continuity.