Survey data were de-identified and analysed descriptively using Microsoft Excel (Version 16.98) (23).

Interviews were recorded and transcribed verbatim by a professional transcription service. All identifying information was removed and transcripts were checked for accuracy by the primary author (JF). Transcripts were analysed thematically using a hybrid inductive-deductive approach described by Braun and Clarke (24) and Proudfoot (25). An essentialist, or realist, method guided the qualitative analysis, focusing analysis on the semantic content of interviews (24). Two researchers (JF and JW), an epidemiologist and a social scientist, immersed themselves in the data by reading transcripts multiple times and identifying initial units of meaning. Units of meaning were then grouped into categories to support data management and retrieval, and subsequently mapped to Kirkpatrick’s four levels (21). Both researchers independently coded a subset of transcripts and met to compare codes to ensure conceptual alignment. One researcher (JF) systematically coded the entire dataset supported by NVivo 14 version 14 (release 14.24.3) (26), giving full and equal attention to each transcript, with regular cross-checking meetings with the second researcher. Compelling quotations were identified for potential inclusion in the analysis report.

The primary analyst (JF) has extensive experience in field epidemiology workforce development and was directly involved in the design and delivery of aFETPNG. While this background provided valuable contextual understanding of the program, it also held the potential to influence interpretation of participant narratives. As part of a reflexive approach, JF documented his potential biases prior to commencing analysis and engaged in ongoing reflection throughout the analytic process. Coding decisions and emerging interpretations were discussed collaboratively with a second researcher (JW) who had no previous engagement with aFETPNG, or FETPs in general, to reduce the risk of interpretive bias.

Graduates reported a high level of confidence and frequent application of key field epidemiology skills. The majority indicated being very confident in identifying unusual events from surveillance data (82% very confident; 94% applied), using surveillance data to guide programming (88% very confident; 94% applied), conducting outbreak investigations (88% very confident; 82% applied), and implementing evidence-based public health interventions (76% very confident; 76% applied) (Table 3). These findings suggest that the program was effective in developing foundational field epidemiology competencies. Graduates expressed lower confidence and less frequent application of more complex or specialised skills, including evaluating surveillance systems (59% very confident; 47% applied), designing and conducting operational research or epidemiological studies (29% very confident; 35% applied), delivering oral scientific presentations (41% very confident, 47% applied), and evaluating public health interventions (47% very confident; 53% applied). Activities linked to research, policy, and preparing abstracts or peer-review papers were associated with the lowest levels of confidence and application.

When asked whether covering some topics more thoroughly, or including additional topics, would have strengthened their learning, 82% (n = 14) of graduates said yes. The areas most frequently identified for further development included data analysis software (n = 7, 50%), scientific writing (n = 4, 24%), and policy development (n = 4, 24%).

Almost all graduates (n = 16, 94%) were employed in roles requiring field epidemiology skills, and all (n = 17, 100%) reported using data to inform their decision-making and to support decision-making by others. Almost all (n = 16, 94%) indicated that their work directly contributed to the development and implementation of public health projects and programs, and 76% (n = 13) reported influencing the development of health policies. Beyond applying field epidemiology skills, all aFETPNG graduates (n = 17, 100%) reported transferring knowledge to colleagues through mentoring or other forms of professional support. Graduates also actively disseminated findings from their field epidemiology-related activities, including through presentations to colleagues and supervisors (n = 16, 94%), to community leaders and members (n = 6, 35%), at national meetings and conferences (n = 6, 35%), and/or at international forums (n = 3, 18%).

When asked about aFETPNG skills that were rarely or never used, graduates most frequently identified operational research and the development of policy briefs. In addition to feeling less confident in these competencies, limited time, competing work demands, and resource constraints acted as barriers to applying these skills in practice.

Graduates highlighted the importance of interpersonal skills and leadership capabilities developed through aFETPNG. They reported improvements in public speaking, community engagement, training and facilitation, program management, and leadership (Table 4). These changes were often noted by colleagues and managers. One graduate commented: “My colleagues saw the positive impact the training has had, and they all want to come and do FETP… My colleagues and everybody are asking, ‘How did you learn that? Where did you learn that?’… They are beginning to see that this is something that can have impact” (G1).

Interviews identified several enablers and barriers which supported or hindered graduates in applying their field epidemiology skills in their respective workplaces. These were organised into the following themes: professional networks, workplace, gender, security, and professional jealousy.

The role of supportive professional networks in enabling the application of FETP skills was strongly emphasised. Graduates described the FETP alumni network as a central source of trusted expertise and problem-solving support: “The network of FETP alumni has become my go-to resource. Whether I need advice on data analysis or outbreak control measures, I can count on a colleague to help” (G7). Engagement with local health workers and community leaders also created a conducive environment within which to apply their skills. One graduate highlighted how community engagement provided access to and support from political leaders: “When you have a good communication with community leaders at the community level… they communicate with the parliamentary member and tell him, this is the kind of person he is, and he wants to do this and that. So then the member himself communicates with them directly” (G8).

Supportive managers and colleagues in the workplace encouraged the use of field epidemiology skills and built the confidence of graduates. As one graduate stated, a supportive workplace “helped motivate and boost morale” (G2). In some cases, recognition of new skills generated numerous opportunities to apply them: “Since I graduated, everybody just throws things at me… I just have to do it, the province is depending on me” (G3). Conversely, workplace cultures that failed to acknowledge or value the skills of graduates undermined their confidence and served as a barrier to the application of their skills. When managers did not act on data or recommendations generated by graduates, they felt demoralised. When this happened, one graduate said: “I feel that this training has not been valued, whatever I have to offer in this place of work has not been valued. So it’s demoralizing.” (G5). Heavy workloads and tight schedules were additional barriers, making it difficult to find focused time to apply new skills: “Many things come in, they bombard me every day. So it’s all about time, that’s the barrier. I can only do so much” (G4). Limited or delayed access to financial, logistical, or human resources also restricted the application of field epidemiology skills and the implementation of projects. Graduates described delayed release of funds, restrictions on fuel for fieldwork, limited phone credit for reporting, and a lack of trained staff to support outbreak response as key constraints.

Experiences relating to gender varied. Some graduates reported gender-based barriers to leadership roles: “Even though you have that knowledge and skills, but because you are female, you may not be given the position … some managers, they still have this mentality” (G2). Others did not experience barriers related to gender: “Personally, I didn’t see any impact of being female, at the workplace and also at training” (G5).

Graduates reported difficulty travelling to collect data or conduct outbreak investigations due to security concerns arising from tribal conflict or criminal activity. At times these security risks prevented graduates from implementing or completing field epidemiology projects, serving as a barrier to the application of their skills. One graduate stated that youth gangs, “might like to come and stop the vehicle, it has become a norm… So it’s not really easy to control them… even my offices have been attacked” (G8).

Several graduates experienced professional jealousy from peers and superiors, particularly when their new expertise was perceived to challenge existing hierarchies. This was reported as a barrier to applying skills: “I am just an HEO (Health Extension Officer), and they are doctors above me. They can’t accept someone like me to run the show and get things right” (G3). Another graduate recalled: “They do have this jealousy, professional jealousy. When I went back to that district and applied the skills, even my District Health Manager, she was threatened with her position because of my performance in that district… When you are producing results, this may cause ill feelings among your colleagues or your managers” (G2).

Graduates proposed several strategies to strengthen support for applying FETP skills following their training. Continued advocacy to provincial health authorities (PHAs) was recommended to ensure organisational support and recognition during and after training: “Not all PHAs are supporting their fellows, we need to continue to advocate through executive management… there are a lot of good stories and impact… we need to [share this] as part of our advocacy to the executive management” (G2). Graduates also emphasised the importance of continuous learning, refresher courses and ongoing mentorship to support their daily practice: “The faculty should continue mentoring the FETP graduates to do more research” (G8). Graduates suggested creating a formal FETP Alumni Association to support the ongoing application of skills. Others appreciated the value of existing e-learning modules for supporting their learning following graduation: “The e-learning modules, I see that it is very important, [I recommend] we complete them and then send them back to you for assessment” (G8).

Most graduates reported being involved in analysing surveillance data (n = 14, 82%) and using surveillance data to guide decision-making (n = 14, 82%), including for the detection of communicable disease outbreaks (Table 5). Interview findings highlighted how aFETPNG consolidated and extended the surveillance capabilities gained during the intermediate FETPNG program. Graduates described becoming more proactive in promoting and supporting surveillance following aFETPNG, including training data providers. Several noted having leadership roles in surveillance during the COVID-19 pandemic.

Graduates provided numerous examples of longer-term surveillance outcomes resulting from their work. For example, a hospital-based surveillance initiative led by a graduate resulted in the addition of new domestic violence indicators into the national surveillance system. Surveillance tools developed during COVID-19 continued to be used following the response. One graduate developed, “a mobile-friendly app where instead of using the paper, the case investigation form is formulated on an app” (G1). Multiple other provinces contacted this graduate wanting to use this app: “They wanted that app to be used in their provinces, because the outcome was that it improved reporting, and the timeliness of reporting… There was a lot of interest from other provinces, [and] not only for COVID, but for other diseases too” (G1). Another graduate described initiating the development of a software app to capture real-time surveillance data from remote areas using satellites and smartphones. The graduate linked this initiative to their aFETPNG training: “One of the things that FETP has given me is the knowledge and skills, and now I am negotiating with one of the software engineers” (G8).

Graduates surveyed collectively investigated 55 outbreaks following aFETPNG (Table 5). The majority (n = 14, 82%) reported involvement in one or more outbreak investigations as a lead or support investigator, while three (18%) had not participated in any outbreak investigations following their training. The different types of outbreaks investigated are shown in Supplementary Annex B. Interview data demonstrated that aFETPNG was perceived as pivotal in equipping graduates with the confidence and technical capability to undertake outbreak investigations. As one participant explained, “the training provided a lot of strength and knowledge and skills to do surveillance and investigations” (G9). Graduates described systematically applying outbreak investigation approaches across diverse contexts: “I can quickly identify cases, define the outbreak, and mobilize a team for immediate action” (G3), and “I have been involved in contact tracing, sample collection, case management, community risk communication, case detection, active case finding” (G5). Many assumed leadership roles during the COVID-19 response.

Graduates also described a range of disease control measures they implemented to control disease transmission, including public awareness on the radio, immunisation campaigns, and the installation of rainwater tanks to provide potable water. One graduate highlighted a community-led approach to implementing control measures. Using skills from their training, they engaged with affected communities when traditional control measures failed: “We have mosquito net distribution… we have clinical treatment…but why do people still get malaria? I decided it’s best that I go and sit down with the community and let the community tell me how they think they should prevent themselves from getting malaria” (G8).

Most graduates surveyed reported being able to apply their aFETPNG-acquired skills to improve data collection (94%, n = 16), data management (88%, n = 15), and data analysis (82%, n = 14) (Table 5). Interview data reinforced the central role of aFETPNG in strengthening analytical capability, with one graduate explaining that the most valuable skills gained through aFETPNG were those related to, “data management, collecting data reports, analysing data, interpreting the data and trying to draw insights into what the data means and what actions we should take” (G6). Graduates reported that increased proficiency in data analysis enhanced credibility and trust within their organisations, improving their influence in decision-making processes.

A number of graduates described how they used their data skills to build the capacity of others. One graduate observed that many frontline officers responsible for key public health programs such as TB, HIV, and maternal and child health, lacked skills in analysing program data: “After going through the training, I realised that many of the officers in facilities do not know how to analyse data” (G4). After raising this concern with senior management, the importance of these skills was acknowledged by the Director of Public Health as, “something that every Officer in Charge of the facility must know”. The graduate subsequently trained health workers to routinely record and analyse data to guide the delivery of their programs: “The information must be analysed so it tells them where they’re going… every data must be recorded and placed on the board in a graph form for them to see”. Recognising the value of this initiative, the graduate’s manager authorised funds to scale up the training across the district, stating that, “once you’ve finished with the district, then you go district by district in the province” (G4).

Sixty-five percent (n = 11) of aFETPNG graduates reported involvement in operational research aimed at strengthening health programs or health systems (Table 5). Many of these initiatives were continuations or expansions of field projects initiated during aFETPNG. Graduates described a range of projects and public health interventions related to disease prevention and control programs (e.g., TB, HIV, COVID-19), non-communicable diseases, water and sanitation, and routine immunisation. Interview findings highlight how aFETPNG equipped graduates with skills to strengthen these public health programs using evidence-based strategies. Graduates spoke of engaging with community stakeholders and securing financial and human resources to strengthen public health programs.

Graduates provided multiple examples of programmatic improvements resulting from their work. These included increased TB and HIV notification rates and improved treatment outcomes through, “extending outreach programs into the community, doing mobile clinics, and combining TB and HIV, together” (G2). One graduate reported improving TB treatment success rates from 80 to 93%, describing this as, “a very significant achievement for the province… we achieved 93% treatment success rate for all TB cases in 2022, and then each quarter for this year 2023, we are also seeing that has been maintained over time” (G6). This improvement was directly linked to training: “That’s because of FETP training, giving me the skills to know how to deal with program data” (G6). Other graduates described strengthening TB and HIV services by establishing a TB and HIV screening clinic at the district level rather than requiring patients to travel long distances to a neighbouring health centre. Field epidemiology skills were also used to improve infection control practices in health centres, including during COVID-19. One graduate described pregnant women and mothers with infants coming for vaccination and waiting alongside suspected COVID-19 cases in the hospital outpatient department. They stated that, “the skills and knowledge that I acquired through the FETP training [were] helpful to improve processes [and] the services in the facilities” (G5), resulting in infectious and non-infectious patents being physically separated while waiting in the outpatient department. Graduates also used operational data to inform service planning and resource allocation. One example involved reviewing caseloads across health facilities and collaborating with partners to open new aid posts to expand access to care. After establishing several new posts, the graduate noted a reduction in caseload pressures at district-level facilities.

Graduates reported a range of broader (non-technical) professional outcomes resulting from their participation in aFETPNG. Almost all (n = 16, 94%) indicated that the program increased their confidence in the workplace. Interview data illustrated the depth of these outcomes. One graduate explained: “I can say that the FETP program has given us a lot of confidence” (G9). Others described significant personal and professional growth: “I was a nobody when I was a clinical HEO, but after being in the program, I can now do presentations, stand confidently and speak to the crowd” (G4); “I would say [FETPNG] brought me out from my place of being quiet… It has built the confidence to make decisions and even make recommendations where management are now actually recognising it” (G1).

Graduates also reported strong outcomes in leadership, communication, and management capability: “Leadership skills are one of the very important components that I’ve learned in field epi, which has helped me to be where I am now and is still pushing me up” (G8). Enhanced communication skills strengthened workplace relationships and influence: “The training had a very great impact on me personally and in the work I do with my team… I learned the communication strategies… I see that officers begin to really appreciate the way I respond to them” (G8). Others highlighted the respect they gained from colleagues: “When I talk, people respect me, I think this is a big change I’ve seen since FETP” (G3). Another described wide-ranging professional impacts: “Personally has changed me a lot, in terms of management, to manage my time, to become a team leader. It has helped a lot of things in my life, my family, my workplace, my colleagues are starting to respect me as a field epidemiologist, some of the work I am doing they are really appreciating. It has changed my life” (G9).

Almost half of the graduates (n = 8, 47%) received a promotion after completing aFETPNG and all 100% (n = 8) reported that aFETPNG was very important in achieving this advancement. Just over one-third (35%, n = 6) commenced or completed further study following aFETPNG, including four Graduate Certificates (67%) and one non-accredited training activity (33%). Interview findings reinforced the critical role of aFETPNG in creating pathways for career progression. One graduate described recognition by senior health officials based on performance improvements following training: “Based on my performance in the district, he wanted to give me a position at the provincial level… the CEO looks on my district as a role model, [he] always uses us as an example to other districts; it is only the FETP skills that I have gained that enabled me” (G8). Similarly, a graduate in a different province was asked to, “climb up higher to be provincial disease controller manager” (G4) because of their competence in data analysis and reporting. This graduate reflected: “I’ve realised it is a very impactful and very good training that I received that has impacted my life so much” (G4). Another graduate described, “being part of [a WHO] training team to support Solomon Islands… that’s a big contribution because of the FETP training” (G6).

Almost one quarter of graduates (n = 4, 24%) reported contributing to a working group or committee at the national, regional, or international level since completing their FETP training. These included a national research advisory group, a regional FETP manual working group, and the national FETPNG faculty. Nearly half of advanced-level graduates (47%, n = 8) went on to serve as FETPNG trainers and mentors. Of these, five (29%) contributed to the Frontline FETP at the provincial level, and four (24%) to the Intermediate FETP at the national level.

Senior managers and executives interviewed spoke highly of aFETPNG, the skills of graduates and the contribution of graduates to public health practice. They emphasised the rigorous nature of the program, noting that graduates, “have been through a lot of mentoring; they have been through a lot of coaching and teaching” (SME8). Improvements in performance at the district level were frequently attributed to the training: “Since we started in 2023, I can see the performance has improved at the district level; it reflects the FETP training” (SME4). Senior leaders valued a wide range of field epidemiology competencies, including, “the ability to collect, analyse, and interpret data, do presentations and develop reports, plans and budgets, and also… confidently carry out outbreak investigation” (SME8). Others stated: “FETP training is adding value… It’s equipping [graduates] with knowledge on epidemiology; that’s the part that has been missing in the medical schools” (SME5), and “You don’t get this in the university or college; this kind of skill-based study has not been taught anywhere in any college that we have in PNG” (SME3). The results produced by graduates, particularly during COVID-19, had strengthened organisational support for the program: “Senior management are aware that the training is useful, they’ve seen the result of it in the COVID response… we have the support [for FETPNG] in the management department, we have the support in the Public Health Authorities” (SME3).

Senior managers and executives described substantial contributions of aFETPNG graduates to disease surveillance, outbreak response, and health system strengthening. Surveillance was identified as a critical priority: “I see [surveillance] as the number one priority for FETP, because I can’t see any other way to improve surveillance” (SME3). Improvements were also observed across investigation, reporting, and control activities: “I could see there’s an improvement in the area of investigation, prevention and control, and also there’s improvement in how they structure their reports… I could see a big difference” (SME4). In one example, a manager spoke of the graduate’s role in a very large methanol poisoning incident which resulted in significant morbidity and mortality. The graduate, “took control of the public health education awareness, collecting samples, doing everything. And he did a very, very good report… It was written as one of the best reports so far” (SME4). This graduate went on to present his findings at the national level. Graduates were also credited with strengthening disease control programs through improved analytical and operational capability. In the HIV program, for example, one senior manager described a graduate’s contribution to, “forecasting and quantification for our drugs and test kits”, stating, “his learning can really help the program” (SME6). Another reflected on the broader shift in culture that graduates had helped drive: “They actually have a lot of influence in their place of work, there’s a lot of change… they are actually very, very conscious about data…. So that helps to uphold and improve indicators of programs” (SME8).

Senior managers and executives observed several challenges and noted areas for improvement. They indicated that, at times, there was underutilisation of graduates, partly due to roles that did not fully draw on their skills and partly due to a lack of confidence on the part of graduates to assert their new capabilities. One senior manager stated that graduates needed, “to put their hands up and say, hey, I’m an FETP graduate, I can go out with a team to do outbreak investigation, or I can do surveillance work” (SME6). Senior managers emphasised the need for greater program visibility and advocacy within health leadership structures: “As a program, we need to do senior management engagement, to tell them what the program’s about and how they can use this training” (SME6). Leadership development was seen as essential for enabling graduates to take on more senior roles, and formal recognition or accreditation of the qualification was highlighted as an important mechanism to strengthen career pathways. Suggestions included establishing a university partnership to award a recognised qualification and creating postgraduate or master’s pathways to extend field epidemiology training.

A total of 17 stories of change were documented by graduates (Supplementary Annex B). These narratives provide examples of how the application of skills acquired through aFETPNG were translated into tangible improvements across a range of public health domains, illustrating real-world outcomes and impacts at the systems, program, and community levels.

Several examples related to the COVID-19 pandemic response. One graduate was selected by the Provincial Health Administrator to serve as the first Incident Manager for the province, applying their field epidemiology skills to analyse data, prepare reports, make evidence-based recommendations for senior management, and secure financial resources for public health interventions. As Incident Manager, they were empowered to make key decisions and were responsible for providing daily updates to the National Emergency Centre. Based on reports presented, funding was secured to build COVID-19 isolation centres and acquire a new disease surveillance vehicle for the district. Another graduate served as the COVID-19 Surveillance Cluster Lead and lead trainer for risk communication and community engagement in the province. The first COVID-19 case detected in PNG occurred while this graduate was leading the provincial surveillance cluster. Another graduate coordinated two national operational research projects to understand hesitancy of healthcare workers to swab suspected COVID-19 cases, and understand drivers of vaccine hesitancy in the general population. The results of the swabbing study were presented to the National COVID-19 Control Centre of PNG and published in a peer-reviewed journal (30), and results from the vaccine hesitancy study were presented to national and international audiences.

Other graduates shared stories of how they applied FETP skills to manage supplementary immunisation activities for measles, polio, pertussis, and rubella. These graduates achieved very high immunisation coverage and were recognised as top performers in the country. They coordinated logistics, supervised immunisation staff, and engaged with communities to address vaccine hesitancy and strengthen service delivery.

Several stories highlighted outcomes and impacts relating to disease control programs. In TB control, policy recommendations developed by a graduate during their training were implemented, including providing incentives for treatment supporters and food vouchers for multidrug-resistant TB (MDR-TB) patients. The intervention resulted in no MDR-TB patients being lost to follow-up, and a 100% treatment success rate in the province since 2020. Another graduate supervised a mass screening program for TB in correctional facilities, identifying a number of previously undetected cases. Optimisation of TB/HIV delivery was also initiated following analysis of district-level data by a graduate, who subsequently established a new integrated clinic and trained staff, improving service accessibility and reducing treatment loss-to-follow-up.

Collectively, these stories of change highlight the program’s value in building national capacity to address major public health challenges and demonstrate the breadth and depth of aFETPNG’s contributions to strengthening disease control, surveillance, outbreak response, and health systems in Papua New Guinea.