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HPPXXX10.1177/1524839913519647Health Promotion Practice / MonthMiner et al. / Public Health Training Centers

Introduction

Public Health Training Centers: Strategies for Preparing the Public Health Workforce Kathleen Miner, PhD, MPH, MCHES1 Susan Allan, MD, JD, MPH2 James F. McKenzie, PhD, MPH, MCHES3

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his special issue of Health Promotion Practice features the achievements and activities of the Public Health Training Centers (PHTCs) to strengthen the skills of the public health workforce. There are currently 37 PHTCs funded by the Health Resources and Services Administration (HRSA), each housed in academic settings with an accredited school or program of public health (HRSA, 2012). The PHTCs represent one of the significant efforts to address the challenge of assuring that the public health workforce has the necessary skills to respond to a wide range of continually changing community health needs and expectations. The intention of this special issue is to demonstrate the value to date of the PHTC investment in public health workforce training and also to contribute to the body of knowledge about public health workforce training so that future training activities can build on the models and strategies used and on the lessons learned from the experience of the PHTCs. Some of the work of the PHTCs has already been published in other public health and educational journals prior to this special issue. This issue features work that has not yet been published that the guest editors believe represents the scope of the training activities of the PHTCs and that also could be valuable as models or examples for the groups and individuals who are shaping public health training for the future. This is very much intended to be a stimulus for bringing greater rigor and investigation to the training and development of the public health workforce. The need for stronger skills in the public health workforce has been a widely discussed concern and is

Health Promotion Practice March 2014 Vol. 15, Suppl 1 5­S–9S DOI: 10.1177/1524839913519647 © 2014 Society for Public Health Education

a recurring priority voiced by public health leaders and organizations. Many prominent studies and reports have explored the importance and challenges of assuring that every community is served by a public health workforce with appropriate skills. Since the iconic 1988 Institute of Medicine (IOM) report The Future of Public Health, at least six other IOM reports have included extensive discussions of the gap between the type of public health workforce that is needed and the then-current state of the workforce. Each of these reports has also included extensive discussion of the challenges and their causes, along with recommendations about the skills and characteristics that are needed and how those might be achieved. Two IOM reports (IOM, 2003, 2007) are entirely about public health workforce training. Many states and national organizations have conducted assessments of public health workforce training and skills, and a consistent finding has been the need for additional training of the public health workforce to effectively meet current and emerging public health issues of the communities they serve (Association of State and Territorial Health Officials, 2011; National Association of County and City and Health Officials, 2010). There are many reasons that training the public health workforce has been identified as an ongoing

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Emory University, Atlanta, GA, USA University of Washington, Seattle, WA, USA 3 Penn State University, Hershey, PA, USA 2

Supplement Note: This article is published in the supplement “Public Health Training Centers,” which was supported by the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) through a Cooperative Agreement (UBGHP20199) to Rollins School of Public Health, Emory University.

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challenge since the 1988 IOM report. Most of the national public health associations and practice organizations have conducted studies on the composition and training background of the public health workforce and have issued analyses of the results. The findings as described by these organizations have been very consistent, no matter the geographic region or the level of public health organization (Koo & Miner, 2010). To note some of the common findings: (a) Few people working in the field of public health, and particularly in governmental public health agencies, have received any formal public health training; (b) even of those in leadership roles, only a small proportion of top managers have studied public health before coming into their positions; (c) many people enter the field of public health midcareer, having experience and often also credentials in other fields but lack understanding of core skills for the population health approach that is the basis of public health practice; and (d) public health agencies experience frequent turnover of staff in many programs, creating an ongoing training need for those newly entering the field. This special issue focuses on the work of the PHTC program, whose reach during its 13-year history has been significant in large part because of the active engagement with public health agencies and organizations across the country. Fortunately, in additional to the PHTCs, there have been more efforts than can be noted here to improve specific skills for some portion of the public health workforce. There are national, regional, and state-based public health leadership institutes. National associations have programs to support and develop new state or local agency leaders: State Health Leadership Initiative (Association of State and Territorial Health Officials [ASTHO], 2013b) and Survive and Thrive (National Association of County and City and Health Officials, 2013). Emerging efforts include the Centers for Disease Control and Prevention’s Public Health Workforce Development Initiative and the Public Health Workforce Strategy and Survey sponsored by the de Beaumont Foundation and ASTHO to identify and strengthen the crosscutting needs of the public health workforce. We trust that these initiatives and others will benefit from the programs, methods, and lessons presented in this special issue.

Public Health Training Center >> Program

The PHTC program was developed by HRSA, in part in response to the need for workforce training described in the The Future of Public Health (IOM, 1988) report. With Congressional authorization and budget allocations for the program, HRSA funded 14 PHTCs in 2000. Additional PHTCs were funded in 2010 and 2011, in part

as a result of the Affordable Care Act, resulting in a total of 37 PHTCs (HRSA, 2012). According to HRSA (n.d.), The purpose of the PHTC Program is to improve the Nation’s public health system by strengthening the technical, scientific, managerial, and leadership competence of the current and future public health workforce. Emphasis is placed on developing the existing public health workforce as a foundation for improving the infrastructure of the public health system. (para. 1)

This HRSA program focuses in particular on the training and development of workers in governmental public health agencies and partners in their enterprise. A key component of the PHTC program is that it brings together public health practitioners and the academic community in a joint effort to strengthen the skills of the public health workforce. This builds on the different knowledge and skills of each partner (Koo & Miner, 2010). Although each PHTC works closely with practice partners and related organizations in specific states or regions, the trainings developed by all PHTCs are available and are frequently used throughout the country. In 2011, the PHTCs collaborated with more than151 academic and 514 practice partners. More than 99% of PHTC trainings were cosponsored with other organizations. Other accomplishments for 2011 included 2,431 trainings delivered, resulting in 210,794 public health workers trained, with 78.5% participating through distance learning modalities. More than 12,000 different trainings or courses had been developed or were in development (Hatot, Sandvold, & Azuine, 2012). The PHTCs have drawn from the recommendations from the IOM and other reports to inform their overall planning and assessments, training content, and training modalities. The trainings that have been developed cover a wide range of topics and target diverse audiences within the public health workforce, including different levels of experience, types of program responsibility, characteristics of the population served, and sociopolitical context. Training modalities have been modified and adapted to be both more effective and more convenient for learners in the workforce, including a significant shift to using distance-based training. Overall, the trainings reflect the current knowledge of effective adult education and are structured using learning objectives, evaluations, and competency sets accepted as relevant to the public health workforce.

Public Health Workforce >>

The public health workforce has been estimated at roughly 500,000 individuals, although estimates have

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varied widely because of the lack of a consistent methodology. A collaborative project to more accurately enumerate the public health workforce is underway, sponsored by both Centers for Disease Control and Prevention and HRSA, with coordination by the Public Health Foundation. When the results are available, it should provide a better baseline for the PHTCs and others who need a detailed understanding of the workforce as a first step for building meaningful training programs. Of the estimated 500,000 public health workers, most are employed at local, state, tribal, and federal governmental public health agencies (Morrissey, 2011). These workers come primarily from the fields of health education, program or public health administration, public health medicine, nursing, veterinary medicine, dentistry, and epidemiology. They also include first responders, food inspectors, laboratory scientists, and environmental health specialists, among others (Morrissey, 2011). For these reasons, there is a particular need for training that can strengthen the public health skills of public health workers currently on the job who have not been formally trained in public health and who are not interested in an academic degree but are interested in improving their skills to be a more effective public health worker. Over the past decade, there has been a dramatic decrease in the number of public health workers, despite continued increases in the size of the U.S. population and the expanding scope of issues identified as having public health implications, such climate change, zoning for recreation, and obesity. Governmental spending cuts associated with the economic downturn of recent years accelerated staffing reductions in the governmental public health agencies. In state and local health departments, approximately 46,000 positions have been eliminated. This represents a loss of about 21% of the state and local public health workforce (ASTHO, 2013a). This situation puts even greater stress on the remaining public health workforce as they attempt to integrate their efforts more effectively and to expand their capacity. It is becoming increasingly difficult to provide the core services to meet the increasing complex needs of communities (Morrissey, 2011). Addressing the public health needs of today and of the future requires a workforce that has the necessary skills and capacity. Clearly we are far from achieving this.

Overview of this Special Issue >> The call for papers for this special theme issue sought manuscripts that describe strategies based on evidence or theoretical frameworks that are applied to the design, delivery, and assessment of PHTC program activities. Of the 24 manuscripts submitted for

consideration, 9 successfully completed a blinded, multistage review process and revisions. The order of the articles in this special issue approximates the sequence of steps for effective training, including assessment, development using validated methodologies and based on accepted public health competencies, and evaluation of outcomes. This issue begins with a future-oriented “vision” article, “Future of Public Workforce Training: Thought Leaders’ Perspectives,” in which the guest editor and coeditor reflect the comments and discussion by public health leaders about training the public health workforce for their future roles and responsibilities. William Foege and Georges Benjamin (Miner & Allan, 2014) provided visionary statements from the breadth of their experience with the field of public health as a whole. Robert Pestronk, Paul Jarris, and James Pearsol (Miner & Allan, 2014) spoke with special focus on governmental public health agencies. Janet Heinrich, Judith Monroe, and Denise Koo (Miner & Allan, 2014) provided a perspective from federal agencies that have played important roles in public health workforce training. Gary Raskob (Miner & Allan, 2014) addresses the roles of public health academia in training practitioners. Brian Castrucci and Gary Nelson (Miner & Allan, 2014) speak about philanthropic investments in developing the public health workforce. We are grateful to all of them for their wisdom and candor. Two articles present processes used to conduct needs assessments of the public health workforce. Frass et al. (2014) describe a collaborative effort between the PHTC and a state agency to assess the state public health workforce. The focus of their article is a collaborative methodology that yielded an impressive return rate. Capriles-Quirós et al. (2014) describe the needs assessment conducted of public health workers serving two very different Hispanic communities. Using survey instruments adapted to the settings, they found that both groups of professionals ranked the assessed competencies in the lowto mid-range and preferred hands-on and face-to-face training to distance learning. Many public health agencies and programs are using competency frameworks to assess workers and to develop individualized development plans. But many existing trainings can be difficult for them to use because the trainings were not developed around a competency framework. Neiworth, Allan, D’Ambrosio, and Coplen-Abrahamson (2014) describe a process for mapping public health competencies to existing trainings, including a step for validating the “retrofitted” competency mapping. Two articles address the development of training to be delivered online. Millery, Hall, Eisman, and Murrman Miner et al. / PUBLIC HEALTH TRAINING CENTERS  7S

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(2014) describe amethodical five-step process for working with instructional technology designers to create online competency-based learning modules. Their steps begin with assessing needs and identifying priority competencies, working through steps to the final feedback and evaluation that are used for continuous cycles of revision and improvement. Also addressing the need to deliver training via a platform that is convenient to employed learners, Kenefick et al. (2014) described the process they used to create a training series called “On Your Time.” This awareness-level series covers topics related to regulatory responsibilities of public health practitioners, public health surveillance, case investigation, disease prevention, health promotion, and emergency preparedness. The article by Uriarte, Cummings, and Lloyd (2014) describes the culturally competent curriculum development process they used to create a curriculum for community health workers by involving both community health workers and community members in the curriculum development process. Matson, Lake, Bradshaw, and Matson (2014) describe the process to create a public health leadership curriculum for employees in public health and medical trainees in primary care. The shared curriculum, offered through an MPH program, includes a series of didactic courses and a community-based participatory research project conducted by teams of trainees under the mentorship of health district directors. The article by McCormick et al. (2014) focuses on field component of public health training. It describes the Interns and Mentors Program for ACTion Field Placement program, a six-step process that begins with identifying field placement opportunities and ends with evaluating the program. The authors share the lessons they learned to help others who are planning similar programs. The final article in this special issue, written by Freedman et al. (2014), focuses on the importance of evaluation in the work of PHTCs. To assist others in the evaluation process, Freedman et al. describe how the Emory PHTC used its logic model to create a comprehensive evaluation plan and to create the tools needed for data collection as part of the evaluation process.

Conclusion >> The work of the PHTCs is also highlighted in other venues, including the “Stories of Impact” (Association of Schools of Public Health [ASPH], 2013a) and “Model Practices and Promising Practices” (ASPH, 2013b) that have been collected by HRSA and ASPPH. Stories of Impact provide “a snapshot of a significant contribution

made by a PHTC to their community’s public health workforce. These stories are designed to paint a picture of the types of activities the Centers are engaged in throughout the year” (ASPH, 2013a, para. 1). Although compelling and suggestive, they are more anecdote than science. The “Model Practices and Promising Practices” are identified through a process that applies clear criteria and includes a review by colleagues, so they are a stronger contribution to the evidence base for the field of public health workforce training. The articles in this special issue are intended to go beyond these and have been selected to help further develop the field of public health training by presenting peer-reviewed articles that include description, investigations, and analysis about significant components of the activities of a PHTC that can make a meaningful contribution to developing the field of knowledge about public health workforce training. We recognize that many of these articles present activities that seem somewhat preliminary or limited in scope and that there is more of what is sometimes labeled “process evaluation” than “research” in this issue. These articles describe processes used to develop and provide training that were effective within the complex academic-practice partnerships and collaborations facilitated by each PHTC. These models can be applied and adapted by other academic-practice partnerships for their particular situations and workforce training needs. Understanding that the development of knowledge is cumulative, we are pleased to offer these articles that demonstrate meaningful contributions to training the public health workforce, and we are eager to stimulate further critical and creative work by the many others who will be engaged in training the future public health workforce. References Association of Schools of Public Health. (2013a). About the PHTC: Stories of impact. Retrieved from http://www.asph.org/ document.cfm?page=1227 Association of Schools of Public Health. (2013b). PHTC model practices and promising practices. Retrieved from http://www .asph.org/document.cfm?page=1213 Association of State and Territorial Health Officials. (2011). ASTHO profile of state public health: Volume two. 2010. Retrieved from http://www.astho.org/Research/Profile-of-State-PublicHealth/ Association of State and Territorial Health Officials. (2013a). Budget cuts continue to affect the health of Americans: Update December 2012. Retrieved from http://www.astho.org/budgetcuts-dec-2012/ Association of State and Territorial Health Officials. (2013b). State health leadership initiative. Retrieved from http://www. astho.org/Member-Services/State-Health-Leadership-Initiative/ ?terms=State+Health+Leadership+Initiative

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Capriles-Quirós, J. A., McCoy, H. V., Darrow, W. W., Ríos, R. E., Rubens, M., Silva-Suarez, G., Hughes, S. (2014). A needs assessment of health department employees in Puerto Rico and Florida. Health Promotion Practice, 15, 23S-32S.

Matson, C. C., Lake, J. L., Bradshaw, R. D., Matson, D. O. (2014). The public health leadership certificate: A public health and primary care interprofessional training opportunity. Health Promotion Practice, 15, 64S-70S.

Frass, L. R., Hopkins, X. L., Smith, L. U., Kyle, J., VanderKnyff, J., Hand, G. A. (2014). A collaborative approach in workforce assessment: South Carolina’s strategies for high response rates. Health Promotion Practice, 15, 14S-22S.

McCormick, L. C., Hites, L., Jenkins, C., Chauvin, S. W., Rucks, A. C., Ginter, P. M. (2014). A regional public health field placement program: Making an IMPACT. Health Promotion Practice, 15, 71S-79S.

Freedman, A. M., Simmons, S., Lloyd, L. M., Redd, T. R., Alperin, M., Salek, S. S., Swier, L., Miner, K. R. (2014). Public health training center evaluation: A framework for using logic models to improve practice and educate the public health workforce. Health Promotion Practice, 15, 80S-88S.

Millery, M., Hall, M., Eisman, J., Murrman, M. (2014). Using innovative instructional technology to meet training needs in public health: A design process. Health Promotion Practice, 15, 39S-47S.

Hatot, N. J., Sandvold, I., & Azuine, M. (2012). PHTC 101: Project management [Webinar]. HRSA webinar series.

Miner, K., & Allan, S. (2014). Future of public workforce training: Thought leaders’ perspectives. Health Promotion Practice, 15, 10S-13S.

Health Resources and Services Administration, U.S. Department of Health and Human Services. (n.d.). Public health training centers. Retrieved from http://bhpr.hrsa.gov/grants/publichealth/ phtc.html Health Resources and Services Administration, U.S. Department of Health and Human Services. (2012). Public health training centers overview. Retrieved from http://bhpr.hrsa.gov/grants/publichealth/phtc.html Institute of Medicine. (1988). Future of public health. Washington, DC: National Academy of Sciences.

Morrissey, T. (2011). The Affordable Care Act’s public health workforce provisions: Opportunities and challenges [Issue brief]. Washington, DC: Center for Public Health Policy, American Public Health Association. Retrieved from http://www.apha.org/ NR/rdonlyres/461D56BE-4A46-4C9F-9BA4-9535FE370DB7/0/ APHAWorkforce2011_updated.pdf

Institute of Medicine. (2003). Who will keep the public healthy? Educating public health professionals for the 21st century. Washington, DC: National Academy of Sciences.

National Association of County and City and Health Officials. (2013). Survive and thrive: Roadmap for new local health officials. Retrieved from http://www.naccho.org/topics/infrastructure/ surviveandthrive/

Institute of Medicine. (2007). Training physicians for public health careers. Washington, DC: National Academy of Sciences.

National Association of County and City and Health Officials. (2010). 2010 National profile of local health departments. Retrieved from http://www.naccho.org/topics/infrastructure/profile/resources/ 2010report/upload/2010_Profile_main_report-web.pdf

Kenefick, H. W., Ravid, S., MacVarish, K., Tsoi, J., Weill, K., Faye, E., Fidler, A. (2014). On your time: Online training for the public health workforce. Health Promotion Practice, 15, 48S-55S.

Neiworth, L. L., Allan, S., D’Ambrosio, L., Coplen-Abrahamson, M. (2014). Charting a course to competency: An approach to mapping public health core competencies to existing trainings. Health Promotion Practice, 15, 33S-38S.

Koo, D., & Miner, K. (2010). Outcome-based workforce development and education in public health. Annual Review of Public Health, 31, 253-269.

Uriarte, J. A., Cummings, A. D. L., Lloyd, L. E. (2014). An instructional design model for culturally competent community health worker training. Health Promotion Practice, 15, 56S-63S.

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Public Health Training Centers: strategies for preparing the public health workforce.

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