The Core Public Health Competencies

• Analysis and assessment

• Policy development and program planning

• Communication

• Cultural competency

• Community dimensions of practice

• Basic public health sciences

• Financial planning and management

• Leadership and systems thinking

SOURCE: Council on Linkages between Academia and Public Health Practice (2001).

was recommended, regardless of the programmatic or categorical focus of the training (CDC, 2000e). Efforts are under way in the various public health training networks to establish models that will contribute to a systematic approach to competency-based training that is linked to the essential services framework and grounded in prior competency validation efforts (CDC, 2000e).

Meeting the Needs for Workforce Development

The issue of workforce training and competency is central to the success of any public health system. Governmental public health agencies have a responsibility to identify the public health workforce needs within their jurisdictions and to implement policies and programs to fill those needs. In addition, an assessment of current competency levels and needs is essential to develop and deliver the appropriate competency-based training, as well as to evaluate the impact of that training in practice settings. Workforce training and education efforts may be conducted in partnership with academia and other relevant and appropriate community partners, and ideally, a percentage of public health employees should be targeted annually for continuing education (DHHS, 2000). These and other issues are discussed in the 2003 IOM report Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century.

Training resources for the public health workforce are expanding, spurred by modest funding by HRSA for Public Health Training Centers and by CDC for Public Health Preparedness Centers. By mid-2002, there were 14 Training Centers and 15 Preparedness Centers, which form the backbone of a national public health training network. Both types of cen ters promote a variety of general workforce development strategies, although the CDC-funded centers place a heavier emphasis on bioterrorism preparedness.

Given the importance of the workforce in carrying out the mission of public health, the committee finds that education and development of the current workforce must continue to be a fundamental priority within the broader efforts to improve the state and local public health infrastructure. Therefore, the committee recommends that all federal, state, and local governmental public health agencies develop strategies to ensure that public health workers who are involved in the provision of essential public health services demonstrate mastery of the core public health competencies appropriate to their jobs. The Council on Linkages between Academia and Public Health Practice should also encourage the competency development of public health professionals working in public health system roles in for-profit and nongovernmental entities.

To facilitate ongoing workforce development, the committee encourages public health agencies to engage in training partnerships with academia to ensure the availability of coordinated, continuous, and accessible systems of education. These systems should be capable of addressing a variety of workforce training needs, ranging from education on the basic competencies to continuing education for individuals in the specialized professional disciplines of public health science.

Furthermore, the committee recommends that Congress designate funds for CDC and HRSA to periodically assess the preparedness of the public health workforce, to document the training necessary to meet basic competency expectations, and to advise on the funding necessary to provide such training.

Preparing Public Health Leaders

Senior public health officials must have the preparation not only to manage a government agency but also to provide guidance to the workforce with regard to health goals or priorities, interact with stakeholders and constituency groups, provide policy direction to a governing board, and interact with other agencies at all levels of government whose actions and decisions affect the population whose health they are trying to assure (Turnock, 2000). These tasks require a unique and demanding set of talents: professional expertise in the specific subject area; substantive expertise in the content and values of public health; and competencies in the core skills of leadership. Those who have mastery of the skills to mobilize, coordinate, and direct broad collaborative actions within the complex public health system must lead in implementing the actions outlined in this report. They require the skills for vision, communication, and implementa tion. Although many of these skills are innate for most professionals and other leaders, they need constant refinement and honing.

CDC has pioneered the development and funding of a national Public Health Leadership Institute, and in the intervening dozen years, more than 500 leaders in public health have been exposed to leadership training and skill building (described in more detail in the Academia chapter). Furthermore, a similar network of State and Regional Public Health Leadership Institutes has been funded and, over time, has developed the capacity to work collaboratively through a national network, which permits institutes to benchmark and share best practices and continue the process of learning needed to help with state-of-the art curriculum and educational training efforts. Equally notable has been the development of the Management Academy for Public Health, a joint effort of the major public health philanthropies. Although effort is still at an early stage, this academy has already generated graduates who work hand in glove with senior leadership in public health organizations. Furthermore, the Turning Point Initiative devotes efforts to increasing collaborative leadership across all sectors and at all levels (Larson et al., 2002)

Another key to leadership is continuity in office long enough to exert the leadership and to provide the institutional memory to defend public health agencies and the public health sector from the political winds of the moment. Yet, the committee finds there has been great difficulty in recruiting, developing, and retaining the leaders so vital to the job.

A state health official's term, if that official is a political appointee, is tied to the governor's term. Health officials must work with legislators who operate on 2-year terms. Given that the average tenure of a state health officer is relatively short (an average of 3.9 years and a median of 2.9 years) (ASTHO, 2002), many state health officials find it difficult to create longer-term plans for achieving health goals on shorter-term time frames (Meit, 2001). Additionally, because state health officers report to many governing bodies, they generally have less direct access to policy makers, and state health officials must prioritize the issues that they think deserve the most attention (Meit, 2001). Political factors at the state level can also have a significant impact on the abilities of public health leadership to influence policy. To address the specific issues of discontinuity occasioned by the rapid turnover, particularly of state health officials, the Robert Wood Johnson Foundation has funded a unique State Health Leadership Initiative administered by the National Governors Association to immerse newly appointed officials in a curriculum for political leadership and provide a network of resources and mentors.

Governmental public health leadership is a critical component of the infrastructure that must be strengthened, supported, and held accountable by all of the partners of the public health system and the community at large. For this reason, the committee recommends that leadership training, support, and development be a high priority for governmental public health agencies and other organizations in the public health system and for schools of public health that supply the public health infrastructure with its professionals and leaders.

Considering Credentialing as a Tool for Workforce Development

Credentialing is a mechanism that is used to certify specific levels of professional preparation. There are many different forms of credentials, including academic degrees, professional certifications, and licenses. For example, medical credentials include medical degrees to certify successful completion of course work, professional testing (e.g., through medical board exams) to provide evidence of qualification to practice medicine, and medical licensing to establish compliance with state standards for medical practice. An individual credentialed as a Certified Health Education Specialist (CHES) has successfully completed a course of study and passed a competency-based test.

Although some public health workers are credentialed as physicians, nurses, health educators, or environmental health practitioners, few are credentialed within those professions specifically for public health practice. Most physicians working in public health lack board certification in preventive medicine or public health; most nurses working in public health lack credentials in community public health nursing; and most individuals working as health educators lack the CHES credential. Furthermore, no single credentialing or certification process has been established to test the various competencies required for the interdisciplinary field of public health; thus, the majority of the public health workforce (80 percent) lacks credentials (HRSA, 2000).

Given the importance of establishing and maintaining a competent public health workforce, CDC and other public health agencies and organizations, including NACCHO, the Association of State and Territorial Health Officials (ASTHO), the Association of Schools of Public Health, and the American Public Health Association (APHA), are examining the feasibility of creating a credentialing system for public health workers based on competencies linked to the essential public health services framework. CDC (2001d) has recommended the use of credentialing. Such a process would complement efforts to establish national public health performance standards for state and local public health systems based on the essential public health services framework and the related objectives of Healthy People 2010 (Objective 23-11) (DHHS, 2000). Although this national effort focuses on experienced public health leaders, support is growing for the concept of credentialing at a basic level all public health workers and at an intermediate level the experienced professionals from many disciplines who share the need for higher-level, cross-cutting competencies in the areas of public health practice, community health assessment, policy development, communication, and program development and evaluation.

Certification or credentialing would help establish that public health practitioners have a demonstrated level of accomplishment in and mastery of the principles of public health practice. In terms of building the capacity of the public health workforce, the credentialing process could help document the knowledge, skills, and performance of experienced workers who may not have formal academic training and could encourage other workers to seek additional training to meeting credentialing requirements. An especially important component of this process is that it could play a key role in shaping the training and preparation of future public health practitioners and leaders.

The key challenge is whether and how public health organizations can begin to integrate competency-based credentialing in their hiring, promotion, performance appraisal, and salary structures. Although the idea of credentialing has considerable support at the federal level, states and particularly localities have voiced concerns that workforce credentialing mandates may become too closely tied to federal funding mechanisms. In these situations, the fiscal impact could be grave for public health departments that do not or cannot meet credentialing requirements (community informants, personal communications to the committee, 2001).

The committee finds that in the ongoing debate about public health workforce credentialing, what is most needed is a national dialogue that can address the full range of issues and concerns. Therefore, the committee recommends that a formal national dialogue be initiated to address the issue of public health workforce credentialing. The Secretary of DHHS should appoint a national commission on public health workforce credentialing to lead this dialogue. The commission should be charged with determining if a credentialing system would further the goal of creating a competent workforce and, if applicable, the manner and time frame for implementation by governmental public health agencies at all levels. The dialogue should include representatives from federal, state, and local public health agencies, academia, and public health professional organizations who can represent and discuss the various perspectives on the workforce credentialing debate.

Special Need for Communication Skills

The role of communication in public health practice cannot be underestimated. It is crucial for the successful performance of public health's core functions and essential services. Governmental public health agencies must communicate effectively internally as well as externally with other governmental agencies and nongovernmental stakeholders and partners. Informing and advising the public about health promotion and disease prevention are standard duties of both state and local public health agencies, and listening to community voices is also critical for programs to be effective. In emergency situations, public health professionals must have the ability to communicate clearly and effectively—being aggressive and credible enough to command attention—with both the public and other officials about the nature of the health hazards and the steps necessary to minimize health risks.

The response to the discovery of anthrax exposures in the fall of 2001 brought into sharp focus the importance of effective communication in the face of serious health risks. According to New York Times medical reporter Dr. Lawrence Altman, lapses and delays in communication with the public and with public health and health care professionals could have made the situation worse had the anthrax exposures been more widespread (Altman, 2001). Altman found that the delay was attributed in part to Federal Emergency Response Act restrictions about disclosing information and to the Federal Bureau of Investigation's (FBI's) criminal investigation. Altman suggested, however, that CDC could have issued information as a part of the parallel public health investigation that was already under way. The initial paucity of information on anthrax and the investigations in the Morbidity and Mortality Weekly Report (MMWR), one of CDC's most valuable means of quickly informing public health and health care professionals about communicable diseases, was also noted (Altman, 2001). MMWR's editor reported being "out of the [information] loop" for some time (Altman, 2001). It should be noted that CDC used the Health Alert Network many times after September 11, 2001, to alert public health officials and to disseminate information.

The federal government's handling of the anthrax attacks also prompted criticism of DHHS for uncoordinated communication as well as a convoluted and inadequate public communication strategy (Connolly, 2001). For example, as reported by the press, the department's initial decisions to direct all media requests through the Secretary's press office effectively silenced CDC, FDA, and NIH, the agencies with the most relevant expertise (Connolly, 2001). The lack of information from DHHS was also frustrating to other federal, state, and local leaders and governmental public health officials, some of whom learned about new cases and contamination in their states though network and cable television newscasts (Connolly, 2001). The lesson from these and other communication breakdowns is evident: clear and effective communication, both internal and external, is a critical service of the governmental public health infrastructure.

Under more normal circumstances, public health communication is important for gathering information from the community about their health concerns as well as delivering and even "marketing" health information to the public. Because the responsibilities of public health agencies cover all aspects of health, public health officials are in a unique position to provide timely, accurate health-related information to the public on a wide variety of topics, ranging from depression and other mental health issues to obesity and physical activity, environmental health and safety, emergency preparedness, and policies that affect health or health outcomes.

However, few public health agencies have staff members who are trained to interact effectively with the public and to work effectively with the news media. In fact, the most recent examination of the public health workforce indicated that 575 individuals in the public health workforce have the expertise to be classified in the category of "Public Relations/ Media Specialist" (HRSA, 2000). Of these 575 people, most are working in DHHS and other federal health agencies. Of the others, 115 are working in state and territorial public health agencies and 12 are working in voluntary agencies (HRSA, 2000).

Given the tremendous potential of the mass media and evolving information technologies, such as the Internet, to influence the knowledge, normative beliefs, and behavior patterns of individuals and groups, governmental public health agencies must be prepared to use these communication tools. The public health workforce must have sufficient expertise in communications to be able to engage diverse audiences with public health information and messages and to work with the media to ensure the accuracy of the health-related information they convey to the public. For example, public health officials can develop relationships with journalists and assist them in accurately representing health risks and interpreting the significance of new research findings so that reporting on public health issues is accurate and members of the public can make informed decisions about protecting their health.

For these reasons, the committee finds that communication skills and competencies are crucial to the effective performance of the 10 essential public health services and the practice of public health at the federal, state, and local levels. Therefore, the committee recommends that all partners within the public health system place special emphasis on communication as a critical core competency of public health practice. Governmental public health agencies at all levels should use existing and emerging tools (including information technologies) for effective management of public health information and for internal and external communication. To be effective, such communication must be culturally appropriate and suitable to the literacy levels of the individuals in the communities they serve. To build this capacity in the public health workforce, communications skills and competencies should be included in the curricula of all workforce development programs. Communication competencies should include training in risk communication, interpersonal and group methods for gathering and transmitting information, and interfacing with the public about public health information and issues, as well as the interpretation of health-related news. This is addressed in greater detail in a companion report, Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century (IOM, 2003).

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