Evaluation of Training Gaps Among Public Health Practitioners in Washington State

Supplemental Digital Content is Available in the Text. Context: Identifying training gaps in public health competencies and skills is a first step in developing priorities for advancing the workforce. Objective: Our purpose was to identify training gaps in competencies and skills among local, state, and nonjurisdictional public health employees in Washington State. Our secondary aim was to determine whether training gaps differed by employees' work-related and demographic characteristics. Design: We used data from our training needs assessment of the public health workforce, conducted as an online cross-sectional survey in Spring/Summer of 2016. Respondents and Setting: Employees from governmental local, state, and nonjurisdictional public health departments in Washington State. Main Outcome Measures: Training gaps were calculated for 8 public health competencies and 8 skills, using a composite score of respondents' ratings of their “training confidence” and “training need.” For each domain and skill area, we calculated the percentage of associated items, where respondents rated their training needs as high and their confidence as low to create scores ranging from 0% to 100%. Results: The largest training gaps in public health competencies were in the Financial Planning and Policy Development domains. For skills, Quality Improvement and Developing Effective Communication Campaigns had the largest training gaps. In adjusted models, female employees or employees working in local health departments in select Washington State regions had higher training gaps in Financial Planning, Policy Development, and Quality Improvement, relative to male or state health department employees. Employees who worked in specialized programs, such as Communicable Disease Control, and Maternal, Child, and Family Health, had higher training gaps in Financial Planning and Developing Effective Communication Campaigns than those who worked in Administrative and Support Services. Conclusions: We identified important training gaps in several competency domains and skills. Findings are informing decisions about tailoring training opportunities for public health practitioners in Washington and other states.


Introduction
Training public health practitioners is pivotal for building effective public health practices and tackling a multitude of diverse tasks to improve population wellness. Undertrained staff may be less able to secure funds, identify community health needs, and prepare for and respond to a public health emergency. However, national survey such as the 2017 Public Health Workforce Interests and Needs Survey (PH WINS) reports that public health practitioners serving both rural and urban populations are having the highest training gaps in financial management, policy development, system thinking public health competencies, and skills in developing a vision for health. 1,2 Equivalently, the 2018 Accountable Community of Health (ACH) Participant Survey, conducted by Center for Community Health and Evaluation (CCHE), identifies that effective communication and quality improvement in communities need further improvements. 3,4 Nonetheless, many public health practitioners do not receive proper trainings due to time constraints, limited resources, and unavailability of training opportunities in their community. 5,6 These barriers are particularly impactful in local health departments in rural areas, where funding is limited and the demand for public health services is high. Since 2008, the 91% of state health department agencies have experienced job losses that have contributed to the decrease of the public health workforce. 7 Implementing training courses that meets with needs of public health practitioners and mitigate increase the workforce retention in local health departments. 8 Yet, there is limited research on the public health training gaps, particularly among local and tribal health departments serving rural populations.
Despite the large sample size of PH WINS, which includes participants from 47 state health departments and 26 large local health departments, smaller health departments serving rural populations are not well represented due to the sampling schemes. 9 In Washington State, most local health departments were not included in the sampling frame for a bigger survey. In the U.S., there are approximately 2,800 local health department agencies, and only six percent of them are classified as large departments, which serve about 51% of the population. 10 Thus, training needs of local health departments serving rural populations are not well understood. In addition, local health departments in rural areas are experiencing the shortage of public health workforce due to budgetary restrictions, the inability to pay competitive salaries, and difficulty in attracting candidates to a certain geographic area. 11 In 2016, the Northwest Center for Public Health Practice (NWCPHP) conducted training needs assessment in Region 10, which includes Washington, Oregon, Alaska, and Idaho. This study specifically explored to identify training gaps in public health core competencies and strategic skills among public health professionals in Washington State.

Methods
Definition of key variables: The questions related to the public health competencies were developed using the Council on Linkages between Academia and Public Health Practice's core competencies for public health professionals. 14 The questionnaire was organized into 11 domains based on the revised competency statements: 1) Data Management, 2) Communication, 3) Community Engagement, 4) Cultural Competency, 5) Financial Planning, 6) Program Planning, 7) Management, 8) Leadership in Systems Thinking, 9) Leadership in Strategic Planning, 10) Policy Development, and 11) Public Health Science. 14 The questionnaire also included questions that were related to strategic skills. The eight strategic skills included, which were: 1) quality improvement, 2) ethnics and public health law, 3) technology use: computers & software Systems, 4) working efficiently, 5) working with others, 6) communication skills, 7) decision making, and 8) developing effective communication campaign. 15 For the secondary aim, Washington health jurisdiction is determined by ACH, which includes 9 regions, and is presented in the appendices (Map 1). 14 Primary program area is defined by Public Health National Center for Innovations, which includes six program areas that are presented in Figure 5 in the appendices. The category of Administrative and Administrative support was added to in primary program area, reflecting the numerous responses for administrative and administrative support as primary program area. The conceptual models for primary aim and secondary aim are represented in the appendices.

Sample and analysis: Survey respondents included public health employees who worked in Washington
State. Public health practitioners from Washington, Alaska, Oregon, and Idaho were invited to participate.
We only reported results for Washington State in this study. The questionnaire was developed by the evaluation team at NWCPHP with the inputs from the Washington State Association of Local Public Health (WSALPHO) workforce development committee and other local and state partners.
Collection Method: The primary target population for this assessment were public health employees at the state, local, and tribal health departments. NWCPHP worked with WSALPHO to develop a communications kit, which included emails and newsletters. Health departments were able to choose from two survey dissemination methods: 1) provide email addresses of employees for NWCPHP to send individualized email links, or 2) send out a weblink to their employees.
Procedures and instruments: Survey data was collected using SurveyMonkey® (Palo Alto, CA). The survey instrument comprised of 72 items; most item response options were 5-or 4-point Likert scales.
Data on characteristics of the respondents included: 1) demographics (i.e., age, gender, race/ethnicity, education), 2) work-related characteristics (years in organization and in current position, part-time or full-time employment status, plans to retire and organizational roles); and 3) work setting characteristics (practice location, primary service area -rural, urban, suburban or all areas, primary program areas).
Statistical methods: Our main outcomes were the training gaps in public health competencies and strategic skills. For each domain within a public health core competency or strategic skill, respondents ranked their training confidence and training needs as "high", "moderate", "low", "no", or "not applicable".
Respondents were coded as having a training gap in that domain if their confidence was "low" or "no" and their need was "high" or "moderate". For each respondent, the percentage of domains with training gaps was calculated to generate a training gap score for each competency and strategic skill. Training gap scores could range from 0 to 100 training gap scores, where 0 indicated no gaps and 100 indicates training gaps in all domains in that competency and skill.
Training gap scores for a public health competency or skill were coded as missing if respondents answered less than half of the domains within that competency. Demographic and work characteristic were summarized for the sample using descriptive frequencies for categorical or continuous variables and means and standard deviations.
Primary Aim: Means and standard deviations (SD) were calculated for training gap scores for each public health core competency variable and selected strategic skills, independently. Boxplots were created to visually compare training gap scores between public health core competencies and strategic skills.
Analytical statistics: We selected two competencies and two strategic skills with the highest training gaps for the secondary aim. In univariate analyses, unadjusted associations between training gap scores for the selected competencies and skills, and demographic and work characteristics were calculated using linear regression. To determine independent associations between demographic and work characteristics and training gap scores, we also used multivariate regression models that included all variables associated with training gaps at p <0.2 in unadjusted analyses. We reported adjusted regression coefficients (b) and 95% confidence intervals (CIs). P values less than 0.05 were considered significant in adjusted analyses. Data were analyzed using Stata Statistics/Data Analysis, version 14 (Stata Corp LP, College Station, Texas). Table 1 describes the study population (n=2,612). Sixty-four percent of survey respondents selfidentified as white and more than half were female. The average of age of public health employee was       14). Compared to public health employees who worked at their organization and held the same position in less than four years, the respondents who worked at their organizations and held the same position in more than ten years had lower training gaps (β: - 12

Discussion
We found that public health employees in Washington State reported the highest training gaps in financial planning, policy development, quality improvement, and developing effective communication campaign. We also found that female public health employees had lower training gaps compared to their male counterparts across the public health competencies and strategic skills. Quality improvement and developing effective communication campaigns are important strategic skills in serving the community. Domains within of quality improvement included items such as establishing a performance management system, reporting systems for a program, developing performance indicators, and using quality improvement tools. We found that training gaps in quality improvement was differed by local health jurisdictions and supervisory roles. For instance, 76 % of survey respondents who had supervisory roles and worked in the state health department were less likely to have training gaps compared to non-supervisory employees who worked in local health departments.
Developing effective communication campaign included skills related to press releases, social media interactions, and public service announcements.
We were surprised to see gender and its associations with training gaps in competencies and strategic skills, particularly since almost half of female survey respondents held front or entry level positions. In the U.S., women represent 79% of the public health workforce and 64% of executive level employees. 12 Only two female employees are likely to reach executive level for every 100 female workers. 2,16 Concordantly, we found that out of the 1067 female respondents, only 4.5% of executive level positions is held by female, compared to 10.5% of the 571 male respondents. This is significant since our finding suggest that female employees are adequately trained, but less represented in executive and senior level positions.
Our research included data from local health departments serving rural populations that have been the subject of limited research. On a national level, 73% of public health employees work in urban health department, while only 13% of public health employees work in health departments serving rural populations. 10 However, almost half of our sample worked for the state health departments, with the remainders were equally distributed between health departments serving urban and rural populations. We found that state public health employees had lower training gaps in financial planning and quality improvement compared to employees in local health departments.
Workforce retention is another issue for both state and local health departments. About 25% of employees currently considering to leaving their organizations are planning to leave in the next year for reasons other than retirement. 10,17 This high turnover may be leading to training gaps in public health competencies and strategic skills. For instance, we found that public health employees planning to retire in more than five years had higher training gaps in financial planning and policy development than employers planning to retire in the next three years. Given that about eighty percent of our sample was public health employees planning to retire in more than five years and aged between 50 and 60 years old, adequate training maybe helpful to increase the public health workforce retention. While the public health workforce is aging for both state and local health departments with nearly a quarter of employees planning to retire by 2020, local health departments may especially face challenges in retaining appropriately trained workforce with limited resources in rural areas. 18 Previous research suggests that organizational role is pivotal in training gaps, where front line or entry-level staff had higher training needs than program management or supervisory level employees. 9 However, we did not find any significant association between organization roles and public health competencies and strategic skills. In addition, our results did not find significant associations between educational attainment and public health training gaps. Although numerous literature reviews report leadership in systems thinking as the highest training gaps in the public health workforce, we did not find significant difference in this competency. 2,19 This disparity might be due to the survey structure. Our survey included leadership in system thinking and leadership in strategic planning competencies as one competency opposed to two competencies in many studies.
This study has few limitations. First, this study utilized an online survey that was conducted by The Northwest Center for Public Health Practice at University of Washington and results only applied to public health employees who participated in the survey. Secondly, the long length of the survey contributed to missing data for the demographic questions since they were placed in the end of the survey questionnaire and often were left unanswered. Categorizing in-text options for demographic questions were not explored due to the significant number of in text answers. Lastly, the survey respondents self-reported their training confidence and needs for executing public health competencies and strategic skills. Respondents could have overestimated capacities of executing public health duties and underestimated needs of duties, which may have impacted the result of the study.

Conclusion
Our study identified training gaps in public health competencies and strategic skills that are essential for the current and future workforce to be able to address evolving public health challenges in Washington State. These findings suggest that there are opportunities for state, local and tribal health departments to prioritize certain training courses that address gaps in financial planning, policy development, quality improvement and developing efficient communication campaign. Although female public health employees have lower training gaps across all competencies and strategic skills, they are less represented at the executive or senior level positions. We did not find differences in training gaps between rural and urban health departments. Thus, this relationship needs to be explored in future studies.

Implications
The findings of this analysis provide further evidence on training gaps in public health