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Since the first health agency's inception, public health has tackled a multitude of diverse tasks to improve population wellness. The insipient retirements among the baby-boom-era public health workforce and the events of 9/11 have stimulated the demand for training and preparedness programs.1,2 Unfortunately, the push for training has not diminished existing training barriers. The reasons for the historic and current barriers to public health training, particularly for small, rural, or medically underserved areas, can be attributed to a variety of components that impede departments' potential to serve their populations.
Training in the public health field is especially important in rural areas because of the lack of face-to-face trainings in the near vicinity and/or availability of distance-learning programs. There may be additional barriers to obtaining necessary training by staff in rural areas, which may lead to gaps in the supply of trained staff. Untrained staff may be less able to secure grant money, identify a major crisis, or prepare for and respond to an emergency event. Today, only 25% of local health departments are able to deliver 60% or more of the essential public health services.1 Furthermore, one-fifth of county health departments consider themselves unprepared for a bioterrorist attack.3
A review of the literature shows that patterns of uneven distribution of certain resources are responsible for this lack of training and occur among many facets of the public health system.1 These unevenly distributed resources include funding, knowledge, and effectiveness of available training programs. The inadequacy of these three necessary resources contributes to public health training barriers in ways that are both unique and universal.
This article describes training barriers discovered as a result of a training needs assessment initiated by the Pennsylvania – Ohio Public Health Training Center (POPHTC) in a rural health department in Ohio and compares and contrasts these empirically identified barriers to those identified through a review of the literature. Compared to this literature review, barriers to training experienced by the employees of this rural health department were found to be similar to barriers found in other rural health departments. An uneven distribution of resources may have contributed to these barriers. This article introduces a model (Figure 1) for demonstrating this uneven distribution of components or resources that can lead to training barriers. The model shows how the necessary resources are interrelated and how a deficiency in one area can affect seemingly unrelated entities in a health department.
POPHTC is one of more than a dozen public health training centers across the country that are funded by the Health Resources and Services Administration and charged with “improving the public health system by strengthening the technical, scientific, managerial, and leadership competencies and capabilities of the current and future public health workforce.”4 Funded since 2000, POPHTC's primary location is within the University of Pittsburgh's Center for Public Health Practice; the Ohio presence is maintained in the Office of Workforce Development in the College of Public Health at The Ohio State University. POPHTC's goal is to assist public health agencies in carrying out the 10 Essential Public Health Services5 (Figure 2).
Through POPHTC, the public health community has access to a wide spectrum of learning opportunities. To make the best use of limited resources, POPHTC works collaboratively with state professional organizations to address priority training topics within existing educational forums such as annual conferences. The Center also forms partnerships with state and local health agencies to assess and meet training needs in a timely and financially feasible manner. One such partnership was formed between Ohio POPHTC and a local rural health department in Ohio for the purposes of assessing training needs, building the organization's capacity to deliver training, and, ultimately, improving the practice of public health.
The health department referred to in this article is located in a rural county approximately 60 miles from the state capital, and is the sole health department in the county. It is located in the county seat and serves a population of approximately 32,500. The minority population is 2%. The percent of residents living in poverty and served by the agency is about 22%. The unemployment rate for the county is close to 9%. Manufacturing industries employ the most workers in the county. Three educational institutions are located in close proximity to the county. Finally, the county is a federally designated medically underserved area.
The health department employs 25 full-time equivalents, of which 18 are professional staff and seven are support staff. The department has five major divisions:
A training needs assessment tool was used to determine the training needs and barriers to training experienced by this local rural health department from the perspective of the organization's leadership as well as its employees. POPHTC developed the needs assessment as a three-step process based on the framework developed by Dato, Potter, and Fertman, and it encompasses five factors that serve as indicators of a learning organization: resources, policies, learning culture, programs, and leadership.6
The first step in the assessment was to administer a questionnaire consisting of 38 questions inquiring about the organization's readiness for training. This survey was administered to the leader of the health department.
The second step was a group interview with employees asking them to report their training needs, prioritize the needs, and report barriers obstructing their efforts to meet those needs. The group interview process was divided into two sections. In one, all participants were asked to respond to the following questions:
The three training priorities receiving the greatest support were further assessed during part two of the process, which asked:
The third and final part of the training needs assessment process consisted of a summary of the self-reported needs and barriers to training, including the development of a training plan for the agency by POPHTC.
The health department has a Policies and Procedures Manual that includes a section devoted to training. The following is an overview of the agency's policies:
A set amount of funding is devoted to training annually in the form of travel reimbursement and, under certain circumstances and upon Board approval, some tuition reimbursement. Training and education for the health department employees is presently obtained through the following sources:
The current technological capabilities and use within the agency is summarized in Table 1. The health department does have access to on-site and nearby satellite programs, and some employees would require training in Internet and/or e-mail use to participate in training.
This county health department:
Table 2 describes how the agency's director scored culture and leadership aspects on a scale of 1 (low) to 10 (high). The director was asked to identify critical training for administrative, supervisory, line/field, or support/clerical staff (Figure 3). During the group interview, participants indicated the highest-priority training areas as: grant writing, Microsoft® Excel, social marketing, Microsoft® PowerPoint, technology, and geographic information systems mapping.
When the group was asked to list barriers to doing their jobs more effectively, the following items were listed:
The group listed these barriers to training:
Based on the results of the assessment, POPHTC developed a training plan for the agency to adopt if desired. First, it was recommended that the health department establish an internal training oversight committee that would guide training efforts at the health department. The training plan will be more likely to succeed if employees feel that they have a part in the decision-making process.
Secondly, it was recommended that the health department review and update (if necessary) its Policies and Procedures Manual section devoted to training. Organizations with a strong infrastructure in place to support employees in their training endeavors are more likely to reap benefits from a better-trained, motivated, and more efficient workforce. The last three recommendations suggested that the health department pursue training for their employees in grant writing, computer software, and social marketing.
Results of the training needs assessment indicated that this agency has supports and barriers when it comes to its employees' training needs. In fact, the circumstances can be used to describe the situations of many local public health employees (Figure 1).
This rural health department identified money as a core barrier to training. Indeed, financial hardship has long been a basis of competency barriers.7 Specifically, securing funds is especially difficult in poor, rural, and minority areas that lack a tradition of philanthropy.8
Funding issues are partially due to dependence on levies for program support, especially at the local level. Due to recent state budget crises, public health agencies may face severe cuts, making them even more dependent on levies, as exemplified by the state of Missouri relying on local taxes for about 43% of operating funds and other local sources for another 12%.9 Similarly, in Alabama, local taxes provide 43% of health agencies' revenues. Ironically, requests for training funds can sometimes hurt the department politically, conveying an impression of departmental ineffectiveness, making communities leery of supplying money.10 This failure to gain levy funding often reduces staff effectiveness by eliminating money available for training.
If levy failure does occur, a local department may become more dependent on grant money. While useful, these funds are often directed at a specific area or disease, producing a “silo effect,”11 and are generally available for a limited time, causing cyclical funding deficits.
A contributing factor to overall rural health disparities, including training, is lack of priority at the legislative and state level.12 Some federal block grants are given to each state to distribute as it sees fit. Depending on the level of communication, remote areas may have difficulty vocalizing their needs, and states may have difficulty knowing how to distribute the funds. Furthermore, the money allotted might not be earmarked for training at the local level.
The current top-heavy distribution of education in the public health field dictates that those with advanced training are more likely to work for either higher-level government or nongovernment jobs.12 Consequently, federal health agencies have all the experts who make decisions with unknown relevance to state and local needs.13
Decisions made in upper government often create new responsibilities at the local level. Unfortunately, local departments do not always have the correct knowledge or manpower to fulfill these roles. Small departments often begin with a skills disadvantage. For example, only 3% of local health employees consider themselves as having advanced computer literacy, compared with 15% of urban workers.14 With more than 75% of local public health administrators never having received formal public health training, it may be difficult to determine if those filling positions are qualified.15 Lack of guidance is a training barrier for true public health preparedness. If no one knows what education is needed, it is likely that necessary training will not be sought.
Distribution of knowledge can also be more strategically undertaken. Many local health departments are small; two-thirds of departments serve fewer than 50,000 people, and 33% of local departments have fewer than four employees.15 Serving far from centers of academia or metropolitan areas, travel to and from training conferences may be time-consuming and costly, with no mechanism for reimbursement. Approximately 32% of local departments did not have Internet connectivity as of October 2001, but by 2005, NACCHO estimated that 93% of local health departments had continuous high-speed Internet access. As such, distance learning should be more feasible than ever.1,16 In Tennessee, only 66% of rural public health nurses—the ones often responsible for the greatest variety of services—have access to a computer at work.14 The health department we worked with has an advantage in this area: 89% of employees have access to a computer and a high-speed Internet connection at work, and 78% of employees reported using e-mail on a regular basis. The health department also has satellite broadcast capabilities.
A third form of uneven distribution is that of effectiveness of a particular training program itself, and particularly evaluation of that program. Finding training programs that are effective is sometimes the greatest challenge. Most public health administrators, including those in this county, cite “locating training to match need” as a major training barrier.7 Time and money often dictate the training; if it is unknown whether a training program is effective, there is little justification for attending.
Standards for public health departments vary greatly among and within states.17 Ohio, West Virginia, and Washington have independently developed statewide health department standards, and only a third of local health departments nationally had training plans congruent with those of their state health departments.18
Possible improvements to dispel this mixed distribution of funding, knowledge, and effectiveness may require systemic public health overhauls. More specific definitions for public health careers would be the first step in diagnosing problems, allowing for greater incentives to attend more useful training. Though implementation may be difficult, credentialing may be a definitive means of describing public health roles and monitoring the effects of training programs, thus silencing critics who question the need for or benefits of training and its funding.
The sticking point for all these improvements is the creation of consistent funding opportunities for training. The Institute of Medicine argues that providing stable funding is needed to support training and assessment.19 To achieve this, legislators and public health decision makers must broaden the scope of federal or state grants to either make them less cyclical and/or less isolated, thus alleviating some of the anxiety related to funding.
Looking at public health training barriers in light of distribution models helps emphasize that an overall global vision is somewhat lacking in today's field. Because public health is focused on the population, the system must collectively evolve to ensure that the entire population, and not just individuals living within certain jurisdictions, is being served.
Effective, affordable training is critical to the missions of local health departments, and reducing barriers to receiving these trainings will create the necessary environment for public health workers to benefit. Trainers need to seek new and innovative ways to reach rural public health professionals.