Creating a Vision for a Healthier Workforce Using a Systems-Based Approach.

CONTEXT: The public health system faces unprecedented challenges due to the pandemic, racism, health inequity, and the politicization of public health. At all levels of the system, the workforce is experiencing distress, burnout, safety issues, and attrition. Public health is being challenged to demonstrate and justify its impact and value, while also leveraging opportunities for learning and system strengthening. PROGRAM: To explore the current state and identify opportunities to strengthen the public health system, the Region 7 Midwestern Public Health Training Center (MPHTC), with support from Engaging Inquiry, embarked on a distinctive type of systems analysis, called "dynamic systems mapping." IMPLEMENTATION: This approach brought together diverse sectors of public health partners in the region to develop a rich contextual narrative and system-level understanding to highlight and align existing and emergent strengths, areas for growth, and tangible goals for the immediate- and long-term sustainability of local and regional health. EVALUATION: Focus groups and workshops were conducted with diverse practitioners to identify upstream causes and downstream effects of 11 key forces driving system behavior. These focus groups resulted in the development of a visual map that MPHTC is utilizing to identify opportunities for leverage, develop strategies to maximize the potential impact of these leverage points, as well as facilitate continuous learning. DISCUSSION: Public health utilization of systems mapping is a valuable approach to strengthening local and national system responses to current and future public health needs. Outcomes and lessons learned from the systems mapping process are discussed.

Capacity Building for Public Health: Participant-Guided Training.

Growth in the demand for public health services, along with limited funding, makes workforce collaboration and capacity building imperative. The faculty and staff of the Midwestern Public Health Training Center, with two Robert Wood Johnson Public Health Nurse Leaders, postulated that training could be more effective, and public health workers more effective in the field, if workers contributed to training format and content. The learning paradigm was tested on diabetes prevention and self-management programs. Public health professionals were surveyed on infrastructure, practices, roles, and gaps in diabetes-related services. Responses influenced the format and content of a one-day diabetes summit training program. Participants submitted evaluations immediately afterward. Eight months postsummit, participants were surveyed to self-assess behavioral changes attributed to the training. Using the Kirkpatrick model for evaluation, participants (n = 112) stated that the training met their expectations and that knowledge gained was consistent with stated training objectives. Qualitative postsummit survey results indicated that improvements in participants' delivery of diabetes prevention services to the public could be attributed to the training they received at the summit. Results suggest that training about specific programs and practices, as well as facilitated sessions of collaboration, can yield individual and organizational change.

Factors affecting the progress of community health assessment and improvement activities in kansas.

CONTEXT: Community health assessment (CHA) and community health improvement planning (CHIP) are important functions for local health departments (LHDs) but may present challenges, particularly in rural settings. OBJECTIVE: The purpose of this 2-year, mixed-methods study was to identify factors that impede or promote the timeliness and quality of CHA-CHIP completion in Kansas. DESIGN: Focus group interviews, conducted at baseline (2012) and at 1 year (2013), included 15 and 21 groups, respectively. Scores from a 12-item attitudinal survey that explored participants' confidence to perform CHA-CHIP activities were collected in tandem with focus groups. SETTING: Kansas counties that planned to conduct a CHA-CHIP process during 2012 and/or 2013 were eligible to participate. PARTICIPANTS: There were 128 study participants (57 in 2012, 71 in 2013), who were predominantly female (83%), aged 51 years or older (61.4%), and lived in rural areas (84.6%). Public health region representation in 2012 and 2013 was 73% and 93%, respectively. MAIN OUTCOME MEASURES: Changes in perceptions about CHA-CHIP inputs, process, outputs, outcomes, and self-efficacy to perform CHA-CHIP activities were explored. RESULTS: Progress in CHA-CHIP implementation was reported in 2013. Most participants perceived the CHA-CHIP process as valuable and enhanced the LHD's visibility. Rural participants reported having completed the CHA phase, whereas urban LHDs had progressed into the planning and implementation stage. Potentiators of the CHA-CHIP process included (1) parallel assessment activities conducted by other community organizations, and (2) for rural counties, a functioning 501(c)3 community health coalition. Perceptions about the importance of partnership and leadership were unchanged. A multivariate regression analysis revealed a significant time effect and rural-urban difference in perceived self-efficacy. CONCLUSIONS: Workforce development and public health system development issues are central concerns identified by this study. Local health departments with constrained resources and limited staff, despite additional training, are unlikely to develop the capacity needed to effectively support CHA-CHIP, making long-term sustainability uncertain.

Voices across Kansas: community health assessment and improvement efforts among local health departments.

CONTEXT: Community health assessment (CHA) and community health improvement planning (CHIP) is central to public health accreditation and essential functions and therefore important to local health departments (LHDs). However, rural states face significant challenges to pursue public health accreditation. OBJECTIVE: The purpose of this statewide study was to identify factors that impede or promote the timeliness of CHA and CHIP completion. DESIGN: Fifteen focus groups, representing 11 of 15 public health regions, were conducted via telephone, using a structured interview script between April and September 2012. SETTING: The sampling frame for the project was represented by counties in Kansas that planned to conduct a CHA-CHIP activity during 2012. PARTICIPANTS: Participants (N = 76) were LHD administrators, hospital representatives, and key community stakeholders from frontier, rural, and urban settings who were involved in CHA-CHIP activities. They were predominantly female (86.0%) and 51 years or older (66.7%). MAIN OUTCOME MEASURES: The study assessed perceptions and opinions about the inputs, process, outputs, and outcomes of CHA-CHIP activities within the community. RESULTS: Overall, CHA-CHIP implementation in Kansas was in its early stages. Rural counties reported a lack of capacity and confidence to perform many CHA-CHIP activities. Early CHA-CHIP adopters were located in more populous, metropolitan areas and had progressed further into the CHA-CHIP process. Regardless of rural/urban status, a history of collaborative activity among community stakeholder groups appeared to promote progress in CHA-CHIP completion. Participants reported that additional funding, time, trained staff, technical assistance, and community leadership were needed to conduct CHA-CHIP activities. Barriers included maintaining required LHD services while conducting assessment and planning activities and differences in public health and federal cycles for performing CHA. CONCLUSIONS: Study findings have implications for strengthening rural workforce development and technical assistance for CHA-CHIP activities.

Generating social capital through public health leadership training: a six-year assessment.

Social capital, or a sense of partnership leading to shared goals, provides a means for addressing today's public health workforce challenges. This concept is particularly important in underserved rural areas, though efforts to intentionally generate social capital have been limited. Within the rural state of Kansas, the Kansas Public Health Leadership Institute (KPHLI) has implemented a social capital pre/post assessment to quantify the impact of KPHLI training on social capital within the state's decentralized public health system. This paper discusses 38 assessment items related to bonding, bridging and linking social capital. The assessment was completed pre and post training by 130 of 148 scholars (87.8%) in six KPHLI training cycles. Data were analyzed using Wilcoxon paired t-tests in SPSS. Thirty-five of 38 items demonstrated statistically significant increases at post-test, across all 10 sub-domains. Leadership training by the KPHLI fosters quantifiable increases in characteristics of social capital, which are essential for public health systems to cope with increased workforce demands and prepare for accreditation. This study represents a key first step in examining the deliberate generation of social capital within a decentralized rural environment.

Competency-based impact of a statewide public health leadership training program.

Previous public health leadership training research has assessed regional or national programs or evaluated program effectiveness qualitatively. Although these methods are valuable, state-level program impact has not been evaluated quantitatively. Public health core and leadership competency assessments are administered pre and post Kansas Public Health Leadership Institute training (N = 94). Wilcoxon signed rank tests note significant increases by each competency domain. Data are stratified by years of experience, level of education, and urban or rural status, and correlations calculated using Spearman's rho tests in SPSS/PC 14.0. Post training, participants improve significantly in all competency domains (p < .001). Participants with lower education, fewer years of experience, and rural status improve more in certain core competency domains. Lower education and rural status correlate with greater improvement in certain leadership competency domains. Similar assessment methods can be used by other public health education programs to ensure that programs appropriately train specific workforce populations for national accreditation.

Perspectives on research among Kansas County health department administrators.

Collaborations between academic researchers and local practitioners build on the strengths of both parties; however, several barriers often prevent the development of such partnerships. The purpose of this focus group study was to gain a better understanding of perceived barriers and benefits of developing academic partnerships from the perspective of local health department (LHD) administrators throughout the state of Kansas. Six focus groups (n = 49) were conducted with LHD administrators from 50 percent of the state's counties. Verbatim transcripts were coded by three independent investigators, and the research team reached consensus on the major themes. Five saturated themes emerged: (1) perceptions about research varied but were initially negative, (2) barriers to engaging in research included limited capacity and poor perceived relevance, (3) perceived benefits of research were largely related to professional growth and practice improvement, (4) uncertainty existed about how research fits into their professional role, and (5) university researchers were perceived as out of touch with community needs. Participants' negative perceptions of research were influenced by a lack of resources, time, and skills, and a lack of connection between research activities and primary clinical responsibilities. However, despite many negative perceptions, research was rated as highly important. Findings have implications for strategies to engage LHDs in academic collaborations such as targeting research projects to fill an existing need identified by LHD staff.

Mental health emergency preparedness: the need for training and coordination at the state level.

INTRODUCTION: The coordination and integration of mental health agencies' plans into disaster responses is a critical step for ensuring effective response to all-hazard emergencies. PROBLEM: In order to remedy the current lack of integration of mental health into emergency preparedness training, researchers must assess mental health emergency preparedness training needs. To date, no recognized assessment exists. The current study addresses this need by qualitatively surveying public health and allied health professionals regarding mental health preparedness in Kansas. METHODS: Participants included 144 professionals from public health and allied fields, all of whom attended one of seven training presentations on mental health preparedness. Following each presentation, participants provided written responses to nine qualitative questions about preparedness and mental health preparedness needs, as well as demographic information, and a program evaluation. Survey questions addressed perceptions of bioterrorism and mental health preparedness, perceptions about resource and training needs, as well as coordination of preparedness efforts. RESULTS: Overall, few respondents indicated that they felt their county or community was prepared to respond to an attack. Respondents felt less prepared for mental health issues than they did for preparedness issues in general. The largest proportion of respondents reported that they would look to a community mental health center or the state health department for mental health preparedness information. Most respondents recognized the helpfulness of interagency coordination for mental health preparedness, and reported a willingness to take an active role in coordination. CONCLUSIONS: The current study provides important data about the gaps regarding mental health preparedness in Kansas. This study demonstrates the present lack of preparedness and the need for coordination to reach an appropriate level of mental health preparedness for the state. These findings are the first step to implementing effective distribution of information and training.

Regionalization: collateral benefits of emergency preparedness activities.

INTRODUCTION: To assess the impact of regionalization of Kansas counties associated with emergency preparedness since 2002 via local health departments (LHDs). METHODS: Three focus groups were conducted in May 2005 with 31 Kansas health department employees. Most participants were public health administrators, women, and 40 years or older. RESULTS: Regionalization was perceived as "absolutely necessary" by participants and resulted in improved collaboration and communication among LHDs. The process supported the development of relationships, trust, and mutual respect among LHDs and other governmental agencies. Participants agreed that LHD functioning has improved the delivery and availability of public health services, increased the efficiency and timeliness of operations, and enhanced public health's visibility in emergency preparedness efforts. Moreover, regionalization added resources to LHDs including personnel, knowledge, technology, technical expertise, and fiscal resources. Dissatisfaction with regionalization was associated with insufficient funding, frustration with changing preparedness guidelines, and differences between state and local expectations. Participants identified four issues necessary to sustain regions: funding, documented benefits, commitment from LHDs and their communities, and engagement from local elected officials. DISCUSSION: The regionalization process has been beneficial for LHDs and produced tangible and intangible benefits. Barriers to regionalization expansion should be addressed for additional collaborative ventures.

Academic-practice partnerships for community health workforce development.

Despite increasing attention to academic-practice partnerships for health practice and workforce development, guidelines for how to implement such partnerships are few. The Kansas Public Health Workforce and Leadership Development (WALD) Center provides a successful example of such a partnership. The WALD Center implements public health education and training projects through a collaborative process of health needs identification, program conceptualization, research, and program evaluation. Such coordination allows for continuous practitioner-oriented program development and the sharing of a rural state's scarce resources between interconnected projects. The WALD Center's methods provide a model for academic-practice partnerships for community health practice and workforce development, even in environments with scarce health resources.

"Public health investigation": a pilot, multi-county, electronic infectious disease exercise.

INTRODUCTION: Funding increases after September 11, 2001 have provided impetus to improve public health emergency preparedness plans. Training of local health department staff and coordination between counties are important components of these plans. Electronic media have been used to facilitate dissemination of training, and a need for evaluation has been identified. METHODS: Public Health Investigation (PHI) was conducted in 6 Kansas counties during February 2005 in an electronic, in-office format. The quantitative evaluation consisted of pre- and postsurveys. Questions measured self-reported improvements in 4 areas: surge capacity, coordination between counties, risk communication, and protocols and procedures. RESULTS: Although all 4 areas showed improvement, 2 showed statistically significant improvement. At the postsurvey, participants reported significantly improved abilities to (1) participate in a coordinated, multidisciplinary response to an infectious disease outbreak (P = .003) and (2) identify the need for and implement surge capacity (P = .017). CONCLUSIONS: Increased collaboration between counties and partner agencies may be the greatest strength of PHI, a multi-county, real-time exercise. This format strengthens regional bonds and is cost-effective. The PHI may be a useful model for other states wishing to use a regional approach for training, thereby strengthening regional bonds.

Social networks and best practices in public health: the example of regional billing groups.

OBJECTIVE: Rising health care costs, increased demand for clinical services, and reimbursement difficulties created a funding shortage among local health departments in the state of Kansas. This intervention established regional billing groups to provide professional support and increase third-party reimbursement. DESIGN: Through feedback sessions, billing clerks provided qualitative responses about training needs. These informed the process of establishing billing groups in each state health district. SAMPLE: All billing clerks in the state's 6 regional health districts were invited to participate, as were insurance and billing software representatives. INTERVENTION: Between April 2002 and September 2004, 6 collaborative groups were established. Billing clerks received professional support and training from peers, insurance representatives, and software providers. An interagency billing advisory team was established to coordinate training activities between groups. RESULTS: These groups have allowed local health departments to increase reimbursement revenue by 50%-75%, allowing for the provision of expanded health services to client populations. CONCLUSIONS: These methods can serve as a model for other states, particularly those with considerable rural populations or decentralized health care systems. Still, funding shortages persist, and public health billing clerks will continue to need ongoing training in the most current and effective billing methods.

Terrorism and mental health in the rural Midwest.

INTRODUCTION: Since the terrorist attacks of 11 September 2001, the amount of terrorism preparedness training has increased substantially. However, gaps continue to exist in training for the mental health casualties that result from such events. Responders must be aware of the mental health effects of terrorism and how to prepare for and buffer these effects. However, the degree to which responders possess or value this knowledge has not been studied. METHODS: Multi-disciplinary terrorism preparedness training for healthcare professionals was conducted in Kansas in 2003. In order to assess knowledge and attitudes related to mental health preparedness training, post-test surveys were provided to 314 respondents 10 months after completion of the training. Respondents returned 197 completed surveys for an analysis response rate of 63%. RESULTS: In general, the results indicated that respondents have knowledge of and value the importance of mental health preparedness issues. The respondents who reported greater knowledge or value of mental health preparedness also indicated significantly higher ability levels in nationally recognized bioterrorism competencies (p < 0.001). CONCLUSIONS: These results support the need for mental health components to be incorporated into terrorism preparedness training. Further studies to determine the most effective mental health preparedness training content and instruction modalities are needed.