Abstract
The Western Region Public Health Training Center (formally the Arizona Public Health Training Center) conducts competency-based needs assessments and provides workforce development assistance to public health agencies in the U.S. Department of Health and Human Services Region IX. Since its launch in 2012, the Center’s Public Health Essentials in Action Training has evolved. It is now offered in-person and online and has been adapted for rural communities. The evolution of the training, beginning with course planning and development, is described, as well as how factors in the public health workforce influenced the course’s evolution and how the course has been adapted for different platforms and populations. Finally, an overview of evaluation efforts offers insight into course effectiveness for this and other trainings offered by the Western Region Public Health Training Center.
Introduction
Public health is the organization of all efforts that advance the well-being of people and communities by preventing disease, promoting health, and prolonging life. The public health workforce (PHW) comprises individuals that provide public health services, which create conditions that ensure population health (Beck & Boulton, 2012; Tilson & Gebbie, 2004) and the workforce can be part of governmental organizations, community-based organizations, voluntary organizations, private or for-profit organizations, and health care systems (Beck & Boulton, 2012; Tilson & Gebbie, 2004). Public health professionals include nurses, educators, physicians, engineers, social workers, community health workers, administrators, clerical staff, volunteers, and many other professions (Beck & Boulton, 2012; Rosenstock et al., 2008; Tilson & Gebbie, 2004).
Currently, less than half of the PHW has formal training in public health and many have only limited training in general (Stewart, Halverson, Rose, & Walker, 2010; Yarber et al., 2015; Lieder, Harper, Bharthapudi, & Castrucci, 2015). Thus, assuring workforce competence is one of the domains required for health department accreditation (Yarber et al., 2015).
The 3 core functions and 10 Essential Public Health Services provide context for the purpose and practice of public health. The first was outlined in the 1988 Institute of Medicine Report and the latter in the 1994 Public Health in America statement. Their relationship is illustrated in Figure 1. Understanding how the public health system functions is a crucial first step in training the workforce and not only clarifies one’s professional role within the public health system but also how other positions inside and outside of an organization are interconnected in the provision of public health services (Centers for Disease Control and Prevention [CDC], 2014).
The 3 core functions and 10 essentials services illustration.
The introductory public health course Public Health Essentials in Action (PHEIA) was developed by the Arizona Public Health Training Center (AzPHTC) for the PHW, particularly those with little to no formal public health education. Underlying the course are concepts and principles related to adult learning, professional education, characteristics of the PHW, delivery of in-person versus online courses, and public health topics.
Applying Adult Learning Principles to the Development of Continuing Education Courses
The development of professional continuing education (CE) courses is guided by principles of adult learning. Merriam (2001) described two foundational concepts of adult learning: andragogy and self-directed learning. Andragogy posits that adults: (a) have an independent self-concept and can direct their own learning, (b) have accumulated a reservoir of life experiences that is a rich resource for learning, (c) have learning needs closely related to their changing social roles, (d) are problem-centered and interested in immediate application of knowledge, and (e) are motivated to learn by internal rather than external factors (Knowles, 1980). Self-directed learning is characterized as learning that is widespread in nature, occurs as part of an adult’s everyday life, and does not depend on a trainer or a classroom (Merriam, 2001).
The use of lectures in medical CE has been widely criticized due to the inherent lack of learner engagement and failure to change performance or health care outcomes (Summers, Waigandt, & Whittaker, 2005). While such interventions may increase competence in other ways, lectures alone have not played a significant role in improving physician performance or patient care (Davis et al., 1999). Thus, CE in public health now uses a less didactic approach, and activity-based CE has become more common. The use of a combination of interactive and didactic formats with a focus on outcomes is recognized as a notable improvement in the effectiveness of CE programs (Forsetlund et al., 2009).
Adapting In-Person Continuing Education Courses to Online Formats
Adapting in-person CE to online formats is a challenge; however, many public health organizations are making this change to meet the demand for online education, with its increased accessibility and sustainability. Importantly, students taking online courses, as well as students in traditional courses, both appear to achieve learning goals (Summers et al., 2005). Course developers now have the opportunity to utilize a wide variety of course platforms with different options for course styles, navigation, and student–course interaction, allowing organizations to offer unique online CE courses that replace traditional in-person training. Online training can also be evaluated via online surveys of participants and training effectiveness can be measured and reported by incorporating pre- and posttraining knowledge assessments.
Studies show that online learning is a promising delivery approach for the CE of health professionals (Wallner, Kendall, Hillers, Bradshaw, & Medeiros, 2007). Best practices for online learning are outlined by the CDC’s E-learning Essentials guide and are incorporated into the Quality Matters standards (CDC, 2011). Six essential components and best practices for CDC’s E-learning developers are analysis, interactivity, interface and navigation, content, product evaluation, and learning assessment (CDC, 2011).
PHEIA Course Development
The evolution of the PHEIA course began with an assessment conducted by the AzPHTC and it was developed based on adult learning principles. Following a pilot of the course, the training was initially offered to the PHW in Arizona County health departments and the state health office. The course was later converted into an online course, making it available nationally through TRAIN.org, an online menu of courses managed by the Public Health Foundation. Finally, the course was adapted for tribal health departments (THDs), and a Training of Trainers (TOT) course for PHEIA was developed to reach a wider audience and address sustainability. Each phase of the evolution of the PHEIA is described below.
Initial Steps
The AzPHTC conducted a training needs assessment with its 40-member Leadership Council, composed of leaders from public health agencies and departments, as well as community-based organizations. This assessment found a pressing need for introductory public health training for entry-level and mid-level public health professionals. Additional feedback included a request for a greater focus on the three core functions and 10 Essential Public Health Services. Thus, the vision for the PHEIA course was of an introductory-level course promoting these principles.
The AzPHTC created the half-day PHEIA course through consultation with expert advisory panels in an iterative, multistage development and review process of the course content and instructional design. These panels comprised individuals representing entry and upper level public health professionals within the Arizona PHW. The intent of this ongoing academic/practitioner partnership was to ensure that the course met local needs while maintaining relevance for a broader audience.
Over 30 individuals representing all levels of the workforce as well as community members were interviewed for video clips used in the PHEIA course. These engaging, highly relevant videos illustrated the core content of the training and were coupled with interactive learning activities and individual action planning to encourage application in everyday professional life.
During the development stage, the production team discussed the role of the course objectives in developing an assessment for the course. The development team determined that the most useful assessment of the program would be participants’ development of a personal action plan outlining a specific goal related to their role within their organization. This plan could be directly implemented at their workplace. It was also determined that the PHEIA instructor would maintain a copy of each action plan for follow-up with participants. The PHEIA course consists of the following sections: Introduction, What is Public Health, Assessment, Policy Development, Assurance (the three core functions and their associated essential services), Bringing it All Together, and Developing an Action Plan.
Pilot Testing and Launch
A pilot test was conducted in February 2013 in Phoenix at the Arizona Health Building where the AzPHTC and the Arizona Department of Health Services share a training room. Attendees included representatives from AzPHTC and individuals from the Maricopa County Health Department. This pilot test provided valuable information about learner engagement strategies, course pacing, instructor training, and learner feedback. Following edits to the course content and methodology, the course was determined to be ready for launch.
The first PHEIA training was offered in March 2013 at a county health department. The plan was to offer the course at health departments that requested training. In addition, the AzPHTC set up monthly offerings of the PHEIA training at the Arizona Department of Health Services and invited employees from all health departments and other health agencies to attend. The state’s largest health department now requires all new employees take the PHEIA training as part of their employee orientation.
Moving to Online
In Spring 2013, the AzPHTC’s instructional designer was one of the 10 individuals chosen by CDC to participate in its inaugural e-Learning Institute. The e-Learning Institute provided a mentor to the instructional designer, who was charged with the task of converting the in-person PHEIA course into an online course. The e-Learning Institute ran for 16 weeks during the spring and summer of 2013 and culminated with an in-person session at the CDC complex. Each participant presented their online course at the final session. After receiving feedback from the group, the development of the online version of PHEIA continued through the next calendar year and was completed in June 2014. Adobe Captivate software was used to create the online PHEIA course, and it was posted to TRAIN.org in order to make it available to a national audience.
Adaptation for Tribal Health Departments
In Summer 2013, the AzPHTC partnered with the University of Arizona’s Native American Research and Training Center to adapt the PHEIA training for THDs. Students from the Native American Research and Training Center conducted interviews with Native American public health professionals working with tribal health organizations during the 2013 Summer and Fall semesters, and the interviews were incorporated into the PHEIA multimedia activities to demonstrate the value of diversity within THDs. The videos used in the PHEIA offer a culturally appropriate perspective for populations that serve Native American communities in rural areas. In November 2014, a pilot of the Native American PHEIA course was conducted for employees of one THD. Twenty-three participants attended the training, which produced specific recommendations to focus on learner activities related to trust issues facing Native American communities and communication barriers that exist between public health professionals and the communities they serve. These changes were made and the course has since been conducted with an additional THD.
Transforming the PHEIA to a Train the Trainer Format
In February 2016, the AzPHTC began the development of the PHEIA TOTs course. This was an important effort, as the AzPHTC had the only in-person trainer for PHEIA. The course increases the number of qualified trainers and will expand the number of offerings of the course. An instructional manual was developed that includes an instructor’s guide and learners’ guidebook. The PHEIA TOT course is a 1-day course divided into two sessions. In the first session, the future trainers participate in the PHEIA course themselves to develop a student perspective on the course and generate detailed observations that will aid them in generating a training plan as outlined in the second session. In the second session, the participants are given a workbook on how to lead a training. The participants practice conducting the training with a live audience with the TOT facilitator present. The participants then create a training plan that will be used to conduct the PHEIA training.
Outcomes
A total of 685 individuals have now taken the in-person PHEIA course (Table 1). These individuals are employees of state, county, and THDs. They work in urban and rural communities and include both entry-level and mid-level public health employees, as well as directors of health departments.
Formats for the Public Health Essentials in Action (PHEIA) Training and Individuals Trained.
The PHEIA training has been delivered as an organization-wide, half-day training for these health department staff; a total of seven Arizona County health departments have participated using this format. The AzPHTC offers the course on a monthly basis at one health department for new employees, and courses have been conducted at both urban and rural health departments. In 2015, the AzPHTC conducted PHEIA courses for another THD after completing the pilot presentation. The trainings were offered in three different locations and in two different states. A total of 142 individuals from THDs have taken the course, including those who participated in the pilot. More than 1,100 individuals from 38 states and Canada have taken the PHEIA course online. Two PHEIA TOTs have been conducted with four and five participants, respectively.
Course participants complete an evaluation form in which they rate the training and the instructor. To date, 98% (n = 125/128) of respondents answered agree or strongly agree when asked to rate the overall value of the course, and 96% (n = 123/128) of respondents answered agree or strongly agree when asked if they would recommend the course to their colleagues.
Beginning in Fall 2015, the AzPHTC sends every PHEIA participant a follow-up survey between 4 and 6 weeks after participating in the training in which they are asked to complete two short sections. The first section asks learners to reflect on the action plan they created during the training. Learners are asked if they created a plan and what percentage of their plan is complete. The second section asks learners specific assessment questions related to the content of the training. To date, 24% (n = 31/130) of those surveyed have responded and 63% of respondents indicated that they have completed 50% to 100% of their action plan 6 weeks after taking the course. The second section’s assessment questions are graded. Learners’ average score on the assessment section to date is 88% correct.
Discussion
Workplace CE remains essential for a competent PHW. The PHEIA course, developed using andragogy and adult learning based principles, has helped fill this important gap for training the current PHW, as health departments often hire staff without sufficient public health training.
At the same time, the delivery of training to the PHW should take advantage of the multiple methods now available for meeting their training needs. The AzPHTC has made the PHEIA course available as an in-person training and as an online course in response to numerous needs assessments with health departments indicating that employees want both in-person and online training. The PHEIA meets the needs of those who provide public health services across the country.
Footnotes
Authors’ Note
The information or content and conclusions of this article are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Health Resources and Services Administration, the U.S. Department of Health and Human Services, or the U.S. government. The Western Region Public Health Training Center works in partnership with the Public Health Learning Network and in cooperation with the National Coordinating Center for Public Health Training.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this article was provided by the Health Resources and Services Administration of the U.S. Department of Health and Human Services under UB6HP27880 and Affordable Care Act (ACA) Public Health Training Centers.
Supplement Issue Note
This article is part of a Pedagogy in Health Promotion: The Scholarship of Teaching and Learning supplement, “U.S. Public Health Learning Network: Innovative Competency-Based Training for the Public Health Workforce,” which was supported by the Society for Public Health Education and the Region IV Public Health Training Center, Health Resources and Services Administration of the U.S. Department of Health and Human Services under Grant Number UB6HP27875, Affordable Care Act (ACA) Public Health Training Centers. The entire supplement issue is available open access for one year at 
.