Comparison of Health Education and Basic Public Health Professional Competencies.

Abstract: The National Health Education Competencies (National Commission for Health Education Credentialing) and the Public Health Core Competencies (Council on Linkages for Public Health Practice) were compared qualitatively in order to determine the extent to which overlap existed between the two. Results showed that a significant number of competencies were similar (33%). Results have implications for pre- and in-service training for public health professionals including health educators, hiring practices in public health, and marketing of health education graduates.

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The current public health work force consists of an estimated 500,000 professionals, including nursing, environmental heath specialist, physicians, health educators, laboratorians, epidemiologists, and managers (Lichtveld, Cioffi, Baker, Bailey, Gebbie, & Henderson, 2001). Health education professionals have become a vital component of the public health workforce in many states. Health educators have been called upon to deal with biological threats in the United States in recent years (Perez, Pinzon- Perez, & Sowby, 2002) and their specific duties have included helping to network and organize various public health workers, developing easy to understand educational and prevention strategies, becoming aware of chemical or biological weapons, and attempting to decrease panic in events by promoting accurate and timely information to the public (Perez, et al.).

The Council on Linkages for Public Health Practice released the first complete draft of the Public Health Core Competencies in 2001--the culmination of a ten year effort by numerous organizations and individuals (Council on Linkages, 2005). These competencies are comprised of eight main domains and 68 competencies and are intended to guide the public health workforce. Health education as a separate discipline also has its own unique set of professional competencies. The health education competencies began to evolve during the 1970's and the final draft was completed and disseminated in 1985. Since 1985, several editions of this document have been distributed (National Commission for Health Education Credentialing [NCHEC], 1996). Health education entry-level competencies include seven main responsibilities, 27 competencies, and 79 sub-competencies. Both are considered competencies for public health workers (Institute of Medicine, 2003).

Competency has been defined as "an ability to apply a certain specified skill in dealing with some defined amount of meaningful subject matter" (NCHEC, 1996, p. 81). Competencies are important in both health education and pubic health because of the complex, constantly changing, demands for critical services placed on these professionals (Wright Rowitz, Merkle, & Reid, 2000). Theoretically, using competencies to provide a framework for professional development will strengthen professional preparation practice (NCHEC, 2005). However, because health educators work within public health, there is a potential for overlap between public health core competencies and health education professional competencies. The identification of the potential overlaps between the two sets of competencies is important for three main reasons. First, the identification of health education related competencies will ultimately help guide curriculum and content development of public health education and training programs for preparation of practitioners, including health educators, and for the ongoing development of practitioners in the field (Council on Linkages, 2005). Second, increased awareness of the discipline-specific skills that health educators possess can be beneficial to the public health profession by potentially increasing the demand for health educators (O'Rourke & Eddy, 2004). Third, human resources may be able to more appropriately align personnel with their formal training and experience, based on these competencies. A modification of and more appropriate placement of public health professionals, including health educators, could lead to positive and productive outcomes relating to hiring practices and evaluation of staff (Council on Linkages). The purpose of this study was to examine the similarities between professional health education and public health core competencies.

METHOD

To determine similarities between public health core competencies and health education competencies a qualitative content analysis was conducted. A content analysis is a systematic descriptive analysis of written material and research techniques used for quantitative or qualitative data (Worthen et al., 1997). Written materials that can be used for a content analysis include: (a) data from focus groups, (b) interviews, (c) minutes from meetings, (d) publications, (e) annual reports, and (f) other written documents. The methods specific for this content analysis include the use of public health and health education professional competencies. A content analysis using quantitative data required the researcher to code data. The researcher identified words, themes, and paragraphs and placed them into categories. The researcher then counted the coding units and interprets findings (Worthen et al.). Qualitative content analysis provides summaries of documents. "Qualitative content analysis seeks to quantify content objectively, according to explicitly formulated rules and mutually exclusive and exhaustive categories" (Worthen et al., 1997, p.384). Borg and Gall (1963) state that "content analyses are aimed at answering questions directly relating to the material analyzed" (p. 254).

The first task was to identify themes in both the public health core competencies and health education competencies. The first set of competencies investigated was the Public Health Core Competencies. The second set of competencies investigated was the Health Education Competencies. Each set of competencies are unique to their respected field. In order to compare them, one must first understand the comparison level.

The public health core competencies are organized in two levels: domain and competency. There are eight domains with varying amounts of competencies. The domain is used to separate and organize the competencies by task. The competencies under each domain define the specific tasks to be proficient.

The health education competencies are organized into three levels: first by health education responsibilities, which represent broad tasks, second by competencies that provides more detail, and third by sub-competencies, which defines specific tasks to be proficient. In other words, the most specific tasks in each set of professional competencies were compared. The public health core competencies were analyzed at competency level, where as the health education competencies were analyzed at sub-competency level. This allowed the researchers to identify the similarities by specific task.

As a researcher it is important to accumulate and provide credible research. In the qualitative phase of this investigation three methods were completed to maintain credibility: (a) an audit trail, (b) reflective journal, and (c) a mode of triangulation using multiple research partners (Lincoln & Guba, 1985).

The first method used in this investigation was an "audit trail" (Lincoln & Guba, 1985). An audit trail is designed to allow an external reviewer to view and inquire the process to determine whether the evaluation procedure was dependable and confirmable (Worthen et al., 1997). An audit trail follows the six Halpern audit trail categories (Lincoln & Guba) including: (a) raw data, (b) data reduction and analysis products, (c) data reconstruction and synthesis products, (d) process notes, (e) materials relating to intentions and dispositions, (f) and instrument development information (Lincoln & Guba, 1985). Not all six categories need to be included in the audit trail; however one who follows Halpern notation will have greater ease at reporting any problems. For this investigation the audit trail consisted of process notes, which "includes using methodological notes (procedures, design, strategies, rationale) trustworthiness notes, and audit trail notes" (Lincoln & Guba, 1985, p.319). The data used during this phase were saved in an organized manner to allow the researchers or outside members to replicate the study if desired. The audit trail was coupled with reflexive journaling (Lincoln & Guba). The primary researcher in this investigation kept a reflexive journal (Lincoln & Guba) to record progress, difficulties, evolving themes, hunches, personal insight, thoughts, progress, methods, and daily activities as well as concerns that come along the way. The secondary researcher also wrote in a journal making notes, comments, and questions. Keeping a journal helped organize thoughts, as well as identify specific examples for the results section. Examples of when reflexive journaling occurred during this investigation include after or during meetings with the research partner, committee meetings, and any other time that is necessary. This task of reflexive journaling also contributed in the audit trail.

Triangulation is the third method used in this investigation to establish credibility. The purpose of using triangulation is to establish consistency among the data (Lincoln & Guba, 1985). Triangulation of data can come from four different sources including: theories, methods, sources, and investigator (Lincoln & Guba). For this investigation the investigators were the focus. When two researchers cannot come to conclusions on the placement of competencies and sub-competencies, the third researcher was consulted.

The research began by identifying two research partners. The criteria for additional researchers included being familiar with health education or public health core competencies, as well as agreeing to time commitments to complete expected tasks. The use of different investigators added to the credibility of the investigation (Lincoln & Guba, 1985). For this study, two research partners were co-authors and one research partner was independent to the current study. Phase one required specific guidelines to ensure that credibility and validity is maintained. To simplify this process, the steps are listed in order of completion. Following this list are detailed steps of this process.

1. Find two research partners.

2. Look at both data sets of sub-competencies-independently.

3. Open code data- independently.

4. Meet to discuss themes found during open coding and placement of sub competencies under themes.

5. Triangulation with third researcher partner.

6. Separate and match health education to public health competencies.

7. Meet to discuss and share placement of sub-competencies from both sets of competencies.

8. Triangulation with third research partner.

9. Meeting to discuss third researcher's comments.

10. Examine remaining competencies and sub-competencies to see if any additional similarities could be made.

11. Discuss similarities with third researcher.

12. Examine similarities to make sure the public health and health education competencies and sub-competencies were a true match.

13. Consult with third research partner.

14. Write up results.

The first step, once a research partner had been chosen, was done independently and includes reading and becoming familiar with the two sets of competencies. Once this task was completed, each researcher open coded the data. Open coding included breaking down data into discrete parts, closely examining them, and comparing for similarities (Straus & Corbin, 1998). Each researcher coded the data independently. When coding the data, the researchers were looking for similar themes that were apparent in both sets of competencies. After open coding was completed a meeting was set up to compare and discuss findings. When conclusions were finalized about themes, the third research partner was called in and triangulation of data began. The third research resolved any discrepancies, reviewed themes, and made comments on placement.

The next step included literally cutting apart both sets of competencies and sub-competencies and identifying similar tasks. This step was done independently. A meeting was arranged to discuss and identify the similar sub-competencies and the placement of the competencies and sub-competencies under the chosen themes. It is important to understand that the themes identified were only important during this first phase of this investigation. The themes were only used to help identify the similar competencies and sub-competencies. After phase one was complete, the Health Education Responsibilities replaced the themes and the health education related Public Health Core Competencies were organized under Health Education Responsibilities. The researchers shared what themes were identified with corresponding rationale. This process was called inter-rater reliability and insured consistency between researchers (Borg & Gall, 1963). If disagreements or discrepancies occurred, they were discussed with the third research partner during the triangulation. When discrepancies did occur, each researcher discussed and explained their rationale. The goal of this activity was to identify the similar competencies and sub-competencies between The Public Health Core Competencies and The National Health Education Competencies.

The themes that were identified out of both sets of professional competencies included: (a) Professional Development, (b) Promoting and Supporting Diversity, (c) General Operations, (d) Communication, (e) Partnership and Collaboration, (f) Leadership and Decision Making, (g) Evaluation, (h) Assessment, (i) Research and Analytic Skills, and (k) Program Planning and Delivery of Services. The health education related Public Health Core Competencies were broken down and placed into the Seven Areas of Health Education Responsibility. The Public Health Core Competencies were placed under the Health Education Responsibility according to the placement of the health education match.

RESULTS

A total of 23-health education related Public Health Core Competencies were identified out of the 79 health education sub-competencies and 68 public health core competencies (Table 1). The remaining 44 public health and 42 health education competencies were found to be unique to each field and therefore could not be matched. Many of the public health competencies that could not be matched with health education competencies had a financial or budgetary focus.

Multiple health education competencies were often matched to one public health competency due mainly to breadth and lack of specificity of the public health competencies. Under Health Education Responsibility II, one public health competency, "developing a plan to implement the policy, including goals, outcomes, process objectives and implementation steps," was found to match six health education sub-competencies due to the multifaceted nature of the Public Health Core Competency wording. The six health education sub-competencies include: (a) Plan a sequence of learning opportunities building upon and reinforcing mastery of preceding objectives, (b) Select strategies best suited to the implementation of educational objectives in a given setting, (c) Match proposed learning activities with those who implicit in the states objectives, (d) Develop a framework of broadly stated, operational objectives relevant to a proposed health education program, (e) Determine the range of health information requisite to a given program of instruction, (f) Incorporate feasible ideas and recommendations into the planning process.

Some public health core competencies and the health education sub-competencies were used multiple times. For example, the Public Health Core Competency, "developing mechanisms to monitor and evaluate programs for effectiveness and quality" was used three times and can be found under Health Education Responsibility III, IV, and V.

DISCUSSION

Several limitations were inherent with this study and the reader should be aware of these when considering the findings. First, many Public Health Core Competencies attempt to cover multiple tasks within one competency making matching with similar health education competencies difficult. This also has implications for assessing competency in and training on the public health core competencies. Second, as stated previously, the health education competencies used to match to the public health core competencies were the "entry level" competencies. If the graduate level health education competencies were to be used in a future replication of this study, there would likely be even more overlap between the two sets of competencies. This is because the graduate-level health education competencies also include financial and budgetary skills.

Approximately one out of three (23/68) public health core competencies were identified as very similar to one or more health education competencies. These twenty-three similarities demonstrate that there is overlap between expectations for workers in the two professional disciplines.

Results of this study have the potential to impact hiring practices in public health, as well as in-service and pre-service training of current and future public health professionals, including health educators. A primary implication associated with the results of this study is that the public health setting could benefit from the hiring of health educators, depending on specific job descriptions (roughly a third of the core public health competencies are directly associated with the health education competencies). This suggestion is echoed by Montes and Johnston (1998). The hiring of individuals trained in health education for jobs that require expertise in primarily the health education related Public Health Core Competencies could potentially greatly reduce the need for some types of on-the-job training for new public health employees. Being aware of these health education related Public Health Core Competencies could also inform future hiring in public health and improve the "fit" of the employee to the job. Additionally, the hiring of health educators to meet specific health education related Public Health Core Competencies job demands could potentially free other public health employees (e.g., public health nurses) to perform more clinical tasks for which they were more likely trained and for which the demand is very high.

A second implication revolves around in-service and pre-service trainings. If many of the existing "front line" public health personnel possess less aptitude in the health education related Public Health Core Competencies, the question needs to be asked, "Should these individuals receive specific training in the health education related Public Health Core Competencies, or should their jobs be redefined so that they are not responsible for these competencies and rather health educators should be hired to fill this need?" If the decision is to train more fully on the health education related Public Health Core Competencies, then perhaps the health education profession should be tapped to provide such trainings. It would behoove the health education profession to work diligently to inform and market to the leadership in public health, about the training of health educators and how this training prepares health educators for strong and contributing roles within public health. This in turn may increase the demand for health educators in the public health sector.

From a pre-service perspective, three avenues could be pursued. First, pre-service programs in health education should make students aware of the degree to which they are being prepared for jobs in public health (in addition to other settings). Health education degree programs could also be modified slightly in order to address the remainder or the majority of the remaining Public Health Core Competencies thus better preparing their students for careers in public health. This possibility should be critically assessed within the profession because there is a strong argument to be made that health education programs do not prepare public health specialists but rather health education specialists. Additionally, students with degrees in health education could be encouraged to market themselves with proficiency in the core public health competencies, no doubt a selling point that few students coming out of other preparation programs could claim. Secondarily, pre-service programs in public health should review their current curricula and map them against the Public Health Core Competencies in order to determine where the "gaps" lie. Currently many public health degree programs are undergoing this process.

The knowledge that 23 competencies (roughly 30%) overlap between basic public health and health education competencies, and that three-quarters of those 23 competencies relate to design, implementation, and evaluation does provide talking points to "link the skills and competencies our health education graduates bring to the table ..." (O'Rouke & Eddy, p. 300). O'Rourke and Eddy also suggest that a key first step to stimulating and legitimizing the demand for professionally trained health educators "would be to match the Responsibilities and Competencies of health educators to core job functions of these voluntary organizations" (p. 300). By matching sub-competencies in health education to basic public health competencies this study achieved a first step to this end.

Last, the need for scientific inquiry to identify the needs from the purchaser's perspective was identified by O'Rouke and Eddy (2004). The present study reinforces that recommendation, with specific emphasis on those responsible for hiring personnel in state and local public health departments. What competencies are in demand? And ultimately, how can health educators fill that gap?

Responding to the notion that all public health professionals, including health educators, should possess the public health core competencies as suggested by the Council on Linkages (2005) leaves many further questions to be answered. For example, should curriculum for health educators be inspected to ensure that there are educational and training opportunities to address the more general public health core competencies? Not all health departments recognize health education or health promotion as a separate division in their organizational structure. Does this suggest that the public health system truly does not recognize health education as a bona-fide profession? Even if health education is truly embraced and integrated into the organizational structure of public health organizations, do health educators want to belong? Do health educators believe that they are or should be public health professionals as represented by those who possess the skills to carry out the Public Health Core Competencies?

REFERENCES

Borg, W. R., & Gall, M. (1963). Educational research: An introduction. New York: David McKay.

Council on Linkages. (n.d.). Background and Prologue. Retrieved June 7, 2005, from http://trainingfinder.org/competencies/background.htm

Institute of Medicine. (2003). Who will keep the public healthy? Washington DC: The National Academies Press.

Lichtveld, M. Y., Cioffi, J. P., Baker Jr, E. L., Bailey, S. B. C., Gebbie, K., Henderson, J. V., et al. (2001). Partnership for front-line success: A call for a national action agenda on workforce development. Journal of Public Health Management Practice, 7, 1-7.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. London: Sage.

Montes, H. J., & Johnston, L. L. (1998). Eliminating health disparities for vulnerable populations through health education interventions within health service programs. Journal of Health Education, 29 (Suppl.), 5-9. National Commission for Health Education Credentialing. (1996). A competency-based framework for professional development of certified health education specialist. New York.

O'Rourke, T., & Eddy, J. (2004). Supply side health education-an Rx for failure; demand side health education-an Rx for success. American Journal of Health Education, 35, 298-301.

Perez, M. A., Pinzon- Perez, H., & Sowby, S. (2002). The role of health educators in dealing with biological threats in the United States. American Journal of Health Education, 33, 216-223.

Strauss, A., & Corbin, J. (1998). Basics of qualitative research (2nd ed.). Thousands Oaks: Sage.

Worthen, B. R., Sanders, J. R., & Fitzpatrick, J. L. (1997). Program evaluation alternative pproaches and practical guidelines. New York: Longman

Wright, K., Rowitz, L., Merkle, A., Reid, W. M., Robinson, G. Herzog, B., et al. (2000). Competency development in public health leadership. American Journal of Public Health, 90, 1202-1207.

CHES AREAS

Responsibility VIII--Apply Appropriate Research Principles and Methods in Health Education Competency B: Use appropriate qualitative and quantitative research methods.

Responsibility X--Advancing the Profession of Health Education Competency A: Provide a critical analysis of current and future needs in health education.

R. Todd Bartee, PhD is an Associate Professor of Kinesiology and Health at the University of Wyoming. Sara E. Olsen, PhD is affiliated with Student Health Services at the University of Wyoming. Scott D. Winnail, PhD is affiliated with the Department of Kinesiology and Health at the University of Wyoming. Address all correspondence to R. Todd Bartee, Dept. 3196, 1000 E. University Avenue, Laramie, WY 82071; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].

Table 1--Health Education Related Public Health Core Competencies

Health Education Sub-Competency         Public Health Core Competency

Health Education Responsibility I-Assessing Individual/Community Needs
for Health Education

* Employ or develop appropriate data    * Collecting and summarizing
gathering instruments                   and interpreting information
                                        relevant to an issue

* Analyze needs assessment data

* Apply survey techniques to acquire
health data

* Determine the extent of available     * Identify community assets
health education services               and available resources

* Investigating physical, social,       * Defining, assessing and
emotional and intellectual factors      understanding the health
influencing health behavior             status, populations,
                                        determinants of health and
                                        illness, factors contributing
                                        to health promotion and disease
                                        prevention, factors influencing
                                        the use of health services
                                        * Selecting and defining
                                        variables relevant to define
                                        public health problems

* Select valid sources of information   * Identify relevant and
about health needs and interests        appropriate data and
                                        information sources

Health Education Responsibility II--Planning Effective Health
Education Programs

* Plan a sequence of learning           * Developing a plan to
opportunities building upon and         implement the policy, including
reinforcing mastery of                  goals, outcomes, and process
preceding objectives                    objectives and
                                        implementation steps

* Select strategies best suited to
implementation of educational
objectives in a given setting

* Match proposed learning activities
with those implicit in the in the
stated objectives

* Develop a framework of broadly
stated, operational objectives
relevant to a proposed health
education program

* Determine the range of health
information requisite to a
given program of instruction

* Incorporate feasible ideas and        * Soliciting input from
recommendations into the                individuals and organizations
planning process

* Seek ideas and options of those who
will be affected or be affected by
the program

* Communicating needs for the program   * Advocating for public health
to those who will be involved           programs and resources

Health Education Responsibility III--Implementing Health
Education Programs

* Appraise applicability to resources   * Identifying, interpreting and
and materials relative to given         implementing public
educational objectives                  health laws,
                                        * regulations and policies
                                        related to specific programs

Health Education Sub-Competency         Public Health Core Competency

* Assess the relevance of existing
program objectives to current needs

* Develop subordinate measurable        * Developing a plan to
objectives as needed for instruction    implement the policy, including
                                        goals, outcomes, and process
                                        objectives and
                                        implementation steps

* Select methods that best
facilitate practice of program
objectives

* Apply individual or group process
methods as appropriate to given
learning situations

* Compare actual program activities     * Developing mechanisms to
with the stated objectives              monitor and evaluate programs
                                        for their effectiveness
                                        and quality

                                        * Evaluating the integrity and
                                        comparability of data and
                                        identifying gaps in data

                                        * Monitoring program
                                        performance

Health Education Responsibility IV--Evaluating Effectiveness of
Health Education Programs

* Select appropriate methods for        * Developing mechanisms to
evaluating program effectiveness        monitor and evaluate programs
                                        for their effectiveness
                                        and quality

                                        * Evaluating the integrity and
                                        comparability of data and
                                        identifying gaps in data

                                        * Monitoring program
                                        performance

* Translate evaluation results into     * Effectively presenting
terms easily understood by others       accurate demographics,
                                        statistical programmatic and
                                        scientific information for
                                        professional and lay audiences

                                        * Communicating effectively in
                                        both writing and orally (unless
                                        handicap precludes one of
                                        these forms of communication)

                                        * Making relevant inferences
                                        from data

Health Education Responsibility V--Coordinating Provision of Health
Education Services

* Stimulate development of              * Facilitates collaboration
cooperation among personnel             with internal and external
responsible for community health        groups to ensure parti-
education programs                      cipation of key stakeholders

* Identify gaps and overlaps in the     * Developing mechanisms to
provision of collaborative health       monitor and evaluate programs
services                                for their effectiveness and
                                        quality

                                        * Evaluating the integrity and
                                        comparability of data and
                                        identifying gaps in the data

                                        * Monitoring program
                                        performance

* Promote cooperation and feedback      * Apply basic human relation
among personnel related to the          skills to the management of
program                                 organizations, motivation of
                                        personnel, and resolutions
                                        of conflict

* Apply various methods of conflict     * Utilizing leadership, team
resolution as needed                    building, negotiation, and
                                        conflict resolution skills to
                                        build community assets and
                                        available resources

* Suggest approaches for integrating    * Identifying, interpreting and
health education within existing        implementing public health
health programs                         laws, regulations and policies
                                        related to specific programs

Health Education Responsibility VI--Acting as a Resources Person
in Health Education

* Access principal on-line and other    * Understanding data collection
database health information resources   process, information technology
                                        applications, transmission
                                        capability and computer system
                                        storage and retrieval
                                        capacities

* Match information need with the
appropriate retrieval system

* Formulate a wide variety of           * Developing and adapting
alternative health education methods    approaches that take into
                                        account the cultural
                                        differences

Health Education Responsibility VII--Communicating Health Education
Needs, Concerns, &Resources

* Act as a liaison between consumer     * Establishing and maintaining
groups and individuals and health       linkages with key stakeholders
care provider organizations

* Utilize a wide range of techniques    * Using the media, advance
for communicating health networks       technologies, and community
to communicate information              health and health education
                                        information

* Demonstrate proficiency in            * Communicating effectively in
communicating health information        both writing and orally (unless
and health education needs              handicap precludes one of
                                        these forms of communication)

                                        * Making relevant inferences
                                        from data