The influence of experience and credential status on perceptions of agency competency in delivery of the 10 essential environmental public health services.
According to the National Center for Environmental Health of the Centers for Disease Control and Prevention (National Center for Environmental Health [NCEH], 2003), "Environmental public health services and sanitation have been the backbone of public health in the United States since 1798." Advances in environmental health (EH) and sanitation have contributed to significantly increase the U.S. life expectancy and eliminate more than 80% of human diseases (NCEH, 2003). When asked to identify the five most important public health program areas, public health professionals listed EH more often than any other program (Hajat, Brown, & Fraser, 2001).
National public health leaders have recognized that there are too few EH practitioners to adequately meet basic EH workforce needs. Concurrent with the shrinking size of the EH workforce is the ancillary issue of professional leadership. In the Pacific Northwest, 25% to 30% of the EH leadership will retire in the next three to five years (Osaki, Hinchey, cCT Harris, 2007). These retirements, along with those in Kansas and other regions of the country, have begun to create a leadership void within the EH field.
While significant programmatic gaps exist among federal, state, and local public health programs (NCEH, 2003), a schism between environmental and public health agencies at all levels of government has occurred. This division has further weakened the link between EH and public health (Shalauta, Burke, Gordon, Stern 8Y Nga, 1999). The EH system in Kansas is representative of EH programs nationwide and can be described as fragmented and poorly connected to other professionals in the field of public health (American Public Health Association [APHA], 2001).
There is also a growing concern that the EH workforce lacks the capacity to meet future challenges (Association of State and Territorial Health Officials [ASTHO], 2005). New and emerging diseases and the threat of bioterrorism have placed additional demands on EH programs (ASTHO, 2005). Additionally, funding--particularly at the local level--has not kept pace with expectations for service delivery (NCEH, 2003). Despite these shortfalls, citizens still expect that public health agencies will monitor and control EH risks (Turnock, 2001b).
In 2003, NCEH outlined six goals in the strategic plan to improve the EH system. These goals are the following: (1) build capacity, (2) support research, (3) foster leadership, (4) communicate and market, (5) develop the workforce, and (6) create strategic partnerships. These goals recognize the importance of developing an EH workforce that has an understanding and appreciation of the 10 essential public health services (Public Health Function Steering Committee, 1994) (Figure 1).
FIGURE 1 The Ten Essential Environmental Public Health Services 1. Monitor environmental and health status to identify community environmental health problems 2. Diagnose and investigate environmental health problems and hazards in the community 3. Inform, educate, and empower people about environmental health issues 4. Mobilize community partnerships to identify and solve environmental health problems 5. Develop policies and plans that support individual and community environmental health efforts 6. Enforce laws and regulations that protect health and ensure safety 7. Link people to needed environmental health services and assure the provision of environmental health services when otherwise unavailable 8. Assure a competent environmental health workforce 9. Evaluate effectiveness, accessibility, and quality of environmental health services 10. Research for new insights and innovation solutions to environmental health problems. Adapted from Public Health Functions Steering Committee. (1994). Public Health in America. Washington, DC: U.S. Public Health Services.
A more exact understanding of the level of competency of the EH workforce is required before public policy can be changed. Research has not been conducted in Kansas to quantify the level of professional competency possessed by the EH workforce. The fact that a demonstration of competency through credentialing or licensure is not often a requirement for employment exacerbates this problem.
Environmental Health Workforce Education and Credentialing
The Kansas Department of Health and Environment (KDHE) and local public health departments require a four-year college degree in EH or a science-related field as a minimum criterion for employment. In Kansas, no degree in EH is available. Nationwide, only 31 undergraduate EH programs are accredited by the National Environmental Health Science & Protection Accreditation Council (2008). As a result, new employees require considerable on-the-job training before they attain the job skills to be effective and productive EH practitioners (Shalauta et al., 1999).
Currently, Kansas EH practitioners may become certified by presenting their qualifications to one of two credentialing agencies: (1) NEHA or (2) the joint Committee for the Credentialing of Sanitarians (JCCS). NEHA (2007) offers national credentialing for the registered sanitarian/registered EH specialist or certified food safety specialist and requires 24 hours of continuing education every two years. JCCS (2004) is the Kansas credentialing organization that offers the registered sanitarian credential and requires 30 hours of continuing education every three years.
KDHE does not require employees working in EH-related programs to be certified. Although public health agencies may encourage their EH sanitarians to obtain credentialed status, few departments make this a requirement (Turnock, 2001a). It is difficult for local EH professionals to develop support for requiring a local standard of competency without a basic statewide requirement. On two separate occasions, JCCS and KDHE unsuccessfully sought support from the Kansas legislature in an effort to recognize registered sanitarians as a professional occupation requiring credentialing or licensure (An Act Authorizing Registration of Public Health Sanitarians, 1988).
Since 1994, the essential public health services have supplied the fundamental framework for providing public health services by describing public health activities that should be carried out in all communities (Public Health Function Steering Committee, 1994). With the intent to provide an operational definition of public health, the essential services present a guiding framework that describes the responsibilities of local public health systems. The primary objective of our study was to assess perceived competency of the Kansas EH workforce in the implementation of the 10 essential public health services. A secondary objective was to determine whether survey respondents' perceptions were influenced by credential status as a registered sanitarian or certified food safety professional.
This preliminary study was designed to capture responses from a convenience sample to accomplish two goals. The first goal was to assess the Kansas EH workforce's perceptions of agency competency in providing the 10 essential public health services (Public Health Functions Steering Committee, 1994). The second goal was to determine whether perceptions of competency were influenced by respondents' credential status as a registered sanitarian or certified food safety professional.
The Northwest Center for Public Health Practice (NWCPHP) Environmental Health Workforce Questionnaire (C. Osaki, personal communication, January 23, 2006) was developed by the University of Washington School of Public Health and Community Medicine. The 40-item survey requires yes/no/unsure responses to statements that assess the respondent's familiarity with and application of the 10 essential services as they relate to the delivery of EH service. Each of the 10 essential services was assessed using four individual item statements. For example, essential service two, diagnose and investigate EH problems and hazards in the community, was measured using the following four statements. (1) "Our unit has a written protocol to analyze the relationship between environmental health hazards and health impacts." (2) "Our unit has a memorandum of agreement with agencies involved in investigating environmental hazards/ risks." (3) "Our unit has communicable disease surveillance capacity to assess environmental hazards." (4) "Our unit has the technical capacity to perform environmental health risk assessments."
Respondent characteristics were collected to describe age, gender, ethnicity/race, type of agency, type of unit, job classification, number of unit employees, number of years of EH work experience, and use of performance measurement standards. Two additional questions with yes/no responses were posed. (1) "Do you hold any environmental health credential from the joint Committee for the Credentialing of Sanitarians OCCS)?" (2) "Do you hold any environmental health credential from the National Environmental Health Association (NEHA)?"
The survey was prefaced by brief instructions asking respondents to consider how their work unit performs or functions based upon this definition of environmental health:
Environmental health and protection is the art and science of protecting against environmental factors that adversely impact human health or the ecological balances to long-term health and environmental quality, whether in the natural or human-made environment (NEHA, 1996).
The survey was distributed to state and local food service inspectors at the KDHE annual training conference and by e-mail to other direct providers of EH services in Kansas. Participation was voluntary and anonymous, and informed consent was assumed with a returned survey. No incentive to participate was offered. Research approval was secured through the Human Subjects Committee at the University of Kansas School of Medicine-Wichita.
To describe the characteristics of respondents and survey items, descriptive frequencies for each categorical variable were run as well as the measures of central tendency for continuous variables. Three respondents did not answer the credential item and were excluded from further analysis. Chi-square analysis was performed on each characteristic (variable) in order to determine if the credentialed versus noncredentialed groups were sufficiently similar in composition. Finally, each of the grouped responses (four items for each essential service) was analyzed to compare responses by credentialing status (credentialed versus noncredentialed). Alpha was set at .05.
Seventy-seven of 166 surveys were completed and returned, a 46% return rate. A complete description of respondent characteristics can be found in Table l. The sample was predominantly white (93.3%) and equally representative in gender (53.2% male) and years of experience (0-9 years, 49.4%; more than 9 years, 50.6%). In terms of organizational characteristics, most participants worked in a local health department (60.0%) or a state agency (36.0%). The majority (64.3%) worked in a setting with 6.5 full-time-equivalent employees (FTEs) or less. More than half (64.0%) reported they were frontline service providers as opposed to supervisors (36.0%). The vast majority of respondents (83.3%) reported that their organization did have a performance standard in place.
Respondent Characteristics by Credential Status
Fifty percent of respondents reported holding either a NEHA or JCCS credential as a registered sanitarian or certified food safety specialist. Differences between respondent characteristics (credentialed vs. noncredentialed) for the majority of variables were not significant with the exception of years of experience and job classification. Credentialed respondents had more years of experience ([chi square]  = 20.071, p = .01) and reported being in a supervisory capacity more often than the noncredentialed group ([chi square]  = 11.123, p =.01).
Perceptions of Agency Competency
For perceived agency competency, credentialed respondents more often answered "no" to survey items than noncredentialed respondents (see Figure 2 and Table 2). This indicates a less favorable perception of agency competency. For three of the 10 essential public health services (ES), no difference in response was found between credentialed and noncredentialed participants as follows:
* ES 3--inform, educate, and empower people about environmental health services;
* ES 8--assure a competent workforce; and
* ES 9--evaluate effectiveness, accessibility, and quality of environmental health services.
Significant differences were found for the remaining seven essential services. A statistically different response was observed for ES 1 ([chi square]  = 12.231, p < .001) in which credentialed respondents more frequently reported their agency did not monitor the status of the community to identify EH problems. For ES 2 (diagnose and investigate EH problems) and ES 4 (mobilize community partners), respondents from the credentialed group were more likely to respond "no" (ES 2: [chi square]  = 16.520, p < .001; and ES 4: [chi square]  = 8.603, p = .003). Policy development (ES 5) and regulatory enforcement (ES 6) were two additional areas in which credentialed participants more often perceived that their agency was not performing the essential services (ES 5: [chi square]  = 15.246, p < .001; and ES 6: [chi square] (1) = 9.980, p = .002). Credentialed respondents were significantly more likely to respond that their agency did not link people to needed EH services (ES 7: [chi square]  = 7.919, p = .005) and did not research for new insights and innovations (ES 10: [chi square]  = 4.337, p = .04).
Competency Perceptions by Credential Status
Credentialed and noncredentialed respondents differed significantly in their perceptions of agency competency. Credentialed respondents were significantly more negative in their view of agency competency for seven of the 10 essential services (ES 1, 2, 4, 5, 6, 7, and 10). One explanation for the differences may be related to demographic characteristics of the sample. Noncredentialed respondents tended to be less experienced and hold nonsupervisory positions. Marrone (2003) reported that frontline employees tend to begin their careers in positions that focus on enforcement and compliance activities versus assessment of essential service activities. These demographic differences may explain, in part, why noncredentialed respondents were more than twice as likely to respond "unsure" about agency competency in essential services (Figure 2).
To apply for the certification exam, an EH worker with a BS degree needs one or two years of work experience in EH, as required by JCCS (2004) and NEHA (2007), respectively. The credentialing process requires experience; therefore, it is likely that credentialed respondents would report more years of experience on the survey. Also, the additional EH experience required for the credentialing process creates a pool of EH employees who may be considered for supervisory positions. Due to their experience, proficiency, and continuing education knowledge (a requirement to maintain their credentialed status [Gebbie 62 Turnock, 2006]), credentialed respondents might have a more realistic assessments of how well the 10 essential services are actually performed.
Another explanation for the difference in perceived competency between groups is that noncredentialed EH respondents are more likely to be involved in direct service delivery to the community. Therefore, respondents may have a greater feeling of connection to the community and a greater sense of personal empowerment in affecting future outcomes within the community (Leach, Wall, Jackson, 2003).
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Responses for ES 5 (develop policies and plans that support individual and community environmental health efforts) suggest that both credentialed and noncredentialed respondents were confident that their work unit could craft policies and plans and had access to policy makers. Leaders in Kansas should build upon this perception of access and equip EH practitioners with additional training in risk communication and issue-driven message communication in order to ensure that EH resource needs are met (Gordon, 1995).
Negative perceptions from respondents about their agency's delivery of essential services may be caused by fragmentation of EH services over time (Gordon, 1995), privatization of EH services (Keane, Marx 8Y Edmund, 2002), or the transfer of EH services away from public health agencies to other governmental organizations (Shalauta et al., 1999). In addition, experienced professionals and leaders continue to leave the workforce at a greater rate than they are being replaced (Berg, 2006; Osaki et al., 2007), which is exacerbated by a shortage of new emerging EH leaders (ASHTO, 2005). Finally, the EH workforce also suffers from a shortage of accredited undergraduate programs in EH; currently only 31 programs exist nationwide and are capable of graduating only a fraction of the workforce required to replace retiring professionals and to meet projected future needs (National Environmental Health Science & Protection Accreditation Council, 2008).
Participants were not randomly selected, and no effort was made to distribute the survey among all EH agencies in Kansas. Thus, a selection bias may be present, most likely expressed as an overrepresentation of less experienced frontline workers present at the two training events. Additionally, the small survey response return rate of 46%, lower than average for mailed surveys, is typically a concern to researchers. We feel, however, that the representativeness of the sample is adequate. Results may not generalize well; nevertheless, the uniformity observed between the two groups reduces the influence of this bias.
The use of a yes/no/unsure response to survey items limited data coding options and may have presented measurement bias. Research experts generally recommend avoiding categorical responses when possible. The survey design, because it was a self-assessment requiring a fixed variable response, did not permit the scaled response that, e.g., a Likert scale (strongly agree, agree, disagree, strongly disagree) would provide. A scale may have reduced ambiguity in response choices and provided for a more straightforward coding procedure.
Noncredentialed respondents answered "yes" to agency competency items at a rate comparable to credentialed respondents, but were much more likely to respond "unsure" rather than "no." In this study, "unsure" responses were coded as missing data in order to limit measurement bias. The potential response bias may have led the noncredentialed group to have greater perception of agency competence to deliver the essential public health services. Additional research is needed to determine whether this observation is due to chance or is related to confounding factors.
The central findings of this study suggest many opportunities exist to improve the provision of the 10 essential public health services within EH in Kansas. Respondents only answered "yes" greater than 50% of the time for three of the 10 essential services (3, 6, and 8), suggesting Kansas EH workers may have limited confidence in their agencies' abilities to deliver the 10 essential public health services. While credentialed and noncredentialed respondents had differing opinions of agency competency, these differences may be ameliorated through enhanced educational efforts focused on essential public health services. For example, the "Essential Services of Environmental Health: A Training Module" developed by Carl Osaki and the Northwest Center for Public Health Management and Practice (2004) could be utilized. Additional training in risk communication, issue-driven message communication, and cultural competency should also be added to EH training programs.
The issue of required credentialing for EH professionals should be addressed, both at the state and national level. The continued lack of consensus about credentialing as a condition for long-term employment hampers future efforts to develop appropriate skill sets within the workforce. It also limits the capacity of the EH workforce to respond to new and emerging public health threats and to meet their traditional scope of work (Gebbie & Turnock, 2006).
Kansas should establish an accredited EH program within its Regents University system. Moreover, within the state of Kansas and the nation, credentialing requirements for EH practitioners should be established and supported as a means to encourage and institutionalize ongoing workforce training programs (Kennedy & Moore, 2001). Future research should collect information about the participant's knowledge, skill, and experience levels (education and practice) to further elaborate the differences in competency levels on the essential public health services. Finally, a comparative study of actual versus perceived performance should be performed and used to facilitate the national dialogue on EH capacity.
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Daniel L. Partridge, MPH, RS
Ruth Wetta-Hall, RN, PhD, MPH, MSN
Angelic M. Paschal, PhD, MEd
Jack A. Brown, MPA, MPH
Carl Osaki, MSPH, RS
Corresponding Author: Ruth Wetta-Hall, Assistant Professor, University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS 67214. E-mail: firstname.lastname@example.org.
TABLE 1 Respondent Characteristics by Credential Status No. Credential Credential [chi df p-Value square] Characteristics No. % No. % Gender 2.680 1 NS Male 24 64.9 17 45.9 Female 13 35.1 20 54.1 Race 2.119 1 NS Minority 1 2.7 4 11.4 Nonminority 36 97.3 31 88.6 Years experience 20.071 1 -0.01 0-9 9 25.0 28 77.8 >9 27 75.0 8 22.2 Job class 11.123 1 0.01 Front line 17 45.9 30 83.3 Supervisory 20 54.1 6 16.7 Jurisdiction 0.424 1 NS Rural 18 58.1 17 50.0 Urban 13 41.9 17 50.0 Agency type 1.458 1 NS Local 26 70.3 21 56.8 State 11 29.7 16 43.2 Number of 1.804 1 NS employees 1-6.5 25 71.4 19 55.9 >6.5 10 28.6 15 44.1 Performance 1.744 1 NS standard Yes 27 77.1 26 89.7 No 8 22.9 3 10.3 TABLE 2 Perceptions of Competency, Credentialed vs. Noncredentialed Essential Service n Response Credential Does your health agency ... Yes No 1. Monitor environmental and health 223 % Yes 23.8 26.9 status to identify community EH % No 34.5 14.8 problems? 2. Diagnose and investigate EH 222 % Yes 25.2 29.3 problems and hazards in the % No 33.3 12.2 community? 3. Inform, educate, and empower 245 % Yes 31.8 29.0 people about EH issues? % No 25.3 13.9 4. Mobilize community partnerships 208 % Yes 21.6 22.6 to identify and solve EH problems? % No 38.5 17.3 5. Develop policies and plans that 214 % Yes 26.2 28.0 support individual and community % No 34.1 11.7 EH efforts? 6. Enforce laws and regulations that 233 % Yes 35.2 35.2 protect health and ensure safety? % No 21.5 8.2 7. Link people to needed EH services 210 % Yes 19.5 23.3 and assure the provision of EH % No 37.1 20.0 services when otherwise unavailable? 8. Assure a competent EH workforce? 254 % Yes 41.3 38.6 % No 12.2 7.9 9. Evaluate effectiveness, 206 % Yes 26.2 25.2 accessibility and quality % No 31.1 17.5 of EH services? 10. Research for new insights and 219 % Yes 18.3 17.8 innovative solutions to EH problems? % No 41.6 22.4 Essential Service [chi df p-Value square] Does your health agency ... 1. Monitor environmental and health 12.231 1 <.001 status to identify community EH problems? 2. Diagnose and investigate EH 16.520 1 <.001 problems and hazards in the community? 3. Inform, educate, and empower 3.568 1 NS people about EH issues? 4. Mobilize community partnerships 8.603 1 .003 to identify and solve EH problems? 5. Develop policies and plans that 15.246 1 <.001 support individual and community EH efforts? 6. Enforce laws and regulations that 9.980 1 .002 protect health and ensure safety? 7. Link people to needed EH services 7.919 1 .005 and assure the provision of EH services when otherwise unavailable? 8. Assure a competent EH workforce? 1.345 1 NS 9. Evaluate effectiveness, 3.585 1 NS accessibility and quality of EH services? 10. Research for new insights and 4.337 1 .04 innovative solutions to EH problems?