Public health practice is an information-intensive and information and surveillance–driven enterprise.1,2 Local health departments (LHDs) are expected to build and maintain a robust informatics infrastructure to access large amounts of data generated by health care providers and other community partners.3 Informatics capacities are considered among the foundational capabilities, important to providing surveillance and other important public health functions and services4 and to enable the most efficient and effective use of the informatics infrastructure and the data it can bring. However, most public health professionals may lack necessary skills in most effectively using information for public health.5 A large proportion of state and local public health employees may not even be aware of the importance of informatics. A study assessing the levels of awareness about public health trends among public health employees shows that only 67.7% of state health department employees and 55.2% of LHD employees were aware that leveraging electronic health information is a public health trend.6 These findings are indicative of low capacity and the importance of assessing informatics-related needs of all public health employees. A focus on all public health employees rather than just the informatics staff may be essential because efficient utilization of public health informatics is a collaborative process involving not only the informatics staff but also the programmatic staff benefiting from these capacities.
Information systems and other information technology (IT) solutions can help improve care coordination and billing functions of health departments providing clinical services. They also improve capacity to assess immunization completion rates, syndromic surveillance of influenza-like illnesses, and food-borne illness.7,8 Informatics capacity also cuts across many public health functions. In this issue, Shah et al9 describe the many ways electronic exchange of health information supports public health activities. In an analysis of how informatics supports the Essential Services of Public Health,10 Dixon and colleagues11 concluded that the relevance and necessity of day-to-day public health informatics knowledge and skills exceeded the current skill level in all areas of the informatics stack. The central challenge put forth for the public health enterprise is managing information used for public health activities, and this challenge ought to be viewed as a strategic imperative. This imperative calls for enhancing competency in informatics for all public health professionals by addressing their learning needs.12 A core strategy for building an informatics-savvy health department is development of a skilled workforce, enabling the organization to be capable of meeting new demands and using resources efficiently.13
For advocacy, policy, and capacity-building initiatives targeting training of LHD workforce in informatics capacities to succeed, it is imperative to understand their specific training needs. In the absence of such knowledge, these efforts may not be as fruitful because what does not get measured may not get done.14 The current literature has a significant gap concerning LHD workforce informatics-related needs. The purpose of this study is to utilize a nationwide survey of LHDs to learn about their workforce development needs related to informatics and information systems. This study also seeks to determine whether there is a significant association between LHDs' governance status and their workforce development needs related to informatics and information systems. The focus of this study is on the general public health workforce, not those whose primary role is informatics-focused but who comprise only 1% of the current overall workforce.1 A discussion of the overall technical maturity of LHDs is presented in several other articles in this issue.
Data and sampling design
Data were drawn from the 2015 Informatics Capacity and Needs Assessment Survey, conducted by the Jiann-Ping Hsu College of Public Health at Georgia Southern University in collaboration with the National Association of County & City Health Officials (NACCHO). This Web-based survey had a target population of all LHDs in the United States. Respondents were informatics staff identified by LHDs prior to the main survey who provided responses about the entire public health workforce of their LHD. A representative sample of 650 LHDs was drawn using a stratified random sampling design based on 7 population strata: less than 25 000; 25 000-49 999; 50 000-99 999; 100 000-249 999; 250 000-499 999; 500 000-999 999; and 1 000 000 and more. LHDs with larger population were systematically oversampled to ensure inclusion of a sufficient number of large LHDs in the completed surveys.
A structured questionnaire that included measures to examine LHDs' current informatics capacity and needs was constructed and pretested with 20 informatics staff members. The completed questionnaire was administered to the sample of 650 LHDs via Qualtrics survey software. The survey remained open for 8 weeks in 2015. A total of 324 completed responses were received (50% response rate). Statistical weights were developed to account for 3 factors: (a) disproportionate response rate by population size (using 7 population strata, typically used in NACCHO surveys), (b) oversampling of LHDs with larger population sizes, and (c) sampling rather than a census approach. For more technical terms, such as business process analysis and redesign, and geographic information systems, among others, respondents were provided with written definitions.
Public health staff needs were measured by asking: “Please identify important areas of need for your agency's staff development, related to information systems (select all that apply).” Response categories were “Yes,” “No,” and “Don't know/Not sure.”
We described the staff development needs of LHDs using frequencies and percentages. Additional analyses of the training needs were examined on the basis of grouping the control responses into state, local, and shared governance categories. The governance category is determined and assigned on the basis of how each LHD is governed. LHDs that are governed by a state health department (ie, the LHDs are units of state health department) fall into the state category. Locally governed LHDs are categorized as local when all governance functions are performed by a local body (county, board of health) and the state health department has no direct authority over the LHD. Shared governance occurs when some governance functions are local whereas others (eg, hiring and firing LHD director, budget allocation) are under the state health department. We used the χ2 test for examining difference in training needs by jurisdiction size. To assess the differences in training needs by LHD governance category, we used the Somers D test. We performed all analyses for this study using SPSS (version 23.0).
Data on staff development needs in informatics were available for a total of 299 LHDs. As shown in Table 1, the most commonly reported development needs, regardless of LHDs' population size, included using and interpreting quantitative data (62.7%), designing and running reports from information systems (59.4%), using and interpreting qualitative data (58.7%), using statistical or other analytical software (53.8%), project management (50.8%), and using geographical information systems (50.6%). The least common needs, regardless of LHDs' population size were acting as a “super user” for your informatics systems (27.9%), basic computing skills (32.6%), developing requirements for informatics system development (33.5%), and maintaining a Web site (34.8%). LHDs of all jurisdiction sizes, except for large health departments serving jurisdictions of 500 000 or more, reported very low rates (≤5.0%) of staff already being sufficiently skilled. Large health departments reported that 40.0% of staff members are sufficiently skilled. Similarly, LHDs of all jurisdiction sizes reported very low rates (≤5.4%) of not having any informatics-related staff development needs. Analysis of the relationship between jurisdiction size and development needs showed significantly higher percentages for all development needs among health departments serving large jurisdictions (≥500 000) except for maintaining a Web site. The results indicate that there is a significant association between the jurisdiction size (<50 000, 50 000-499 999, ≥500 000) and staff development needs.
Table 2 shows the results of the Somers D test to determine association between the LHDs' governance category and the staff development needs. In all cases with the exceptions of using word processing, spreadsheet, and presentation software (eg, Microsoft Office) (P = .71), maintaining a Web site (P = .11), and basic computing skills (P = .98), the P value was highly significant. The results indicate that there is a significant association between the governance category (state, local, shared) and the staff development needs. The association indicates that those with shared or local governance have many more staff development needs than those with state governance.
While health informatics is complex and evolving, local public health agency employee training needs are mostly related to their skills in use of data and information to support their specific programmatic functions and services. For instance, the most common training needs were reported to be using and interpreting quantitative data, designing and running reports from information systems, and using and interpreting qualitative data. In the absence of an understanding of these needs, most efforts might have focused on IT training related to software and hardware. Using statistical or other analytical software, project management, and using geographical information systems were among the other top needs. These training needs may be met better if these capacities are recognized as strategic issues and proper resources are allocated.
In general, the larger the population served by the LHD jurisdiction, the greater the training needs are. And LHDs with local governance reported higher percentages of training needs than those with shared governance, or state governance, who reported the lowest percentages. These findings are consistent with other reports describing workforce needs related to informatics.1,14–17
What is striking about these findings is that not only are basic computing skills and use of Microsoft Office products a need but also are data and statistical analyses (quantitative and qualitative). These analytical core public health skills, which are critical elements in data and information–driven public health decision making, are a development need for more than half the LHDs reporting. In addition, use of clinical systems, such as extracting public health data from electronic health records (EHRs), was a need for 76.7% of large (≥500 000) LHDs. Without this capability, LHDs will be at a significant disadvantage despite the increased adoption of EHRs and the vast quantities of EHR data becoming available for public health surveillance, reporting, and registry development.18 Consistent with other findings,14 use of geographic information systems was a training need for more than half of the LHDs. Increasingly, epidemiologists are using geographic distribution of disease in addition to temporal distribution to characterize outbreaks and develop better public health interventions. The reported needs related to developing and procuring new information systems, such as project management, business process analysis and redesign, and informatics system requirements gathering paint a grim outlook for development of new systems that will meet the needs and expectations of public health users.
Barriers to training and development of the public health workforce are well understood and include cost, time, funding systems, distances to be traveled to reach training,19 inadequate incentives for participating in training and continuing education, lack of an integrated delivery system for lifelong learning, and no consensus on necessary competencies.20 Innovative training and workforce professional development programs such as the Informatics Academy of the Public Health Informatics Institute,21 and the Association of State and Territorial Health Officials and de Beaumont Foundation partnership building on the Public Health Workforce Interests and Need Survey (PH WINS: Research to Action),22 are needed to overcome these barriers.
Limitations of this study include the reliance on the informatics staff to provide information about the training and development needs of the entire public health workforce at their LHD. The informatics staff may not be aware of the needs of other staff related to informatics and information systems. In some cases, the technologies in question (ie, EHRs) may not be available to all LHDs and therefore training on using and interpreting data from these technologies may not have been reported as a need, even if LHD staff lack the capability to effectively use these systems and their outputs. No information was collected about which public health workers need what training. Assuming that not all workers will need a comprehensive knowledge of informatics, the need for additional information about targeted training remains unknown and further supports the need for comprehensive, role-based, updated informatics competencies for the field.
Substantial training needs exist for LHDs across many areas of informatics ranging from very basic to more specialized skills. Many of these needs are related to core public health practice skills and must be met if LHDs are to function effectively in the information age.
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