The success of our public health system rests on the ability of a qualified workforce to deliver vital public health services effectively. The continuing gap between the capacity of the public health workforce and its ability to meet current and emerging challenges has been well documented in the last 20 years.1 , 2 A 1988 report by the Institute of Medicine (recently renamed the National Academy of Medicine), The Future of Public Health, noted the urgent need for the public health workforce to update its skills and knowledge in light of the continuous evolution of the public health field.3 In response, there has been significant attention to the development of crosscutting competencies, as the alignment of workforce competencies with professional responsibilities is associated with increasing organizational effectiveness.4
In the midst of this critical need for public health workforce skill development, there has been a growing recognition among public health practice and academic organizations that a deficiency exists in public health financial and management competencies and skills.4 Both the Association of Schools and Programs of Public Health and the Council on Linkages Between Academia and Public Health Practice have comprehensively addressed foundational competencies for the public health workforce, including categories or domains that relate directly to financial planning and management.5 , 6 In 2009, a comprehensive set of public health financial management competencies was identified with detailed information on knowledge, skills, and abilities (KSAs) that capture the technical expertise needed to fulfill anticipated responsibilities in this domain.4 Additional work was done to then prioritize areas for future educational programming.7 These results along with other national and regional workforce reports point to a continued gap in knowledge of financial and management services as well as specific areas of need that include budget-related activities, analysis and interpretation of financial data, and assessment of an organization's financial status.7 , 8
Public health finance and management are complex, and the current challenges facing the system in terms of evolving threats and significant reductions in both human and financial resources place undue burdens on state and local health agencies.9–11 The implementation of the Patient Protection and Affordable Care Act (ACA) adds another layer of complexity, leading to increased demand on health agency services and programs.12 Despite the fiscal challenges, there is a sense of urgency in strengthening the public health workforce's capacity to manage and deliver effective services. The purpose of this study was to characterize business skills among state public health agency employees and to examine factors associated with job satisfaction, annual compensation, and worksite training environment. Findings should support the development of educational programs that are tailored to the needs of agencies and take into consideration time and fiscal constraints.
Data used for this study were drawn from the 2014 Public Health Workforce Interests and Needs Survey (PH WINS). The PH WINS study design is described in detail elsewhere in this supplement.13 PH WINS included a nationally representative sampling frame of central office employees of state health agencies (SHAs) across the United States. This frame was stratified by 5 paired, contiguous Health and Human Services (HHS) regions and includes all permanent (ie, not temporary or intern) staff members of SHAs who work in the SHAs' central office, as opposed to regional or local health departments. On the basis of the sampling design, approximately 25 000 of a total population of 42 000 central office staff nationwide were contacted electronically and invited to participate in PH WINS. After accounting for undeliverable e-mails and individuals who had left their position, the response rate was 46%, with approximately 10 250 permanently employed central office staff completing the survey.13 Balanced repeated replication weights were used to account for a complex sampling design.
Respondents were asked a series of questions related to workforce priorities and then asked to rate the overall importance of these items relating to their day-to-day work and their current skill level on each of these items. Skill level was captured on a scale that included “not applicable,” “unable to perform,” “beginner,” “proficient,” or “expert.” For the purposes of this study, the following 4 workforce priorities were included in the domain of business-related skills referred to throughout this article: (1) managing change in response to dynamic, evolving circumstances; (2) applying quality improvement concepts in my work; (3) preparing a program budget with justification; and (4) ensuring that programs are managed within the current and forecasted budgets. These 4 workforce priorities were determined by examining the competencies of both the Association of Schools and Programs of Public Health and the Council on Linkages Between Academia and Public Health Practice that focus on financing, budgeting, and management.6 , 14 In addition, Honoré and Costich4 published a comprehensive list of public health financial management competencies in 2009, and these were also taken into consideration. For the purposes of analyses, we collapsed response variables and considered survey respondents proficient if they self-rated their current skill level as proficient or expert and not proficient if they rated their skill as nonapplicable, unable to perform, or beginner. Because of the correlated nature of the 2 budget items in the survey (r = 0.77), we collapsed them into a single budget skill variable. Participants were then labeled as proficient if they rated themselves as proficient or expert on either of the budget items.
Independent variables of interest include job classification, supervisory status, tenure in public health practice, annual compensation, educational attainment, paired HHS regions, and sociodemographic characteristics, including gender, and race/ethnicity.13 Educational attainment was collapsed into 4 categories based on highest academic degree earned, with respondents categorized as earning a doctorate degree, a master's degree, a bachelor's degree, or an associate's degree or less. Role classification was collapsed into 4 groups: administrative role, a clinical or laboratory role, a public health sciences role, or social services and other roles. Job satisfaction was coded using the Job in General score scale. Using previous literature as a guide, low job satisfaction was defined as a Job in General score of 19 or less.15 Participants with a Job in General score of 19 and above were classified as being either neutral or satisfied with their job. Self-reported race was defined as white, black, Hispanic of any race, and all others including Asian American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and those who identify as 2 or more races. Supervisory status was defined for survey respondents as nonsupervisor, team leader, supervisor, or manager/executive.
The variable for workplace environment with respect to support of training and continuing education was created from 2 survey items. First, participants were asked to characterize the type of support their health department provided with respect to continuing education and training, including the following: require continuing education, include education and training objectives in performance reviews, allow use of working hours to participate in training, pay travel and registration fees for training, provide on-site training, have staff responsible for internal training, and provide recognition of achievement. These 7 items were on a binary scale. Second, participants were also asked to rate their level of agreement with the following 2 training-related items: (1) supervisors/team leaders in my work unit support employee development; and (2) my training needs are assessed. We collapsed these 2 self-rated questions into 2 categories (those who agree and strongly agree with the statement vs those who strongly disagree, disagree, or neither agree or disagree) in order to put them on the same scale as the previous questions related to training environment. These 9 items were then used to create a training environment index for modeling.
The final training index was created by summing the mean of each variable, multiplied by the number of factors included in the index. The suitability of these 9 questions to form an index of workplace training environment was assessed using principal components of factor analysis, which indicated that these items loaded on a single factor. Internal consistency/reliability of these summed items was 0.74.
To examine the association of business skills and job satisfaction, a multivariable logistic model, adjusting for complex survey design, was fit while controlling for gender, race, and education. To understand the relationship between training environment and business skill proficiencies, a multivariable logistic model controlling for the same sociodemographic variables was used (Table 1). To model how business skill proficiencies affect compensation, a multivariable linear regression was utilized to model salary compensation. A model of gender, race, education, HHS region, job classification, supervisory status, and tenure in public health practice was fit. Interactions of supervisory status and job classification were also assessed to account for salary differences within each job classification. A 1-unit increase in salary corresponds with an approximate $10 000 increase in salary among full-time employees. Outliers in full-time salary were excluded (salaries <$25 000 and >$145 000).
Statistical analyses were performed with SAS software (version 9.3; SAS Institute, Inc, Cary, North Carolina). This project received a determination of “exempt” from the University of Miami institutional review board.
Approximately half of PH WINS respondents describe themselves as proficient in budget preparation and budget management (49.3%). The majority of the workforce respondents perceive themselves to be proficient in their ability to apply quality improvement concepts in their work (67.5%) and to manage change in response to dynamic and evolving environments (69.2%). Variation exists in the distribution of business skill proficiency by education level. Those with bachelor's and associate's degrees reported lower budget skill proficiencies overall (47.4% and 34.4%, respectively) than those with master's and doctorate degrees (60.8% and 60.6%, respectively). This variation in skill level was also noted when comparing self-reported proficiency in managing change from those with an associate's degree to those with bachelor's degree (54.3% vs 70.2%) and among those with master's and doctorate degrees (77.4% and 79.7%, respectively) Overall, those classified as public health science professionals self-reported higher proficiency across all business skill categories. Nonsupervisors were least likely to self-report budget skill proficiencies (35.0%), and they reported lower proficiency across the other 2 business skill categories (61.0% and 59.8%). There was a notable linear trend among those with increasing supervisory responsibilities and business skill proficiency. This same directional trend was evident when examining tenure in public health workforce and with annualized salary. There was minimal variance between business skills and race of any category. Significant associations between groups are shown in the multivariable modeling.
Table 2 presents a multivariable model of the 3 business skill variables with job satisfaction, controlling for sociodemographics. Hispanics were significantly less satisfied with their jobs than whites (OR = 0.71; 95% confidence interval [CI], 0.58-0.87) and other race groups (OR = 0.72; 95% CI, 0.62-0.83). Compared with those with an associate's degree, respondents with a doctorate degree were more likely to report job satisfaction (OR = 1.67; 95% CI, 1.30-2.15). Of the 3 business skill proficiencies, participants who perceived that they were proficient in applying quality improvement concepts to their work were more likely to report job satisfaction than those who perceived they were not proficient (OR = 1.27; 95% CI, 1.08-1.48).
Table 3 presents multivariable models of associations between work environment and each of the 3 business skill variables controlling for the same covariates. Male gender was significantly associated with each of the 3 business skill categories (range of OR = 1.25-1.29). Associations with race/ethnicity varied across the models. Those defined as “Other” were less likely to report proficiency in managing change environments than whites (OR = 0.77; 95% CI, 0.69-0.87). In contrast, however, Hispanics (OR = 1.18; 95% CI, 1.02-1.36) and “Other” (OR = 1.35; 95% CI, 1.12-1.64) were more likely to report quality improvement proficiency.
Educational attainment was associated with the 3 self-assessed proficiencies. Relative to those with an associate's degree, public health workers with a bachelor's degree were 1.2 to 1.9 times more likely to report proficiency in the 3 business skill categories. For those with a master's degree relative to an associate's degree, these associations ranged from an OR of 1.4 to 2.8. Associations ranged from 1.7 to 3.8 for those with a doctorate degree relative to an associate's degree. Finally, the training environment index was significantly associated with all 3 business skills. A 1-unit change in this index was associated with an 8% to 11% increased odds of reporting proficiency across the 3 business skills.
Controlling for gender, race/ethnicity, role classification, supervisory status, tenure in public health practice, and the interaction between role classification and supervisory status, both proficiency in managing change (β = .15; P = .003) and proficiency in budget skills (β = .37; P < .0001) are associated with an increase in annual reported salary (Table 4). Applying quality improvement concepts was not significantly associated with salary (β = −.070; P = .211). In addition, significant associations exist between annual salary and gender, race/ethnicity, education, role classification, HHS region, supervisory status, and tenure in public health practice (data not shown).
This study shows a positive correlation between self-reported business skill proficiency and advanced education, higher annual earnings, and a supportive worksite training environment. In addition, self-reported business skill proficiency correlates with higher overall job satisfaction in at least 1 business skill. Our findings also confirm the significant role that a supportive training environment plays in self-reported business skill proficiency. This finding was consistent across all business and management skills measured. This study provides support for the development of appropriately designed business skill training opportunities to increase competencies in this critical domain and to support the advancement and professional mobility of the public health workforce.
Professional development of public health leaders has been the focus of competency-based management academies and public health leadership institutes over the last decade, and substantial advances have been made in building strong and effective national, state, and local leadership.16–18 This has been critically needed, given the increasing demand on public health leaders to address complex and continuously evolving demands to the public health system in a time of diminishing resources.11 The results of this study are suggestive that this investment has benefited those at the top tier of the workforce. Self-rated abilities to manage change and apply quality improvement concepts are highest among those with advanced degrees, supervisory responsibilities, and higher salaries. More provocatively, this study may provide support for the prioritization of business skill training aimed at increasing financial management competencies across the workforce, not just for those in the top tier. This will require rethinking the way management and leadership training has taken place. Resources in public health departments for training and development have been significantly reduced in recent years.9 Travel to in-person opportunities over multiple days stresses an already overburdened and understaffed public health system. There is a clear need for innovative and engaging online workforce learning opportunities. Such opportunities could improve the mobility and enumeration of low- to mid-level employees who need business and management skills to meet the challenging demands of the changing health care and public health system.
The study also revealed a significant association between proficiency in self-reported business skill training and a supportive training worksite environment. This is a critical component to consider for future efforts to provide training in this domain. There is growing literature to support Web-based training as a key training strategy to reach the public health workforce.19 Within the last decade, online continuing education programs supporting training of public health workers have grown and are available on existing public health networks. As of 2014, more than 800 000 learners have registered in TRAIN.14 , 18 , 20 , 21 Both SHAs and their leaders need to be cognizant that their workforce requires a supportive training environment to attain proficiency in business skills.
Specific items that formed our training environment index include the allowance of work hours to participate in training, requirement of continuing education, inclusion of education and training objectives in performance review, and recognition of achievement. State health agencies should provide more than physical access to a computer for Web-based training. Improving proficiency in business skills needs more than a “if you build it, they will come” approach. Those involved in building the capacity of the public health workforce need to provide specific worksite supports in order to meaningfully increase proficiency.
PH WINS was designed to support efforts to comprehensively examine areas of importance to workforce development. To that end, it provides a macro-level view of broad range of competencies important to the field of public health today. Given the nature of the survey, our ability to examine specific business- and management-related skills was limited to those items contained in the survey. Nonetheless, the significant associations between self-reported proficiency in business skills and job satisfaction and higher annual salary support additional research to expand upon this national effort. Both SHAs and other interested public health practice organizations can use PH WINS and these findings to develop follow-up surveys that explore more deeply the gaps in business skill training.
A comprehensive set of public health financial management competencies has been identified with detailed information on KSAs that capture the technical expertise needed to fulfill anticipated responsibilities in this domain.4 Regional surveys could build on PH WINS and utilize these KSAs to examine business skill proficiency and attain a more accurate assessment to guide training efforts. This would help ensure that the public health workforce attains the financial management and business skills necessary for an efficient and productive workforce.
The timing for this type of workforce development becomes more critical in the era of accreditation and the implementation of the ACA.22 The ACA calls for improvements in both health care and the public health system to improve the population's health. In several recent articles, Honoré12 , 22 links the ACA mandates for strategies to effectively deliver, finance, and organize public health services. It is vital to ensure that the workforce has the needed training and skills to meet the demands of the US populace. Furthermore, the Public Health Accreditation Board is leading a voluntary public health accreditation initiative across the United States. In June 2014, the Public Health Accreditation Board released the Standards and Measures (version 1.5), which contains a domain (domain 8) specific to the maintenance of a competent public health workforce and a standard (domain 8.2) that states that health departments must provide a health department–specific workforce development plan.23 This framework for health departments to demonstrate specific strategies to assess staff competencies and implement workforce development strategies could serve as a critical leverage point for professional development and training in financial management and business skills. Overall, this study supports movement toward improving education aimed at addressing these critical gaps in business skills. If educational opportunities were equally available to all SHA employees, we could have a public health workforce that is more satisfied, has higher earning potential, and has the skills necessary to improve the health of the nation.
This study has several limitations. As described elsewhere, there are limitations that relate to PH WINS itself and the potential of nonresponse bias.13 , 20 Specific to our study, there are several limitations to note. First, the outcomes of interest, proficiency in business skills, rely on self-reported data. Although PH WINS is anonymous and the identity of individual respondents is confidential, employees tend to overreport behaviors viewed as important to their job or organization.24 This tendency may have led to increased ratings of proficiency level in important management areas such as managing change and applying improvement concepts. Second, we limited our analyses to 4 business-related items from PH WINS. Selection of these items was based on the literature and published core competencies in the financial and management domains from the Association of Schools and Programs of Public Health and the Council on Linkages Between Academia and Public Health Practice.4 , 6 , 14 It is possible that additional items may have provided additional insight into the nature of business skills in the public health sector. Finally, regression models with salary as the dependent variable were based on a subset of observations, with those earning at the income extremes being excluded. This approach was consistent with those reported in another article in this supplement,25 but interpretation of our findings is relevant only for full-time public health workers earning between $25 000 and $145 000.
Public health workers who self-report proficiency with business skills report increased job satisfaction, higher annual salaries, and a more supportive training environment. These findings support the need for the development of appropriately designed business skill training opportunities to increase competencies in this critical domain at all levels of the public health workforce. Change is needed to create a core foundation of business skill knowledge that reaches a broader audience of the public health workforce. Given the dynamic environment in public health against the backdrop of the ACA and a national accreditation movement, improving business knowledge, skills, and abilities across the workforce is urgent.
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