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Advancing Leadership Training to Address Health Equity and Respond to Public Health Emergencies

Levis, Maria MPH, MPA, PCMH, CCE, CFRE; Ugarte, Raisa MA; Arana, Mayela MPH, CHES, CPH; Ocasio, Carolina BA; Viera, Tariz MS; Ortiz, Sofía MPH; Murrman, Marita EdD, MS

Author Information
Journal of Public Health Management and Practice: September/October 2022 - Volume 28 - Issue 5 - p S254-S262
doi: 10.1097/PHH.0000000000001521
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Abstract

Context

Puerto Rico (PR) has overcome multiple catastrophic events and public health emergencies over the past 5 years. In 2015, the Commonwealth Government declared that it would default on its public debt requiring significant reductions in public health financing while managing the effects of a 6-month water drought and the ensuing spike of dengue and chikungunya resulting from mosquito propagation in the water storage containers used by the population. The Advancing Leadership in Times of Crisis (ALTC) program was developed by Impactivo, and the Region 2 Public Health Training Center (R2PHTC) led by the Columbia University Mailman School of Public Health under a subaward from the Health Resources and Services Administration (HRSA) to provide public health officials with the tools to face this fiscal and public health crisis. Impactivo is a women-owned, minority-owned, PR-based, social impact consulting firm with a mission of transforming health systems. The firm has significant subject matter expertise to provide direct assistance to public health organizations in areas that range from data-driven decision making and the implementation of evidence-based practices to training in public health competencies as outlined by federal agencies including Health Resources and Services Administration, Centers for Disease Control and Prevention, Patient-Centered Outcomes Research Institute, National Institutes of Health, and National Science Foundation.1 The Impactivo's instructional design team that developed and adapted the ALTC includes multiple ethnically diverse public health experts, instructional designers, evaluators, leadership experts, educators, and clinicians (the design team).

“The professional development of public health leaders requires competency-based instruction to increase their ability to address complex and changing demands for critical services.”2 Various studies have documented the effectiveness of leadership programs to support public health workers.3–7 In 2015, the design team developed the ALTC to address the gap in Spanish-language public health leadership training to address crises. The ALTC was initially designed as an in-person training program to increase Mid-and-High-Level Public Health practice professionals' capacity to successfully exercise leadership within the context of the Centers for Disease Control and Prevention's Essential Public Health Services (EPHS).

Since 2015, PR has faced diverse public health emergencies; therefore, the design team used quality improvement methods and a participatory design approach to develop the ALTC to meet the changing needs of public health leaders to address unanticipated events. In 2016, the ALTC was tailored for its first cohort as a contextualized and modularized learning program, which was deployed in the context of participant's need to respond to the Zika epidemic. Zika affected more than 35 000 people living on the Island, putting infants at risk of congenital Zika disease and microcephaly, which made vector control and prevention a priority.8,9 In 2018 and 2019, the ALTC participants were immersed in relief efforts from the devastation caused by Hurricanes Irma and María; a disaster that left the island without water, power, and communications for months, requiring massive public education, mental health interventions, and community organizing.10 In addition, in late 2019 and early 2020, the ALTC participants were charged with responding to a series of earthquakes that exceeded 6.5 on the Richter scale and the aftershocks, which created infrastructure risks, prompted mass hysteria, and left many in southern PR homeless.11

From 2016 to 2019, the ALTC evolved into a training program that affords participants the opportunity of deep exploration in current leadership challenges and practical experience to enhance their effectiveness. It aims to engage participants in an active space to improve their leadership skills, enhance their competencies with dynamic learning, improve their ability for effective collaborations with stakeholders, and fortify their network. At the start of 2020, when the world began to see the effects of the novel COVID-19 pandemic, the ALTC 2020 on-site program was canceled and Impactivo adapted the latest iteration of the ALTC program using a fully virtual asynchronous format that could replicate the program's interactive learning experience for a new cohort.12

The purpose of this article is to describe the program 2016-2019.

Approach

Target audience

The design team worked collaboratively with leadership at the Puerto Rico Department of Health (PRDoH) since the inception of the ALTC to define the target audience and learning objectives that form the basis for the instructional design. The 2016-2019 ALTC target audience were senior and mid-level public health professionals working at the PRDoH or a nonprofit organization in the local public health system. The participants were required to apply to the program and were selected by an independent panel based on the rank of their scores for review criteria. The PRDoH Deputy Public Health Officer reserved the right to directly appoint a handful of senior-level employees. A new cohort was admitted to the program each year for the 5-month program. The ALTC has a total of 82 graduates including 80% who are women, 100% who are Hispanic, and 61% who are PRDoH staff. Positions held by ALTC graduates include deputy directors, a medical school president, a chief medical officer, nonprofit executive directors, grant officers, and program directors, among others.

Content identification

The design team carried out a scoping review of literature on public health leadership training and identified gaps in the availability of Spanish-language leadership training that is interactive, practical, grounded in practice, addresses health equity, and focuses on public health crisis. The PRDoH senior leadership, public health experts and local system stakeholders were interviewed using open-ended questions regarding the issues they understood needed to be addressed in a course, with the purpose of increasing participants' capacity to sustain the demands of leadership and to strengthen their ability to successfully exercise both leadership and authority in times of crisis. Consensus formed around structuring the program so that it would address the following questions:

  • What does it mean to be a leader in a time of crisis?
  • What have other leaders done in a crisis to achieve positive public health outcomes?
  • How can leaders identify community needs and build on their strengths?
  • How can the federal government contribute to supporting leaders' initiatives?
  • Is it possible to develop public health programs and initiatives that are sustainable?
  • How can effective partnerships lead to better outcomes with less resources?
  • What role do leaders play to secure the EPHS?

Following the input provided in the interviews, leadership development models were identified as most aligned with the course purpose and objectives to form the basis for the ALTC course content:

Adaptive leadership model

Heifetz et al13 defined adaptive leadership as the practice of mobilizing people to face difficult challenges and make behavioral changes. Public health crisis tends to be adaptive in nature, requiring significant community mobilization, which is why we found the model relevant. Adaptive leadership is not about converging expectations but rather about mobilizing people to adapt to challenges and act.14–16 Key concepts incorporated in the ALTC from this model include identifying the difference between adaptive and technical problems, performing a systemic stakeholder versus a personal analysis, conflicts of values, understanding the use and sources of formal and informal authority, crafting interventions within the productive zone of disequilibrium, the importance of partnerships, and the role of self.

Public narrative and community organizing

Marshall Ganz defines community organizing as a process in which people who live near each other or share common problems come together into an organization that acts in their shared self-interest.17 Specifically, the ALTC emphasizes the use of Ganz's Theory of Change to establish strategies and his work on a Public Narrative to create trust and motivate others to overcome inhibitors and make a difference. This is the kind of work that needs to happen in times of crisis, which is why we found this model relevant. The aspects of Ganz's work that were incorporated in ALTC include motivating commitment; risk taking; cultivating the experience of shared values; public narrative; building relationships to engage participants; creative strategizing based on inclusive, continual, and recognized heuristic processes; and channeling collective resources into action based on commitment, intrinsic reward, and accountability for measurable outcomes.15

The leadership challenge

The ALTC also draws from Kouzes and Posner's Leadership Challenge, specifically defining the 5 key practices for extraordinary leadership: modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart. The Leadership Challenge has been used previously in other jurisdictions in addition to public health leadership.

Other models and disciplines

The ALTC also draws on other disciplines including public health practice, leadership development, health system's research, management, public policy, and sociology to enhance the learning experience. The ALTC focuses on contextualizing leadership lessons in the EPHS, social determinants of health, public health emergencies, and health equity. The participants reflect on and discuss how policy and laws can be used to improve the community's health and how to determine the feasibility of programs and services. Other skills that are taught include communication skills and cultural competency. The ALTC also emphasizes how to interact with the larger interrelated system of organizations that influence the health of populations, creating opportunities for organizations to work together or individually to improve the health of a community.

Course structure

The ALTC 2016 began with 4 in-person sessions totaling 16 contact hours. The competencies addressed included the de Beaumont Foundation's Strategic Skills. Based on feedback from participants, the course was adapted in 2017 to blended learning instruction (4 in-person and 2 virtual sessions delivered via a synchronous webinar format via Zoom) totaling 10.5 contact hours and was adapted again in 2018-2019 to incorporate more group working time to a total of 20 hours carried out over a 5-month period. Content was divided into small modules that allowed for contextualized instruction, reflection, application, and networking. Modules were sequenced according to time, relevance, and interests, and typically included an ice breaker, followed by a lecture by a subject matter expert with a group-guided discussion and application exercise. Closing remarks included a recap, instructions for next session, an assignment, and a networking activity. Some sessions included a second lecture or panel discussion. Each session covered different topics through lectures, videos, readings, panels, discussions, group activities, and practical exercises. Sessions build upon the previous and by the end of the program, the participants learn about developing a vision of health for their community and to empower others as part of their leadership commitment. The modules can be grouped as follows:

Contextualized lectures

Lectures were presented by one or more subject matter experts (SMEs) and included a group-guided discussion. The SMEs contextualized lectures to the relevant public health challenges, including public health emergencies and health equity. In addition to expertise in public health and leadership development, the SMEs shared in-depth knowledge about the local health system and the specific public health challenges addressed by participants at the time. For each cohort, a diverse team of SMEs delivered the content of the lecture modules and was chosen paying particular attention to ensuring that the age, racial, gender, professional, and geographic composition of the participants was reflected in the choice of trainers and panelists. Demographic information for the participants was collected during the program application process and the SMEs selected by Impactivo for the sessions were intentionally representative of the demographics of program participants. This effort entailed a thorough search of diverse SMEs. The majority of the trainers and/or panelists also had practical experience in the field. The learning objectives, leadership concepts, and public health competencies taught in the contextualized lectures and topics covered in the ALTC since its inception are shown in Table 1.

TABLE 1 - Contextualized Lectures, Learning Objectives, Essential Leadership Concepts, and Essential Public Health Services Competencies
Lecture Modules Learning Objectives Leadership Concepts Public Health Competencies
What is leadership? Learn about basic leadership conceptsIdentify leadership stylesDescribe the interrelated nature and components that affect public health Leadership as a skill, not a traitLeadership versus management Systems thinking skillsCommunity dimensions of practice skillsTime management
Exemplary leadership Comprehend the 5 practices of exemplary leadershipUnderstand the 10 commitments of exemplary leadership Practice of exemplary leaders
Network analysis Analyze their network to identify areas of risk/opportunityIdentify opportunities and structure for effective collaborations Network analysisTeam buildingTeamworkCollaboration AssessmentsSupport partnerships
Types of leadership Understand the differences between leadership and authorityLearn from health sector leaders how to manage crisisLearn how to develop an effective elevator pitch Adaptive leadershipPersuasive communication
Quality improvement in public health Describe how quality improvement in public health is leading to improvements in health outcomesDescribe the project management process and the components of a project management plan Project management process versus quality improvementDeveloping a project planPerformance improvement Quality improvementAnalytical/assessment skills
Leading your community Determine community health status and factors influencing health in the communityIdentify opportunities for and structure for effective collaborations Community organizingPublic narrative Determine community health status/factors influencing healthCommunicate effectivelyCultural competency skills
The power of the law Describe the interrelated nature and components that affect public healthAssess the roles and responsibilities of governmental and nongovernmental organizations in providing programs and services to improve the health of a community Policy lawPolicies and proceduresAdministration and advocacy Policy development and effectivenessProgram planning skills
Interpersonal communication and leadership: getting your message across Understand the difference between leadership and managementGrasp the importance of emotional intelligence in communicationLearn about motivational strategies to engage team members Leadership versus managementStrategic, effective, and persuasive communicationEmotional intelligence Communication skills
Public Health 101 Explain the CDC's essential public health services CDC's essential public health services
Your commitment as a leader Develop their theory of change Community organizingResiliency Create, champion, and implement PH initiatives
Abbreviations: CDC, Centers for Disease Control and Prevention; PH, public health.

Reflexive and networking activities

These activities were designed to provide participants with an opportunity to better understand themselves, implement the concepts and competencies in their context, and support one another in this process. Activities were structured to help participants apply the learning to the public health challenges they were facing, including public health emergencies and health equity, and increase relevance to the participant's reality. The learning objectives, public health emergency context, and health equity context addressed through these activities are shown in Table 2.

TABLE 2 - Contextualized Reflexive and Networking Activitiesa
Activity/Projects Learning Objectives Public Health Emergency Context Health Equity Context
Yesterday was World Day of Social Justice: Let's talk about access to care and equity Review and reflect about access to essential services in PRIdentify how your organizations address health equity Mental healthAccess to care after the earthquakes and hurricanes Health disparitiesAccess to essential services such as education, health, food, and housing in Puerto Rico
Network analysis Analyze their current network and identify areas of opportunity within it Establishment of networks for community response to PHEs Understanding of personal networks and connections that may be limiting their communities from accessing health and economic development
Quality improvement—Mr Potato Head Describe how quality improvement can be used for PH improvements in health outcomesDescribe at least 2 tools or resources for quality improvement Structuring quick metrics in PHEs Establishing HE metrics
Project management fundamentals: Developing a project management plan (team projects) Define a projectDescribe the project management process and componentsOutline the role of a project manager, tools, and techniques Establishing an ER/preparedness plan Establishing projects that address HE
Are you an adaptive leader? Discuss the difference between leadership and authority, technical versus adaptive challenges, and how they relate to their experiences Analysis of the current PHE from the lens of an adaptive problem Analysis of HE from the lens of an adaptive problem
Community leaders panel Panel with community leaders who have inspired movements for the better of their communities Practical examples to address PHEs Practical examples to address HEs
Policy Law 101Administrators versus advocate strategy (group exercise that simulate a strategic planning process) Figure out how to turn the resources they have into the capacity they need to achieve a specific, measurable goal Establish a strategy for communicating with the government in PHEs Improving HE in your organization
Responding to whose needs? Giving data a voice and finding trends Analyze and interpret data to make decisions Rapid data-gathering methods Data on HE that should be gathered
Getting your message across—Origami Exercise Identify the barriers of communication and establish a plan to overcome them Effective communications in PHEs How to access populations facing health disparities
16 Personalities: your leadership personality Identifying leadership style and preferences of self and others Knowing yourself to address PHEs Knowing yourself to address HE
Zoom and GO-AHEAD tools Learn how to use different tools to work with their teams more efficiently Using technology to address PHEs How to onboard health disparate populations to technology and other tools
Abbreviations: ER, emergency response; HE, health equity; PH, public health; PHEs, public health emergencies; PR, Puerto Rico.
aActivities and projects and public health emergencies/health equity topics to which they have contextualized.

Group project

In year 2 of the program, the ALTC added the development of a group project that was carried out over the course of the program to teach collaborative problem solving and give participants an opportunity to practice their leadership skills. The participants were divided into groups and tasked with developing an intervention plan for various public health issues. The group members were responsible for choosing the topic of interest, providing data to identify a gap they were planning to fill and establish goals and objectives, and intervention or strategies, including a plan to carry out activities to reach those goals and objectives and how they would measure their success. Group participants were expected to define the process of collaborating with individuals and organizations within communities to address health needs of importance and urgency. Group participants presented their final project to a panel of experts in a 30-minute presentation where they were evaluated and given feedback by the experts and their peers.

Course adaptations

Impactivo used quality improvement methods (specifically the Plan-Do-Study-Act Cycle) and a participative design approach in collaboration with PRDoH leadership to adapt the program after each session and each cohort. The Plan-Do-Study-Act Cycle is an action-oriented scientific method that tests a change with 4 steps—planning it, testing it, measuring its results, and then trying to do better next time. The methodology is used at Impactivo to improve training programs. As a result, minor modifications to the program were incorporated between sessions, and the program underwent 2 major adaptations of its instructional design. The first adaptation happened between the program's first and second years in response to the need for increased contextualization due to changing public health emergencies, increased attention to health equity due to increasing poverty, increased need for collaboration among system stakeholders, and to provide a blended learning experience for participants. The second major adaptation is currently happening in response to the pandemic to provide a completely asynchronous modality. This second adaptation is in its pilot phase and has been well received among participants for its flexibility (see Table 3). The asynchronous design consists of easy-to-follow and self-paced readings, videos, scenarios, quizzes, animations, and practice exercises within Impactivo's Learning Management System (LMS), the ImpACTivista Learning Hub. The modules are built using Rise 360, a Web app that publishes Sharable Content Object Reference Model (SCORM).

TABLE 3 - Online 2021 Advancing Leadership in Times of Crisis Program ALTC
Questions Score n
How many stars (1-5) do you give ALTC? Scored 4.83/5 (96%) 12
How confident are you that you can recognize the practices and identify the essential characteristics of leadership, public health, and governance? (From 1 to 4) Scored 3.67/4 (92%) 12
Do you think that the organization of the module helped you understand the topics discussed in leadership, public health, and governance? 100% answered “Yes” 12
Do you consider the platform used to Advance Leadership in Times of Crisis as one that is easy to use and navigate? 100% answered “Yes” 12
Do you think Impactivo should improve the experience of this educational course? 100% answered “No” 12
Abbreviation: ALTC, Advancing Leadership in Times of Crisis

Course evaluation

Program evaluation activities include qualitative and quantitative survey data used by the design team to facilitate course design, development, and implementation. Evaluation metrics evolved as training needs and circumstances changed. The core evaluation methods were primarily pre-/posttests and satisfaction surveys that asked about the overall satisfaction, utility, and improvement in knowledge, skills, and attitudes among participants. Overall, the 2016-2019 ALTC data revealed that (1) the average participant satisfaction and perceived benefits score has remained above 90% agreement, and (2) fidelity to the 2017 ALTC has been maintained through various iterations although modules have been sequenced differently and contextualized to increase relevance. Program evaluations were specific to each session and were distributed both in-person and via online surveys. All evaluations were anonymous and included Likert-style, open-ended, and demographic questions. Evaluation surveys were developed by the R2PHTC in collaboration with an experienced evaluator to ensure rigor and consistency of use across all 10 Regional PHTCs.

Results

A total of 343 evaluation surveys were completed from 2016 to 2019. The ALTC program generated positive outcomes perceived by participants throughout all cohorts (2016-2019) with extremely high levels of satisfaction and benefits. The participants showed high levels of agreement for increased knowledge and understanding of subject matter, the applicability of concepts, clear presentation of topics, and overall satisfaction with the program from 2016 to 2019 (see Tables 4 and 5). Among the strengths of the program, the participants reported that the diversity of SMEs reflected communities they served and the opportunity of growing their professional connections with renowned public health leaders. These results were measured through level of agreement with each item in the survey. Preliminary data for the new asynchronous pilot in 2021, which has been used by 12 participants, have also shown promising results (see Table 3).

TABLE 4 - Evaluation Results From 2016 ALTC Programa
Question Responses (Strongly Agree or Agree)
The information was presented in ways that I could understand. 97.6%
I have identified actions I will take to apply information I learned from this training in my work. 97.5%
My understanding of the subject matter has improved as a result of having participated in this training. 98.6%
Overall, I was satisfied with today's training. 96.7%
aData were collected for sessions 2 to 4 of the program for all the participants (S2 = 23, S3 = 21, and S4 = 20). The response is the average of the scores for these sessions. Session 1 was not evaluated.

TABLE 5 - Evaluation Results From 2017, 2018, and 2019 ALTC Program
Responses (Strongly Agree or Agree)
Question 2017a 2018b 2019c
Did your understanding about the topic improved after the training? 91.2% 100% 96.6%
Have you identified actions to apply the information? 85.1% 100% 100%
Was the information presented clearly? 90.5% 100% 98.3%
Overall, were you satisfied with the session? 89% 100% 98.4%
aData were collected at all 5 sessions (S1 = 20, S2 = 24, S3 = 30, S4 = 13, and S5 = 28). Session 4 was the only online session. The response is the average of the scores for these sessions.
bData were collected at sessions 1, 3, 4, and 6 for all the participants (S1 = 29, S3 = 27, S4 = 28, and S6 = 27). The response is the average of the scores for these sessions. Sessions 2 and 5 were offered online and data were not collected.
cData were collected at sessions 3, 4, and 6 for all the participants (S3 = 21, S4 = 12, and S6 = 20). The response is the average of the scores for these sessions. Sessions 1 and 5 were offered online and data were not collected. Data for session 2 were not collected because of human error.

A follow-up survey sent to the participants of the 2016-2019 ALTC cohort participants in August 2021 found that 89% continue to work in public health and 92% agree that the ALTC content is relevant to their current role. The participants who are currently working in the public health field reported that 25% were promoted and 49% feel confident to train others. The areas they felt most confident to present on were Problems Solving, EPHS, and Public Policy. The participants also reported that the ALTC helped them increase their public health tools (91%), expand their network (84%), and strengthen knowledge about the EPHS (90%). The survey was administered to the 82 graduates who completed the course, was completed by 42 participants, and partially completed by 6 participants.

Discussion and Conclusion

The COVID-19 pandemic is redefining leadership and public health in seemingly unending ways.20 Public health leaders capable of addressing adaptive problems, mobilizing group resources, organizing communities, and building robust networks capable of establishing trust across communities are needed to address new challenges. The ALTC was designed to teach leadership and EPHS competencies in a way that contextualizes and adapts according to the public health challenges. Lessons learned from the implementation of the ALTC could serve as a model for future programs with the goal of providing leadership training to face crisis and complex situations for health organizations. The ALTC is an innovation born out of a place in need in a vulnerable community with significant health disparities and it merits attention as an initiative that can be scaled or adapted to other low-income areas requiring health equity.

Instructional design that incorporates mechanisms for contextualizing training to public health challenges, including emergencies and health equity, is important. This type of approach considers the ever-changing context in which public health professionals operate; however, this approach is time-intensive and requires additional investments from funders interested in health equity.

Preliminary results from the ALTC asynchronous distance-learning pilot are promising and open the opportunity to use integrating technology and interactive educational content that involve a variety of learning tools such as text, audiovisual, role playing, and group exercises to provide training on public health leadership. These tools can help participants understand their context and reflect on key learning concepts they can incorporate in their workplace while also helping them establish the networks necessary to practice effective leadership.

Health Organizations invest significant financial resources to train their workforce in leadership using untested methods.21 High levels of learning, adoption, and satisfaction among ALTC participants indicate the program's promise in enabling public health leadership. More research needs to be carried out to understand the program's transferability to other scenarios and with other populations.22 The ALTC program has been effective in increasing knowledge and understanding of leadership concepts in times of crisis. The participants expressed multiple benefits and satisfaction with elements illustrated by the ALTC, such as hybrid modalities, framework-based knowledge, competency-based learning, and contextualized and practical approaches. Next steps include refining the program further to develop more rigorous and consistent evaluation methods and provide ongoing leadership development within and beyond PR.

Leaders are not born and to quote Sharon Daloz Parks, “Leadership can be taught.” Effective public health interventions require effective leaders, and our health system now needs more public health leaders than ever.

Implications for Policy & Practice

  • The ALTC was designed using a participatory design approach that used iterative quality improvement methods to understand gaps in public health leadership training, target questions that practitioners understand are important, and establish mechanisms for contextualization within the real-life priorities of participants in a predominantly Hispanic low-income jurisdiction. This approach is time-intensive and requires additional investments from funders interested in health equity.
  • The selection of a variety of SMEs who are competent, experienced in practice, and reflect the ethnic, cultural, age, gender, professional, and geographic composition of participants and the communities they serve is key to connecting the participants with the content.
  • The ALTC has demonstrated how a modularized approach to public health leadership development that includes competency-based contextualized lectures, reflective and networking activities, and group projects can maintain relevance in varying public health emergencies and amidst increasing health equity concerns.
  • Public health workforce retention and development is a system priority with an already aging and shrinking workforce and with 66% of professionals reporting burnout.18,19 The ALTC shows promise for retaining public health leaders with 87% of participants reporting that they continue to work in public health after the pandemic. Additional research should explore how this kind of program may act as a protective retention factor and as a tool to support the transition of younger public health professionals into leadership roles.

References

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8. Rodríguez-Díaz CE, Garriga-López A, Malavé-Rivera SM, Vargas-Molina RL. Zika virus epidemic in Puerto Rico: health justice too long delayed. Int J Infect Dis. 2017;65:144–147.
9. CNN Español. Puerto Rico declara el fin de la epidemia del Zika. https://cnnespanol.cnn.com/2017/06/07/puerto-rico-declara-el-fin-de-la-epidemia-del-zika/. Published 2017. Accessed November 1, 2021.
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12. World Health Organization. The Impact of COVID-19 on Global Health Goals. Geneva, Switzerland: World Health Organization. https://www.who.int/news-room/spotlight/the-impact-of-covid-19-on-global-health-goals. Published 2021. Accessed November 9, 2021.
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15. La práctica del liderazgo adaptativo. Las herramientas y tácticas para cambiar su organización y el mundo. Revista EAN. 2016;(81):236–241. https://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=asn&AN=121620760&site=ehost-live Accessed November 10, 2021.
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19. Stone KW, Kintziger KW, Jagger MA, Horney JA. Public health workforce burnout in the COVID-19 response in the U.S. Int J Environ Res Public Health. 2021;18(8):4369.
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Keywords:

health equity; Hispanic participants; leadership development; population health; public health emergencies; Puerto Rico

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