Ensuring a competent public health responder workforce: The CDC experience.

INTRODUCTION: From 2009 to 2016, the Centers for Disease Control and Prevention (CDC) activated its Incident Management System for a public health emergency 91 percent of the time. The CDC must ensure its workforce is prepared for the evolving nature of emergencies. OBJECTIVES: The purpose of this assessment was to identify perceived preparedness and response training needs for the CDC responder workforce. METHODS: Between November 2012 and January 2013, focus groups and in-depth interviews were conducted with CDC responders, including senior leaders. The evaluation questions were: (1) How well does the current training system prepare CDC staff to respond to emergency events? (2) What gaps exist in the current training system? and (3) What trainings are essential and should be included in the training system? RESULTS: Eight focus groups were conducted with 51 responders and 18 interviews with response leaders. Themes were identified for each main outcome measure and translated to training improvements. CONCLUSIONS: The CDC workforce received foundational training. Recommendations are provided to better prepare responders during an emergency. Periodic assessments are necessary to expand training and remain responsive to the complexities of emerging threats.

Applying Instructional Design Strategies and Behavior Theory to Household Disaster Preparedness Training.

CONTEXT: Interventions and media campaigns promoting household disaster preparedness have produced mixed results in affecting behaviors. In large part, this is due to the limited application of instructional design strategies and behavior theory, such as the Transtheoretical Model (TTM). This study describes the development and evaluation of Ready CDC, an intervention designed to increase household disaster preparedness among the Centers for Disease Control and Prevention (CDC) workforce. OBJECTIVES: (1) Describe the instructional design strategies employed in the development of Ready CDC and (2) evaluate the intervention's impact on behavior change and factors influencing stage progression for household disaster preparedness behavior. DESIGN: Ready CDC was adapted from the Federal Emergency Management Agency's (FEMA's) Ready campaign. Offered to CDC staff September 2013-November 2015, it consisted of a preassessment of preparedness attitudes and behaviors, an in-person training, behavioral reinforcement communications, and a 3-month follow-up postassessment. RESULTS: Ready CDC employed well-accepted design strategies, including presenting stimulus material and enhancing transfer of desired behavior. Excluding those in the TTM "maintenance" stage at baseline, this study determined 44% of 208 participants progressed at least 1 stage for developing a written disaster plan. Moreover, assessment of progression by stage found among participants in the "precontemplation" (n = 16), "contemplation" (n = 15), and "preparation" (n = 125) stages at baseline for assembling an emergency kit, 25%, 27%, and 43% moved beyond the "preparation" stage, respectively. Factors influencing stage movement included knowledge, attitudes, and community resiliency but varied depending on baseline stage of change. CONCLUSIONS: Employing instructional strategies and behavioral theories in preparedness interventions optimizes the potential for individuals to adopt preparedness behaviors. Study findings suggest that stage movement toward household preparedness was not spurious but rather associated with the intervention. Therefore, Ready CDC was successful in moving staff along the continuous process of adopting household disaster preparedness behaviors, thus providing a model for future interventions. The TTM suggests factors such as knowledge, beliefs, and self-efficacy will differ by stage and may differentially predict progression towards behavior adoption. Thus, tailoring interventions based on an individual's stage of change optimizes the potential for individuals to adopt desired behaviors.

Influences of Preparedness Knowledge and Beliefs on Household Disaster Preparedness.

In response to concern about strengthening the nation's ability to protect its population and way of life (i.e., security) and ability to adapt and recover from emergencies (i.e., resilience), the President of the United States issued Presidential Policy Directive 8: National Preparedness (PPD-8) (1). Signed on March 30, 2011, PPD-8 is a directive for the U.S. Department of Homeland Security to coordinate a comprehensive campaign across government, private and nonprofit sectors, and individuals to build and sustain national preparedness. Despite efforts by the Federal Emergency Management Agency (FEMA) and other organizations to educate U.S. residents on becoming prepared, growth in specific preparedness behaviors, including actions taken in advance of a disaster to be better prepared to respond to and recover, has been limited (2). In 2012, only 52% of U.S. residents surveyed by FEMA reported having supplies for a disaster (2), a decline from 57% who reported having such supplies in 2009 (3). It is believed that knowledge influences behavior, and that attitudes and beliefs, which are correlated with knowledge, might also influence behavior (4). To determine the association between knowledge and beliefs and household preparedness, CDC analyzed baseline data from Ready CDC, a personal disaster preparedness intervention piloted among Atlanta- and Morgantown-based CDC staff members during 2013­2015. Compared with persons with basic preparedness knowledge, persons with advanced knowledge were more likely to have assembled an emergency kit (44% versus 17%), developed a written household disaster plan (9% versus 4%), and received county emergency alert notifications (63% versus 41%). Similarly, differences in household preparedness behaviors were correlated with beliefs about preparedness. Persons identified as having strong beliefs in the effectiveness of disaster preparedness engaged in preparedness behaviors at levels 7%­30% higher than those with weaker preparedness beliefs. Understanding the influences of knowledge and beliefs on household disaster preparedness might provide an opportunity to inform messages promoting household preparedness.

Preparedness and Emergency Response Learning Centers: supporting the workforce for national health security.

The importance of a competent and prepared national public health workforce, ready to respond to threats to the public's health, has been acknowledged in numerous publications since the 1980s. The Preparedness and Emergency Response Learning Centers (PERLCs) were funded by the Centers for Disease Control and Prevention in 2010 to continue to build upon a decade of focused activities in public health workforce preparedness development initiated under the Centers for Public Health Preparedness program (http://www.cdc.gov/phpr/cphp/). All 14 PERLCs were located within Council on Education for Public Health (CEPH) accredited schools of public health. These centers aimed to improve workforce readiness and competence through the development, delivery, and evaluation of targeted learning programs designed to meet specific requirements of state, local, and tribal partners. The PERLCs supported organizational and community readiness locally, regionally, or nationally through the provision of technical consultation and dissemination of specific, practical tools aligned with national preparedness competency frameworks and public health preparedness capabilities. Public health agencies strive to address growing public needs and a continuous stream of current and emerging public health threats. The PERLC network represented a flexible, scalable, and experienced national learning system linking academia with practice. This system improved national health security by enhancing individual, organizational, and community performance through the application of public health science and learning technologies to frontline practice.

Concerns in workforce development: linking certification and credentialing to outcomes.

Investments in public health workforce development are based on the assumption that capacity and competencies are linked with the effectiveness and efficiency of providing essential public health services. However, evidence of the effects of workforce quantity or quality on the performance of core public health functions is limited. A review of public health, health care, and teacher education literature was conducted to determine the state of research in the field and to identify promising approaches and study designs for application to public health workforce training. A total of 861 articles and abstracts were reviewed from the health literature and 470 from teacher education literature. Sixty-five reports in the public health or health care literature and 68 in the education literature met the inclusion criteria. Eleven studies in public health or health literature reported positive correlations and 3 determined no substantial correlation to credentials. In the education literature, 10 studies reported a positive link, whereas 9 studies reported mixed or nonsignificant results. We conclude that a paucity of quality research or compelling evidence exists linking certification or credentialing to any related outcome. Until further research is conducted, discussions on the need for public health workforce certification and credentialing will be based on good-faith expectations for improving individual and organizational performance.

Partnering for preparedness: the project public health ready experience.

Effective partnerships between local and state public health agencies and schools of public health have tremendous potential to improve the health of communities nationwide. This article highlights successful collaboration between local public health agencies (LPHA), state health departments, and Academic Centers for Public Health Preparedness (ACPHP) in schools of public health developed through participation in Project Public Health Ready, a program to recognize LPHA emergency preparedness. The project's pilot phase illustrated that LPHAs, state health departments, and ACPHP can effectively work together to improve individual public health worker competency and organizational response capacity in local public health agencies nationwide.

The public health infrastructure and our nation's health.

Threats to Americans' health-including chronic disease, emerging infectious disease, and bioterrorism-are present and growing, and the public health system is responsible for addressing these challenges. Public health systems in the United States are built on an infrastructure of workforce, information systems, and organizational capacity; in each of these areas, however, serious deficits have been well documented. Here we draw on two 2003 Institute of Medicine reports and present evidence for current threats and the weakness of our public health infrastructure. We describe major initiatives to systematically assess, invest in, rebuild, and evaluate workforce competency, information systems, and organizational capacity through public policy making, practical initiatives, and practice-oriented research. These initiatives are based on applied science and a shared federal-state approach to public accountability. We conclude that a newly strengthened public health infrastructure must be sustained in the future through a balancing of the values inherent in the federal system.

A research agenda for public health workforce development.

In the past decades, public health research has focused on categorical rather than cross-cutting or systems issues. Little research has been carried out on the infrastructure required to support public health programs. This article describes the results of an interactive process to develop a research agenda for public health workforce development to inform all those with stakes in the public health system. This research is defined as a multidisciplinary field of inquiry, both basic and applied, that examines the workforce in terms of costs, quality, accessibility, delivery, organization, financing, and outcomes of public health services to increase knowledge and understanding of the relationships among workforce and structure, processes, and effects of public health services. A logic model and five priority research areas resulted from meetings of expert panels during 2000 to 2003. Innovative public and private partnerships will be required to advance cross-cutting and systems-focused research.

Public health workforce development: progress, challenges, and opportunities.

The public health workforce is key to strengthening public health infrastructure. National partners have articulated a vision of a sustainable and competent workforce prepared to deliver essential public health services. Six strategic elements provide a framework for action: monitoring workforce composition; identifying competencies and developing related curriculum; designing an integrated life-long learning delivery system; providing individual and organizational incentives to ensure competency development; conducting evaluation and research and assuring financial support. Partners convened in January 2003 to review progress and to re-evaluate strategies in light of the recently released Institute of Medicine reports on infrastructure and workforce issues. Although significant challenges remain, there is convergence on priorities for competency development, research questions to be addressed and next steps in the national dialogue on certification and credentialing in public health.

Credentialing the public health workforce: an idea whose time has come.

The importance of a well-prepared public health workforce is widely recognized and appreciated. Strategies for enhancing workforce capacity and competency have been discussed by agencies, associations, committees, and expert panels since the landmark 1988 Institute of Medicine report. The need to foster the development of incentives for lifelong learning and career growth is of current interest to national public health associations and federal agencies. The fact that the public health workforce is not a single profession, but rather a fabric of many professions dedicated to a common endeavor, creates challenges to any singular approach. This article explores the relationships among competency, certification, and accreditation and summarizes the expert panel dialogue on workforce development incentives, specifically regarding certification and credentialing. The authors challenge public health leaders to become actively involved in framing the issues so the best possible strategies can be developed.

A model for public health workforce development using the National Public Health Performance Standards Program.

Workforce development programs in public health should link improvements in workers' performance with improvements in their agencies' performance. The "ten essential services" of public health provide criteria for measuring both individual worker training (as in workforce competency standards) and agency performance (as in the Centers for Disease Control and Prevention's National Public Health Performance Standards Program). This shared foundation was the basis for a model strategic training program developed for use in a 500-employee urban county health department. Full implementation of this model as a foundation for assessment, curriculum development, and evaluation requires careful attention to management issues, confidentiality of employee records, and evaluation methodologies.

Are public health services available where they are most needed? An examination of local health department services.

Local health departments (LHDs) play a key role in the provision of public health services in the United States. Little is known about the extent to which LHD service availability varies by the socioeconomic characteristics of regional populations. This study merges data from the 1996 National Association of County and City Health Officials LHD profile survey and the Area Resource File system. The empirical analysis suggests that LHDs in low-socioeconomic background counties are more likely to provide services such as family planning. For other services, either LHD involvement is low across the board or the distribution of LHD services does not favor low-socioeconomic background counties. Thus, there is often room for improvements in service availability and targeting.