public health workforce us

The Public Health Workforce:An Agenda for the 21st Century

A Report of the Public Health Functions Project

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service

TABLE OF CONTENTS

Executive Summary.............................................................................................................. vAcknowledgments............................................................................................................... viiIntroduction.......................................................................................................................... 1Context .................................................................................................................................3

Composition of the Public Health Workforce................................................................... 4Competency-Based Curriculum...................................................................................... 7Distance Learning System Development.......................................................................... 8

Future Directions................................................................................................................ 11National Leadership...................................................................................................... 11State and Local Leadership........................................................................................... 12Workforce Composition............................................................................................... 12Curriculum Development............................................................................................... 13Distance Learning......................................................................................................... 16

Implementation................................................................................................................... 17

Appendix A: The Public Health Functions Project............................................................ 19Appendix B: Public Health in America ..........................................................................21Appendix C: Revision of the Federal Standard Occupational Classification (SOC) System:

New Occupational Categories Recommended for the Field of Public Health 23Appendix D: Descriptions of Selected Public Health Workforce Assessment Studies........ 27Appendix E: Competencies for Providing Essential Public Health Services....................... 29Appendix F: Healthy People 2000 Consortium .............................................................. 43Appendix G: The Faculty/Agency Forum Competencies by Discipline.............................. 47Appendix H: Competencies Reviewed by the Competency-Based Curriculum

Work Group............................................................................................... 49Appendix I: Public Health Functions Steering Committee and Working Group;

Subcommittee on Public Health Workforce, Training, and Education andWork Group Member Lists......................................................................... 51

References......................................................................................................................... 57

Bibliography....................................................................................................................... 61

Today our Nation faces a widening gap betweenchallenges to improve the health of Americans andthe capacity of the public health workforce to meetthose challenges. Deeply concerned with this trend,the Public Health Functions Steering Committee inSeptember 1994 commissioned the Subcommitteeon Public Health Workforce, Training, and Educa-tion, charged to:

provide a profile of the current public healthworkforce and make projections regardingthe workforce of the 21st century. TheSubcommittee should also address trainingand education issues including curriculumdevelopment to ensure a competentworkforce to perform the essential functionsof public health now and in the future.Minority representation should be analyzedand the programs to increase representationshould be evaluated. Distance learningshould be explored. The Subcommitteeshould examine the financing mechanisms forcurriculum development and for strengthen-ing the training and education infrastructure.

The plan presented here builds on work already inplace with a call to practical action of Federal, State,and local public health agencies; academic publichealth departments; community health coalitions andorganizations; philanthropies; and all others con-cerned with the health of Americans.

This report uses as an analytic framework thestatement Public Health in America, with itsenumeration of 10 essential services of public health,incorporating and building upon previous discussionsof public health functions. The public healthworkforce includes all those providing essentialpublic health services, regardless of the nature of theemploying agency. The report endorses individualand organizational excellence as the only standardacceptable to the public and decisionmakers who

EXECUTIVE SUMMARY

must play a vital role in realizing the vision of“Healthy People in Healthy Communities.” TheSubcommittee divided its efforts into:

• Enumerating the current workforce in public health function positions and assessing future changes in workforce roles and the impact of these changes on the workforce composition;• Identifying training and education needs for core practices/essential public health services; and• Developing a strategic plan for using distance learning approaches to provide high-priority public health education and training.

The specified action items listed below, and elabo-rated upon in the full report, represent essential firstefforts and will require the concerted attention of allpartners on the Public Health Functions SteeringCommittee and many others if they are to have thedesired impact. These steps are not sequential,and work on all of them should proceed concur-rently. The necessary actions include:

1. National LeadershipThe Public Health Functions Steering Committeeshould continue to serve as the locus for oversightand planning for development of a public healthworkforce capable of delivering the essential publichealth services across the Nation, including supportfor any legislative authorization or financing mecha-nisms needed to fully implement this report and acommitment to ensure that current workforcedevelopment resources are wisely invested inachieving identified goals. Each partner organizationis encouraged to develop specific plans and policiesthat complement this collaborative effort.

2. State and Local LeadershipIn order to ensure that programs are appropriatelytailored to the unique configuration of needs andresources in each State and in each local jurisdiction,a mechanism to develop State public health

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*By “Federal, State, and local public health agencies” this report means any health, substance abuse, environmentalhealth and protection, or public health agency charged with some portion of the roles encompassed in the statementPublic Health in America.

The Public Health Workforce: An Agenda For The 21st Century

workforce planning and training should be devel-oped and implemented. This mechanism shouldinclude not only development of identified leaders,but also cultivation of leadership qualities throughoutthe workforce. The State, or where appropriate,regional, efforts should emphasize possible partner-ships among practice and academic entities involvedin public health. These efforts should be responsiveto and provide input into those at the national level.In addition, these efforts must involve local publichealth entities and be responsive to their needs.

3. Workforce CompositionA standard taxonomy should be used to identify thesize and distribution of the public health workforce inofficial agencies (health, environmental health andprotection, mental health and substance abuse; local,State, and national) and private and voluntaryorganizations. This effort should be coordinatedwith the Bureau of Labor Statistics to enhanceuniformity in occupational classification reporting.To the extent possible, the taxonomy should beconsistent with Public Health in America,recognizing that specific occupational titles willvary across organizations.

Using the same taxonomy, the Steering Committeeshould recommend and support a mechanism toquantify the future demand for public health work-ers, paying particular attention to issues of diversityand changing demographics in the workforce.

4. Curriculum DevelopmentThe statement of competencies for the public healthworkforce developed by the Subcommittee shouldbe refined and validated, identifying the subset(s) of

competencies associated with each of the variousprofessions that make up the workforce.

Basic, advanced, and continuing education curriculato train current and future public health workers inthe identified competencies should be supported(where existing) and developed (where not yet inplace). Implementation should be coordinated withthe State planning efforts (above) and make maxi-mum use of new technologies (below).

Improved methods (such as certification) of identify-ing practitioners who have achieved competencyshould be identified and implemented if demon-strated effective.

5. Distance LearningAll partners in the effort to strengthen the publichealth workforce should make maximum use ofevolving technologies such as distance learning.A structure should be established to develop anintegrated distance learning system building onexisting public and private networks and makinginformation on best practices readily available.

The agenda presented in these recommendationsonly partially fulfills the original charge to the Sub-committee. In its continuing leadership role, theSteering Committee should identify other tasks thatneed continuing attention and make plans for theircompletion. With the continued attention of thePublic Health Functions partners, the public healthworkforce will be strengthened to contributeeven more to the health of communities in the21st century.

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It is difficult to acknowledge all the individuals whohave contributed to the development of this complexand detailed report. The major contributors werethe members of the Subcommittee on Public HealthWorkforce, Training, and Education and they arelisted in Appendix I. In addition, members of thePublic Health Functions Working Group and Steer-ing Committee provided important comments onearlier drafts of this report and their input has beengreatly appreciated and valued.

The Subcommittee would like to recognize thespecific efforts of the staff, Alex Ross, HealthResources and Services Administration; D.W. Chen,Health Resources and Services Administration;Nona Gibbs, Centers for Disease Control andPrevention; Nicole Cumberland, Office of Disease

ACKNOWLEDGMENTS

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Prevention and Health Promotion; Kristine Gebbie,Office of Disease Prevention and Health Promotion;the workgroup chairs, Doug Lloyd, Health Re-sources and Services Administration; Neil Sampson,Health Resources and Services Administration; DickLincoln, Centers for Disease Control and Preven-tion; Dennis McDowell, Centers for Disease Controland Prevention; and specific contributors andreviewers, Jerre Jensen, Public Health TrainingNetwork; Susanne Caviness, Indian Health Service;Valerie Welsh, Office of Minority Health; FayeMalitz, University of Maryland; Anthony Moulton,Centers for Disease Control and Prevention;Herbert Traxler, Health Resources and ServicesAdministration; and Michael Weisberg, NationalLibrary of Medicine.

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Today our Nation faces a widening gap betweenchallenges to improve the health of Americans andthe capacity of the public health workforce to meetthose challenges. The public health community isactively engaged in a wide range of activities to keepthe current workforce up to date and to anticipatefuture needs. As a leadership forum for action onpublic health infrastructure issues, the SteeringCommittee of the Public Health Functions Project(see Appendix A) in September 1994 commis-sioned the Subcommittee on Public HealthWorkforce, Training, and Education to reviewfactors related to workforce challenges and to makerecommendations for an action plan. Their chargewas as follows:

To further an understanding of the public healthworkforce, a Subcommittee . . . is charged with providinga profile of the current public health workforce andmaking projections regarding the workforce of the 21stcentury. As a part of this effort, the Subcommittee shouldexamine the current and future shortfalls in the publichealth workforce, looking broadly at Federal, State andlocal levels, in public health departments as well asmental health, substance abuse, and environmentalhealth agencies and at the emerging need for publichealth competencies in managed care systems, healthplans, and in other governmental agencies such asdepartments of agriculture, education, and justice. TheSubcommittee should also address training andeducation issues including curriculum development forgraduate training in public health and ongoing trainingand development activities to ensure a competentworkforce to perform the essential functions of publichealth now and in the future. Minority representation inpublic health disciplines should be analyzed and theprograms to increase representation should be re-viewed and evaluated. Distance learning and otheradvanced technology training methods should beexplored to ensure that training and education activitiesare carried out in the most efficient and cost-effectivemanner. Therefore, the Subcommittee shall examine thefinancing mechanisms for curriculum development andfor strengthening the training and education infrastruc-ture, as well as explore the feasibility of establishing aCouncil on Graduate Public Health Education.

The Public Health Functions Steering Committeealso developed a consensus statement, entitledPublic Health in America, in 1994 (see AppendixB). Building further upon the core functions ofpublic health (assessment, policy development, andassurance) identified by the Institute of Medicine(IOM) in its 1988 study The Future of PublicHealth, the consensus statement describes whatpublic health does and what services are essential toachieving healthy people in healthy communities.Successful provision of these essential servicesrequires collaboration among public and privatepartners* within a given community and acrossvarious levels of government. The Subcommitteeused these essential services as a framework fortheir respective activities.

INTRODUCTION

*The partnership must include all agencies and private or voluntary organizations in the areas of health, mental health,substance abuse, environmental health and protection, and public health responsible for fulfilling Public Healthin America.


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As the American health care system evolves, avariety of forces are driving changes in the practiceof public health. In addition to other dynamics, thecontinually changing ethnic, racial, immigrant, age,and economic groupings within our society requirean increasingly skilled body of public health profes-sionals. Accompanying these changes are shifts inthe roles of public health practitioners and otherhealth care workers within the various public healthdisciplines and in their need for training, continuingeducation, and related skill development.

One of the major training and education challengesresults from the movement of some public healthagencies away from a primary role directly providingpersonal health services to underserved populationstoward greater emphasis on providing population-focused services to entire communities (Baker, et al.,1994). This transition is accelerating as more Statesmandate the enrollment of Medicaid populations intomanaged care arrangements; however, many publichealth systems will continue to provide direct careto some populations, including the growing numberof uninsured.

Medicaid and other contracts between governmentagencies and managed care organizations (MCOs)establish new roles and relationships, which in turnaffect the public health workforce. Also, newcommunity-wide collaboration to achieve objectivesof Healthy People 2000 or other goals requiresstrong participation from health departments.Governmental health agencies will continue tooversee basic public health concerns such as ensur-ing clean water and environmental safety. Further-more, the public looks to the Government forleadership in times of “health emergencies”such as hurricanes, floods, and communicabledisease outbreaks.

The public health workforce requires up-to-dateknowledge and skills to deliver quality essential

public health services. To meet the training andcontinuing education needs of an evolvingworkforce, a clearer understanding is requiredconcerning the functions and composition of thepublic health workforce both now and in the future.This information should be communicated clearly tolegislators and other government leaders so thatpolicy can be based on an understanding of thecurrent demand for public health services and thesupply of trained professionals required to meet thatdemand. Furthermore, because this is a geographi-cally dispersed and demographically diverseworkforce, new strategies for presenting efficientand effective training must be developed.

Based on a review of previously published re-ports,** barriers to strengthening the public healthworkforce can be summarized as:

• Inadequate knowledge about the competencies the workforce will need to meet future challenges and about new training and education resources that will be needed to develop those competencies;• Lack of formal training in public health and in the application of broad public health competencies to emerging new functions, e.g., constituency building, leadership, and use of electronic information systems;• Limited public health professional certification requirements that can serve as incentives for participation in training and education;• Indecision about workforce development across multiple public health and health financing agencies;• Absence of stable funding for public health and the fragmentation imposed by categorical funding streams; and• Failure to use advanced technology to its full potential, e.g., to provide training.

CONTEXT

** Individual reports are cited in the body of this report as appropriate and are included in the References.


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The following sections present background on thethree interrelated topics addressed by the Subcom-mittee on Public Health Workforce, Training, andEducation. The first section explores what is knownabout the composition of the public health work-force and focuses on methods of identifying whocarries out which public health functions. Theimpact of the changing role of public health on thefuture composition of the workforce is also exam-ined. The next section addresses the public healtheducation and (re)training challenges in an evolvinghealth care system. In the third section, the use ofdistance learning strategies to meet the training andeducation needs of a widely dispersed population ofworking health professionals is discussed. Thereport then details the recommendations (FutureDirections) of the Subcommittee to address theseissues, and implementation.

COMPOSITION OF THE PUBLIC HEALTHWORKFORCE

Current changes in the public health system necessi-tate planning for organizational change (Nelson etal., 1994, 1995). This process emphasizes theimportance of knowing the composition of thepresent workforce and being able to describe theworkforce providing essential public health servicesto community members. Knowing which profes-sionals are currently performing specific public healthfunctions is integral to projecting what types ofpublic health professionals will be required in thefuture. Effectively and efficiently providing trainingand education for an evolving public healthworkforce requires a clear understanding of thecomposition of that workforce. The landmark IOMstudy (1988) on public health noted that althoughpublic health workers had adequate technicalpreparation in specific fields, many may lack trainingin management, political skills, and communityorganization and diagnosis, all of which are essentialfor leadership in complex multifaceted public healthactivities. The IOM study further emphasized thechallenge facing public health personnel to updatetheir knowledge and skills in light of the continuousevolution of the public health field.

Definition of the Public Health Workforce

The public health workforce has frequently beendefined as those individuals employed by local,State, and Federal government health agencies. Useof this definition is limiting; for example, individuals inacademia who educate, train, or perform research inpublic health should be considered part of the publichealth workforce. As private sector health caredelivery organizations provide more community-based public health services, their employees alsoshould be considered part of the workforce. Fur-thermore, current models of the determinants ofhealth (Evans and Stoddard, 1994) suggest thatindividuals from many sectors of a community (e.g.,education, economic development) must be involvedto produce health and well-being.

For purposes of this discussion, the public healthworkforce includes all those responsible for provid-ing the services identified in the Public Health inAmerica statement (see Appendix B) regardless ofthe organization in which they work. As an ex-ample, all members of the U.S. Public HealthService Commissioned Corps, whether currentlyassigned to the Department of Health and HumanServices (DHHS) or elsewhere are included. At theState level, many workers in environment, agricul-ture, or education departments have public healthresponsibilities and are included. This expansivedefinition does not include those who occasionallycontribute to the effort in the course of fulfillingother responsibilities.

Given this breadth, identifying organizations wherepublic health is operationalized is a challenge. In thepublic sector, responsibilities for public healthfunctions are shared among multiple agencies. Forexample, in the six States visited by the IOM Futureof Public Health Committee, six different publichealth systems were observed. The committeefound that States varied in their concept of publichealth and in the importance they placed on publichealth activities. The health agencies in each of theseStates were diverse in organization, authority,activities, and resources (IOM, 1988). At each

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level of government, agencies charged with publichealth, environmental health and protection, mentalhealth, and substance abuse services must beincluded in the process. As an increasing proportionof essential public health services are provided bythe private and voluntary sectors, the difficulties inclassification will be exacerbated.

Identifying, Classifying, and Enumerating thePublic Health Workforce

Over the past 25 years, assessing the composition,size, function, and adequacy of the public healthworkforce has been the subject of numerous studies.Many of these initiatives have confronted myriadbarriers in their attempts to track the workforce.The studies continuously encountered the followingthree problems as they sought to assess the publichealth workforce:

• Lack of clear, concise, mutually exclusivepublic health profession classificationschemes/categories;

• An absence of consistent public healthprofessional credentialing requirements; and

• A professional workforce educated inspecific disciplines such as medicine, nurs-ing, dentistry, or administration but lackingformal public health training.

As a further problem, support staff (e.g., reception-ists, clinic assistants, laboratory assistants) often arenot effectively oriented to the public health goals ofthe organization and are limited in the contributionsthey are able to make to the overall effort.

For example, the American Public Health Associa-tion (APHA) has 31,000 members actively engagedin public health practice and can enumerate them bytheir self-selected area of expertise or interest by theAssociation section with which they affiliate. Withfunding from the Bureau of Health Professions of theHealth Resources and Services Administration,APHA actively pursued a comprehensive workforceenumeration in the mid-1980s, investigating methodsof counting the workforce. The APHA Workgroupfound that there was neither clear differentiation

between persons trained at a given level nor be-tween persons trained at different levels within thesame occupational category. The Workgroupconcluded that using professional titles to definefunction was inadequate since localities in each Statecould define the functions of specific personnel titlesdifferently (APHA, 1983). The APHA groupproposed a functionally based classification systembased on three criteria—type of work setting, typeof work performed, and type of position. Oneapplication of this approach is discussed below.

In 1989, the Bureau of Health Professions organizeda Public Health Workforce Consortium that devel-oped a series of position papers on the public healthworkforce (Public Health Workforce Consortium,1989). The Consortium suggested that many of thedifficulties encountered in gathering workforce datawere the result of shortcomings in classificationschemes for public health work, work settings, andworkers. These inadequacies were traced to a lackof standardized methods for categorizing publichealth professionals and their work that oftenresulted in ambiguous classifications. Existingoccupational classifications failed to consistentlyidentify the duties and qualifications expected of theincumbents (Moore and Hall, 1989). The Consor-tium also cited the lack of clear boundaries betweenpublic health occupations as problematic. Forexample, the knowledge base, skills, and tasksrequired in epidemiology and biostatistics overlapextensively; there is no single defining characteristicthat unequivocally places a professional in onecategory as opposed to the other. Absolute clarityand consistency may never be possible, given thenature of public health. However, failure to describethe workforce clearly hampers efforts to assistdecisionmakers to make appropriate investment inthe entry level and continuing education of publichealth workers.

In 1996, the Standard Occupational Classification(SOC) Revision Policy Committee convened by theBureau of Labor Statistics, Department of Labor,and the Bureau of Census, Department of Com-merce, sought the DHHS’s assistance in revising and

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updating the health occupation categories used inregular tabulations of the entire U.S. workforce.

Drawing on the earlier work of APHA and theWorkforce Consortium discussion, some additionalcategories were identified and forwarded to theSOC Revision Policy Committee. Adoption ofthese changes (see Appendix C) will enhanceuniformity in occupational classification and datacollection activities within the Departments of Healthand Human Services, Labor, and Commerce andwith their State, local, and private sector partners.

Estimates of Workforce Compositionand Supply

The objectives of a recently completed study by TheGeorge Washington University Medical Center,Center for Health Policy Research (Solloway et al.,1996) were to assess the size and composition ofthe government agency public health workforce infive States, examining the changing patterns of publichealth practice and linking the workforce to theessential public health services. The study alsosought to identify education and training needs ofpublic health personnel as well as barriers to meetingthose needs. In meeting these objectives, the studyhighlighted difficulties in developing a nationalworkforce data set (Solloway et al., 1996). Investi-gators found that the detail needed to classify theworkforce was typically not available in existingState personnel data systems and needed agencyinput. Applying a standard public health occupa-tional taxonomy in the five States proved to be laborintensive and time consuming. Investigators re-ported that by the completion date of the report thedata were no longer valid, because of reductions orturnovers in personnel, although the magnitude oferror was not clear.

Study findings also suggest that the aggregation ofdata into a standard occupational taxonomy ob-scures variations in workforce activities. Theinvestigators felt that aggregated workforce datawere not useful in understanding the functionsof the workforce, identifying personnel shortages,

or addressing training and educational issues(Solloway et al., 1996).

The Center for Health Policy Studies of The Univer-sity of Texas, Houston Health Science Center, usedthe methodology developed by the APHAWorkgroup in the mid-1980’s to assess the profes-sional public health workforce in Texas (Kennedy etal., 1996). Using a two-staged survey, the TexasPublic Health Workforce Study Group first surveyedemployers and potential employers of health person-nel and then focused on individual employees. Thestudy provides an estimate of the supply of publichealth professionals and identifies shortage areas inTexas. A description of this and other selectedpublic health workforce assessment studies is foundin Appendix D, presenting study objectives, meth-ods, and information available for each project.

In addition to these efforts, the DHHS Data Councilhas been asked by the Public Health Council toconsider mechanisms for improving public healthworkforce reporting; no action date for a reply hasbeen set. Proxy measures of the workforce couldbe used to further the enumeration. Possibilitiesinclude reported graduations from schools andprograms in public health, reported certifications aspublic health specialists within professions such asmedicine, nursing, or health education, and reportedposition vacancies or association membership trendsover time. Each of these approaches has significantshortcomings but might be used to supplement orclarify other data.

This discussion has illustrated a number of method-ological concerns that have hampered the ability ofpolicymakers to accurately enumerate the level ofpublic health personnel across the country. Amongthe more notable concerns for data collection are:

• Occupational classifications in use rarelyreflect the duties and qualifications currentlyexpected of the incumbents;

• Boundaries between public health occupa-tional categories often are not delineated;categories are not mutually exclusive and

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overlap extensively with regard to knowl-edge base, skills, and tasks;

• Classification systems lack consistency;some occupations are defined by whatpeople do, while others are defined by thepopulations they serve or by the requiredunderlying skills;

• Position descriptions/job titles for publichealth professions lack uniformity acrossStates and organizations; and

• No comprehensive public health profes-sional licensure or certification requirementprovides categories for data collection.

COMPETENCY-BASED CURRICULUM

As the entire health system changes, major trainingand continuing education challenges will emerge.Training and retraining in the public, private, andvoluntary sectors are needed to prepare theworkforce for new challenges and responsibilities.Six priority areas for a competency-based curricu-lum are cultural competency, health promotion skills,leadership development, program management, dataanalysis, and community organizing (Joint Council ofGovernmental Public Health Agencies, 1995).

It is clear that the public health workforce must becompetent in the latest approaches to traditionalpublic health skills (e.g., epidemiology, health policydevelopment, and health education) and mustunderstand the impact of efforts to manage care andintegrate delivery systems on health, the changingrole of government, the building of communitypartnerships, the use of new information technolo-gies, and the uses of data in policy development anddecisionmaking (Nelson et al., 1996a, 1996b). Inaddition, to be an effective participant at the com-munity level, the public health workforce must beconversant with continuous quality improvement, thestrengths and challenges of diversity, and systemdevelopment. If the public health organizationprovides personal care services, they must be of thehighest quality as well. Current projects such as theSAMHSA Mental Health Managed Care andWorkforce Training Project focus on these con-

cerns. No one worker or profession will master allknowledge, but an agency’s entire workforce shouldencompass the full range of public health competen-cies identified by the Competency-Based Curricu-lum Work Group (see Appendix E).

Education and Training: Reassessment andRetooling

The Pew Health Professions Commission report(1995), entitled Critical Challenges: Revitalizingthe Health Professions for the Twenty-FirstCentury, observed: “The needs of the integratedsystems will not be met simply by hiring [new] publichealth professionals [but by] substantial and ongoingretraining of nurses, physicians, allied health person-nel, and managers . . . [who are] required to applythe skills in new contexts.” The report calls forcreative and risk-accepting leadership in providingtraining and education, a “renaissance” for educatingpublic health professionals. The training andretraining for public health should be based incompetencies, that is, in what people should beable to do, rather than what they should know(Lane et al., 1994).

What is needed, then, is a reassessment and aretooling of the entire public health education andtraining enterprise. The goal is to make efficient andeffective use of scarce resources so they will beresponsive to emerging health systems (Lincoln etal., 1996). This educational “renaissance” will bedistinguished by several features. First, it will involvea stronger role of partnerships and collaborationsbetween groups from the public, voluntary, andprivate sectors—MCOs, business and industry,schools of public health and other health professions,State and local health departments, professionalassociations, community-based organizations,foundations, Federal Government, and other keystakeholder groups. Partnerships and collaborationswill enhance the relevance of education and trainingand provide potential financial support resulting in amore effective and efficient educational program.The potential range of partnerships can be appreci-ated by considering the array of interested bodies

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participating in the Healthy People 2000 Consor-tium (see Appendix F).Another distinguishing feature will be the recognitionthat traditional approaches to delivering instruction(e.g., classroom settings) are no longer the solemethod of adequately preparing students to enterpractice or for providing continuing education to awidely dispersed public health workforce. Field-based learning experiences that take full advantageof state-of-the-art learning technologies, such asthose involved in distance learning, must be imple-mented. Care and creativity will be required toeffectively use these technologies in situationstraditionally done face-to-face such as internships inmental health or substance abuse. As the workforcebecomes more diverse, methods should be adaptedto meet the needs of each student.

Finally, the educational “renaissance” will be charac-terized by continuing movement from the conven-tional approach of teaching a curriculum based onsubject matter areas toward the teaching of perfor-mance-based competencies. The new emphasis willbe on demonstrated skills and behavior. Focusingon measurable learner-centered competenciesprovides the additional benefit of accountability andfacilitates consideration of issues surroundingperformance improvement at the organizational andindividual employee levels (Nelson et al., 1997),licensure, certification, and enumeration.

The previous work of the Faculty/Agency Forumand the Council on Linkages Between Academiaand Public Health Practice and the competenciesidentified by a number of public health disciplines(see Appendix G) provide an excellent beginning forthis effort, as does the report Taking TrainingSeriously, issued by the Joint Council of Govern-mental Public Health Agencies. Other discipline-specific competencies that helped to inform therecommendations in the Future Directions section ofthis report are presented in Appendix H.

DISTANCE LEARNING SYSTEMDEVELOPMENT

As noted in the previous section, compelling andurgent programmatic forces are making enhancedtraining and education opportunities for public healthprofessionals a necessity. Public health professionalsare “knowledge workers,” professionals whointerpret and apply information to create and pro-vide “value added” solutions and who make in-formed recommendations in continuously changingwork environments (Winslow and Bramer, 1994).Public health workers require the ability to acquireand apply theoretical and analytical knowledge andthe habit of continuous lifelong learning to remainviable and productive.

The emergence of a world interconnected bynetworks of computers, satellite downlinks, andtelecommunications technologies represented by theInternet, World Wide Web, and corporate andprivate intranets offers great potential for the lifelongtraining and education of public health workers. Incombination with traditional classroom learning,networked computers and telecommunicationstechnologies provide distance learning systems thatenable diverse groups of geographically dispersedindividuals to access information for training andeducation anytime, anywhere. These same tech-nologies also provide an infrastructure for integratingnational efforts with local community needs andconcerns. Local networks of electronic informationresources further stimulate and provide opportunitiesfor involvement across all segments of a community:education, health care, local government, business,and individual citizens. Blacksburg ElectronicVillage (Virginia) and Smart Valley (California) areexemplary demonstrations of such communityinvolvement. Care is needed, however, to ensurethat access to such resources is equitable acrosscommunities and populations.

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Organizations responsible for public health programsand training have a unique opportunity to participatein the creation and utilization of the National Infor-mation Infrastructure. There is an opportunity toleverage the enormous intellectual efforts, products,and services that already exist to achieve costefficiencies and to explore new and exciting ways toprovide education and training that emphasizeindividual differences, collaborative learning, experi-mentation, learner responsibility, skills for lifelonglearning, freedom from constraints of time and placefor learning, immediacy of information, a multiplicityof distributed learning environments, enhanced rolefor teachers/trainers as facilitators, and a renewedsense of responsibility for learning outcomes.

Distance learning is a system and a process thatconnects learners with distributed learning resourcescharacterized by:

• Separation of place and/or time betweeninstructor and learner, among learners,and or between learners and learningresources; and

• Interaction between the learner and theinstructor, among learners, and/or betweenlearners and learning resources conductedthrough one or more media; use of elec-tronic media is not necessarily required(American Council for Education, 1996).

Federal agencies currently using distance learningsystems include: Defense, Agriculture, Education,Veterans Affairs, Federal Aviation Administration,Environmental Protection, and Social SecurityAdministration and within DHHS—Centers forDisease Control and Prevention, Food and DrugAdministration, Health Care Financing Administra-tion, and Health Resources and Services Adminis-tration. Schools of public health, State healthagencies, the American Hospital Association, andothers also have used distance learning systems,

often with award-winning success. Additional success in public health is cited in arecent study by Solloway, et al. (1996), whichconcludes that distance learning: (1) provides aconsistent message to a large number of peoplewithin a short time period; (2) overcomes barriers totraining such as time away from the job and travelrestrictions; (3) promotes collaborative relationshipsamong colleagues as well as communities, andprovides increased opportunities for informationexchange; and (4) provides an excellent vehicle fordisseminating information, updating scientific knowl-edge, and teaching technical skills.

To develop an effective competency-based curricu-lum requires accurate information concerning thecomposition, functions, and education needs of thepublic health workforce. After developing curriculato meet the workforce’s needs, the use of suchstrategies as distance learning are critical in providingtraining to a geographically dispersed and diversepublic health workforce. An effort to improvevaccine coverage for preschool children initiated bythe Clinton Administration 3 years ago serves as anexample of the interrelationships between workforcecomposition, education, and the delivery of training.To meet the new vaccination goals, the NationalImmunization Program (NIP) staff had to develop acurriculum and training program on vaccine-prevent-able diseases. Equally important was identifying thesector of the workforce requiring training—nursesand other prevention personnel. Traditionally,training for NIP was delivered in a 5-day workshopfor 50 students. NIP staff realized that it wouldneed to greatly increase the number of public healthpractitioners receiving training in order to meet theprogram’s goals. Using distance learning strategies,a series of satellite video conferences on vaccinepreventable diseases was designed and produced tosuccessfully train 25,000 participants nationwidethrough the first series.

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Public health is integral to the well-being of theNation’s communities. It is time to take a seriousand deliberate look at the composition, activities,and education needs of the public health workforce.Completing and fulfilling the charge made to thisSubcommittee will require the coordinated andcollaborative effort of the Public Health FunctionsSteering Committee partners and others. In order tomove this agenda forward, the Steering Committeemakes five major recommendations in the areas of:

• National Leadership

• State and Local Leadership

• Workforce Composition

• Curriculum Development

• Distance Learning

These steps are not sequential. Work on all ofthem should proceed concurrently. Using aconsensus process involving groups of individualsrepresenting over 20 public-health-related organiza-tions (see Appendix I), the Subcommittee putsforward the following proposed action steps foreach of the identified recommendations. Ultimatelythe goal is to develop a seamless approach toenhancing the workforce: identifying the workforceand assessing individual skills, examining changes inthe evolving public health environment to identifyareas requiring additional skill development, deter-mining how best to obtain those skills, and finally,using strategies such as distance learning to providethe necessary training and education.

NATIONAL LEADERSHIP

The Public Health Functions Steering Committeeshould continue to serve as the locus for oversightand planning for development of a public healthworkforce capable of delivering the essential ser-vices of public health across the Nation. Thisincludes maintaining support for any legislativeauthorization or financing mechanisms needed tofully implement the recommendations of this report

and a commitment to ensure that current workforcedevelopment resources are wisely invested inachieving identified goals. Each partner organizationand others are encouraged to develop specificplans and policies that complement thiscollaborative effort.

Workforce policies and funding priorities for publichealth workforce training must be responsive to boththe supply of public health workers and the demandfor their skills. Meeting the public health needs ofindividual communities requires an understanding ofthe types of public health professionals needed toprovide required services, the actual positionsavailable (the demand), and an understanding ofwho currently provides these services and their skills(the supply). The Federal role of (1) providingstandards and guidelines; (2) conducting researchand disseminating its findings; (3) ensuring equityacross States; and (4) developing priorities for theNation (APHA Policy Statement, 1996) should beappropriately incorporated into the national effort.

Proposed Action Steps

A. Organize a national forum of key stakehold-ers from both the public and private sectorsto examine human resource allocation andtrends in public health. Potential forumparticipants in addition to the Public HealthFunctions Steering Committee membersinclude the American Association of HealthPlans, Health Care and Financing Adminis-tration, State Medicaid directors, socialworkers, substance abuse and mental healthprofessionals, nurses, professional organiza-tions, and the business community in general.

B. Develop and implement modules for Lead-ership Training Institutes that enable publichealth leaders to better assess their roles inproviding public health services in a changingenvironment.

C. Involve frontline public health practitionersfrom all types of organizations in the efforts

FUTURE DIRECTIONS


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to enumerate, plan for, and educate thepublic health workforce.

STATE AND LOCAL LEADERSHIP

To ensure that programs are appropriately tailoredto the unique configuration of needs and resources ineach State and in each local jurisdiction, a mecha-nism for development of State public healthworkforce planning and training should be devel-oped and implemented. This mechanism shouldinclude not only development of identified leaders,but also cultivation of leadership qualities throughoutthe workforce. The State, or where appropriate,regional, efforts should emphasize possible partner-ships among practice and academic entities involvedin public health. These efforts should be responsiveto and provide input into those at the national level.In addition, these efforts must involve local publichealth entities and be responsive to their needs.


A. Ensure that workforce planning takes placein all appropriate jurisdictions. Allocation ofhuman resources should be determined byState and local governments or on a regionalbasis when appropriate due to resources,geography, or other factors.

B. Within each jurisdiction encourage theparticipation of medical care deliverysystems and others with public healthresponsibilities to achieve mutual goals inworkforce development.

C. Develop a partnership with States to quan-tify the supply and demand of personnelproviding essential public health services atthe State, local, and private sector levels.

WORKFORCE COMPOSITION

A standard taxonomy should be used to regularlyidentify the size and distribution of the public healthworkforce in official agencies (health, environmentalhealth and protection, mental health, and substanceabuse; local, State, and national) and private andvoluntary organizations. This effort should be

coordinated with the Bureau of Labor Statistics toenhance uniformity in occupational classificationreporting. To the extent possible, the taxonomychosen should be consistent with the Public Healthin America statement, recognizing that specificoccupational titles will vary across organizations.

It is in the public’s interest to have a public healthworkforce that is ethnically and culturally diverseand is adequately trained and deployed to provideessential public health services. Using the sametaxonomy, the Steering Committee should recom-mend and support a mechanism to quantify thefuture demand for public health workers, payingparticular attention to issues of diversity and chang-ing demographics in the workforce.


A. Identify a lead agency or organization toprovide leadership in continuing efforts toassess the size, composition, and distributionof the workforce as related to essentialservices of public health.

B. Examine methods used by professionalorganizations such as American NursesAssociation, American Medical Association,American Psychological Association,American Dental Association, and NationalEnvironmental Health Association to classifytheir respective workforces and incorporatewhere helpful.

C. Develop a standard taxonomy based on the10 essential public health services to qualita-tively characterize the public healthworkforce. This classification scheme mustbe derived through collaboration andconsensus of the entire public health com-munity.

D. Use the SOC System of the workforce anddata from the Bureau of Labor Statistics andcensus surveys to track shifts in the staffingmix of personnel among the governmental,private, and voluntary sectors.

E. Identify and take action steps to ensure thatthe public health workforce is ethnically andculturally diverse.

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F. Work with the Office of Management andBudget to include appropriate public healthentries in the SOC System to facilitateidentification of public health worksites, suchas local health departments and otherorganizations providing essential publichealth services.

CURRICULUM DEVELOPMENT

Preparation of the current and future workforcerequires clarifying essential competencies, makingassociated curriculum revisions, and identifyingmethods to keep both current.

Part I. Competencies

The statement of competencies for the public healthworkforce developed by the Competency-BasedCurriculum Work Group (Appendix E) should berefined and validated, with the subset(s) of compe-tencies associated with each of the various disci-plines identified.

The competencies needed to meet the public healthchallenges of today and tomorrow should form thefoundation for all future efforts to train and educatethe workforce. Competency specification is a vitalstep for two reasons: (1) During the process ofcurriculum planning and development, it provides acentral focus for the providers of training andeducation—schools of public health, medicine,nursing, dentistry, and the allied and associatedhealth professions, as well as other academicinstitutions, public sector agencies, and privatesector organizations; and (2) By determining compe-tencies that will be needed, it is possible to examinethe current capabilities and qualifications of theworkforce, to identify gaps in the workforce, and todesign and support systems for training/education ofthe workforce to fill those gaps.


A. Verify that identified competencies areindeed necessary for efficient and effectivepractice of public health. Validations ofthese competencies should be providedby a panel of practice-based expertswho are in public health organizations,including employers.

B. Identify competencies critical to all publichealth practitioners and those critical tosuccessful practice in specific organizationalsettings. The competencies presented inAppendix E should be viewed as “organiza-tional” competencies, those required for theentire workforce deployed within a givenpublic health setting. (Although all publichealth practitioners should be familiar withthe essential services of public health, few, ifany, individuals will be equally competent inall areas.) Categorizing competenciesshould be conducted by a review panel ofexperts including practitioners and employ-ers from all practice settings.

C. Improve long-range planning. Public healthcompetencies are evolutionary. They areaffected by changes in responsibilities andthe practice of public health. There must bea formal mechanism to update competenciesto reflect changing demands. A mechanismfor assuring current and accurate competen-cies may take the form of an institute, taskforce, or other entity supported by govern-ment, foundations, and/or the academiccommunity. Responsibilities will includemonitoring trends in the demand for publichealth services and interpreting thosedemands in terms of the skill and knowledgeneeded to provide the 10 essential servicesof public health.

Future Directions


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Part II. Curriculum Development

The curriculum development process should beguided by attention to key competencies that areadequately addressed within existing curriculumofferings and those that are deficient. This processof development or enhancement of curricula focusingon competencies, rather than content, is a challeng-ing task. Competencies are derived from an analysisof the performance of proficient practitioners withconcentration on skills and abilities rather than onactivities. A primary function of competency-basedcurricula in public health is that they can provideboth educators and employers of public healthpersonnel guidance and structure in the allocation ofeffort and resources.

Basic, advanced, and continuing education curriculato train current and future public health personnel inthe identified competencies should be supported(where existing) or developed (where not yet inplace). Implementation should be coordinated withState planning efforts and make maximum use ofnew technologies.

Improved methods (such as certification) of identify-ing practitioners who have achieved competencyshould be implemented if demonstrated effective.

Because the public health workforce is characterizedby a diverse range of experiences, education back-ground, and ethnicity, any program for systematicallyaddressing the training and education needs of theworkforce must direct its resources toward meetingthe most important skill enhancement areas,especially considering the needs of communitiesand populations currently underserved by publichealth programs.


A. Ensure that the practice community has asubstantial role in the curriculum develop-ment process. Examine existing models thatlink the academic and practice communitiesas a first step in facilitating practitionerinvolvement and target efforts and resourcesin their replication.

B. Determine the current status of “compe-tency” of the workforce. Develop andimplement a methodology (survey, directobservation, etc.) to assess the current levelof proficiency in the practice of the compe-tencies. This research effort will include anevaluation of how the competencies havebeen acquired (on-the-job training, formaleducation, mentoring, continuing education,etc.) and the perceived adequacy of theseapproaches in the context of the communi-ties being served.

C. Develop measurable performance indicatorsfor identified competencies.

D. Survey public health training/educationinstitutions to assess the extent to whichcompetencies are currently being employedto structure the curriculum.

E. Conduct an analysis of the competencystatements (Appendix E) and make revisionsfor their most effective use in curriculumdevelopment. Education and trainingspecialists should conduct this analysis.

F. Identify gaps between high-priority compe-tencies that are needed and those compe-tencies already present in the workforce.The competencies proposed by the Compe-tency-Based Curriculum Workgroupincorporate projections of competenciesneeded now and in the future (5 yearshence). After additional review, theseprojections can serve as a baseline. Identifi-cation and prioritization between the actualand the needed profile of competencies maybest be accomplished by a panel composedof practice association representatives,academic institutions, and Federal agencies.

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G. Translate competencies into discrete didacticand field-based learning experiences andactivities.

H. Create a matrix of addressed and unad-dressed competencies based on publichealth organizational needs with the resultsof the instructional provider survey (datacollected during the needs assessmentactivity) by cross-referencing each elementin the competency listing.

I. Support a curriculum development processthat is sensitive to the needs of local commu-nities in order to be responsive to the localpriorities of each agency, State, or localcommunity relating to the essential servicesof public health.

J. Recommend to the Council for Education inPublic Health and other organizations withinthe accreditation community that compe-tency-based approaches be incorporatedinto the standards for educational institutionaccreditation and into the standards forprofessional certification and/or licensure.

K. Develop criteria for identifying providersof public health training and education thatare “models of excellence” and supportthese providers through grants andother forms of support. Implement theoperation of a “clearinghouse” to promotesharing of exemplary teaching approachesamong institutions.

Part III. Curriculum Update and Maintenance

Public health practitioner competencies are evolu-tionary in nature; hence, a curriculum to supportthe establishment of such competencies mustinclude a formal mechanism for keeping themcurrent and accurate.


A. Create and support an organizational entitywith responsibility for conducting an ongoing“environmental scan” at the national, State,local, business, and industry levels to assessthe demand for specific essential publichealth services. As shifts in essential ser-vices are detected, accompanying “correc-tions” in the competencies need to bereflected within curricula. The organizationalentity may take the form of an institute,task force, or other entity supported bygovernment, foundations, and/or the aca-demic community.

B. Follow up graduates of competency-basedtraining and education programs on a regularbasis to determine the extent to which theyare using the competencies they havepreviously acquired.

C. Maintain close liaisons with organizationssharing an interest in public healthcompetencies to facilitate input from allkey stakeholders.***

D. If judged to be appropriate, establish anational “competency assessment system”for public health practice. The system will(1) establish standards of practice based onapproved competencies; (2) develop amechanism for assessing whether thesestandards are being met; and (3) administera nationwide program for assessing compe-tencies on an individual basis and for thepotential credentialing of “competent” publichealth practitioners.

Future Directions

***Examples of these key organizations include: The Council on Linkages Between Academia and Public Health Practice;schools of the health professions; Federal, State, and local governments; professional organizations; MCOs; The RobertWood Johnson and W.K. Kellogg Foundations; and the Pew Charitable Trust.


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DISTANCE LEARNING

All partners in the effort to strengthen the publichealth workforce should make maximum use ofevolving technologies such as distance learning.A structure should be established to develop anintegrated distance learning system building onexisting public and private networks and makinginformation on best practices readily available.

Distance learning presents tremendous potential toaccelerate and expand training opportunities, but italso represents a paradigm shift in most agencies’training strategies. Therefore, public health leadersmust drive this change in their organizations.


A. Establish a formal structure to advocate forthe integration of distance learning tech-niques into practice and academicentities involved in public healthstrategies for training, education, andcommunication. Actions necessary forthis to proceed include:

• Evaluate previous studies that documentdistance learning resources among partners.

• Develop a strategy for participant registra-tion that is compatible across agencies andthat is supported by a technology that allowsfor orders of magnitude expansion andcomparability of data.

• Establish a standard practice and methodol-ogy for stakeholder’s evaluation of distancelearning results.

• Institute a common practice for programpromotion and marketing.

• Develop a strategy to facilitate sharingresources across organizational lines (e.g.,interagency agreements, cooperativeagreements, grants, memorandumsof understanding).

• Initiate standards for distance learningtechnology that permit system integrationacross agencies.

• Encourage and support the use of public/private assignments to promote collabora-tion in training.

• Share innovative and effective procurementmechanisms for distance learning services(e.g., task order contracts and other pro-curement mechanisms).

• Assist in identifying and developing distancelearning faculty and subject matter expertsand establishing incentives for their support.

• Provide grant assistance for development ofdistance learning programs at regional andlocal levels.

B. Directly link distance learning systems andprogram development priorities to theinformation generated by the Workgroupson Workforce Composition and Compe-tency-Based Curriculum.

C. Routinely gather input from keypartners regarding training needs andtechnological capabilities.

D. Develop agency expertise in distancelearning; participate in relevant organizationssuch as the United States Distance LearningAssociation (USDLA) and GovernmentAlliance for Training and Education (GATE).

E. Provide access to information about publichealth distance learning programs andresources through mechanisms such asFedWorld Training Mall and the PublicHealth Training Network web site.

F. Organize a mechanism for pooling andaccessing resources and expertise ondistance learning across all of public health.

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Due to the multiplicity of responsibilities within publichealth, no single agency or organization has theresponsibility of addressing the workforce composi-tion, training, and education needs of a diversepublic health workforce. Focusing the attentionof a broad array of organizations on the priorityissues presented in this paper will be critical tothe success of any proposed followup. Enhanc-ing the feedback loop between public healthemployers, communities, and training institu-tions will be one of the most important links inresponding to the need for a well-trainedworkforce. Harnessing the varied interests of

IMPLEMENTATION

governmental, private, and voluntary public healthorganizations and creating a body with appropriatelevels of resources allocated to this activity will becritical to the success of any proposed public healthworkforce initiative. The agenda presented in theserecommendations only partially fulfills the originalcharge to the Subcommittee. In its continuingleadership role, the Steering Committee shouldidentify other tasks needing continued attention andmake plans for their completion. With the energeticand sustained attention of the Public Health Func-tions partners, the public health workforce willcontribute even more to the health of communities inthe 21st century.


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Background: Several recent analyses of the statusof public health activities in the United States indi-cate the fragility of the public health infrastructure(Public Health Foundation, 1994; PreventionReport, 1995; Schade, 1995). The Public HealthFunctions Project was created to help clarify theissues and develop strategies and tools to addressthe matters identified. Special emphasis will begiven to: marshaling consensus on the essentialservices of public health; quantifying the investmentin those services at the Federal, State, and locallevels; assessing the current capacity and needs forpublic health workforce in various areas; developingguidelines for sound practices in public health; linkingwith activities to characterize the information systemelements necessary for the conduct of public healthservices, including the relationship of those elementsto the personal health services information systems;and developing strategies for enhancing public andprofessional awareness of the nature and impact ofpublic health activities.

Project: To address these issues, the followingtasks will be undertaken as part of the Public HealthFunctions Project:

1. Develop a taxonomy of the essential ser-vices of public health that can be readilyunderstood and widely accepted for use bythe public health community.

2. Using the taxonomy developed, assess thepublic health infrastructure and document theFederal, State, and local expenditures onessential services of public health.

3. Propose a mechanism to ensure accountability for outcomes related to the delivery ofessential public health services at the Stateand local levels, in return for greater flexibil-ty in administration of Federal grants tosupport public health.

4. Develop a strategy for communicating to thegeneral public and key policymakers thenature and impact of essential publichealth services.

5. Document and publish analyses of the healthand economic returns on investments inessential public health services.

6. Identify the key categories of public healthpersonnel necessary to carry out the essen-tial services of public health, assess theNation’s current capacity and shortfalls, andestablish a mechanism for ongoing monitor-ing of workforce strength and capability.

7. Develop and publish a full set of evidence-based guidelines for sound publichealth practice.

8. Collaborate with the PHS Data PolicyCommittee to identify the information anddata needs for the effective implementationof the essential services of public health anddevelop a strategy for the interface betweenthe personal services and population-widesystems, ensuring the availability of informa-tion necessary to both.

9. Develop a process to ensure the appropriatecollaboration of the public health communityand adequate inclusion of public healthperspectives in the development ofnational health goals and objectives for theyear 2010.

10. Develop a strategy for regular communica-tion among interested parties at the national,State, and local levels on progress related tothese activities.

Project Coordination: The project will be coordi-nated by a Steering Committee chaired by theAssistant Secretary for Health and the SurgeonGeneral, and composed of the PHS agency headsand the presidents of the American Public HealthAssociation, the Association of Schools of PublicHealth, the Association of State and TerritorialHealth Officials, the Environmental Council of theStates, the National Association of County and CityHealth Officials, the National Association of LocalBoards of Health, the National Associationof State Alcohol and Drug Abuse Directors,the National Association of State Mental

Appendix A:The Public Health Functions Project


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Health Program Directors, Partnership forPrevention, and the Public Health Foundation.

Execution of activities will be overseen by aStaff Working Group co-chaired by theDeputy Assistant Secretary for Health(Disease Prevention and Health Promotion)and the Director of the Centers for DiseaseControl and Prevention, and composed ofdesignees from each of the organizationsrepresented on the Steering Committee.

Each specific activity undertaken within this projectwill have identified leadership and staff support fromPHS. Wherever possible, existing structures andcommunication devices will be used as the basis forPublic Health Functions efforts (e.g., the PublicHealth Service Data Policy Committee, the JointCouncil of Governmental Public Health Agencies,the Council on Linkages between Academia andPublic Health Practice).

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PUBLIC HEALTH IN AMERICA

Vision:Healthy People in Healthy Communities

Mission:Promote Physical and Mental Health and Prevent Disease,

Injury, and Disability

Public Health• Prevents epidemics and the spread of disease• Protects against environmental hazards• Prevents injuries• Promotes and encourages healthy behaviors• Responds to disasters and assists communities in recovery• Assures the quality and accessibility of health services

Essential Public Health Services• Monitor health status to identify community health problems• Diagnose and investigate health problems and health hazards in the community• Inform, educate, and empower people about health issues• Mobilize community partnerships to identify and solve health problems• Develop policies and plans that support individual and community health efforts• Enforce laws and regulations that protect health and ensure safety• Link people to needed personal health services and assure the provision of health care when

otherwise unavailable• Assure a competent public health and personal health care workforce• Evaluate effectiveness, accessibility, and quality of personal and population-based health

services• Research for new insights and innovative solutions to health problems

Appendix B

Adopted: Fall 1994, Source: Public Health Functions Steering Committee, Members (July 1995):American Public Health Association • Association of Schools of Public Health • Association of State and Territorial Health Officials • Environmental Council of theStates • National Association of County and City Health Officials • National Association of State Alcohol and Drug Abuse Directors • National Association of StateMental Health Program Directors • Public Health Foundation • U.S. Public Health Service—Agency for Health Care Policy and Research • Centers for Disease Controland Prevention • Food and Drug Administration • Health Resources and Services Administration • Indian Health Services • National Institutes of Health • Office ofthe Assistant Secretary for Health • Substance Abuse and Mental Health Services Administration


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Definitions are provided for each new occupationalcategory; examples of job “titles” (i.e., “index”items) are provided in parentheses

(1) EpidemiologistInvestigates and describes the determinants anddistribution of disease, disability, and other healthoutcomes and develops the means for their prevention and control.

(2) Environmental Engineer (e.g., WaterSupply/Waste Water Engineer, Solid Waste Engi-neer, Air Pollution Engineers, Sanitary Engineer)Applies engineering principles to control, eliminate,ameliorate, and/or prevent environmental healthhazards.

(3) Environmental Engineering Technicianand Technologist (e.g., Air Pollution Technician,Water/Waste Water Plant Operator and TestingTechnician)Assists Environmental Engineers and other environ-mental health professionals in the control, elimina-tion, amelioration, and/or prevention of environmen-tal health hazards. May collect data and implementprocedures or programs developed by Environmen-tal Engineers and other environmentalhealth professionals.

(4) Environmental Scientist and Specialist(e.g., Environmental Researcher, EnvironmentalHealth Specialist, Food Scientist, Soil and PlantScientist, Air Pollution Specialist, Hazardous Mate-rials Specialist, Toxicologist, Water/Waste WaterSolid Waste Specialist, Sanitarian, Entomologist)Applies biological, chemical, and public healthprinciples to control, eliminate, ameliorate, and/orprevent environmental health hazards.

Appendix C:Revision of the Federal Standard Occupational

Classification (SOC) System: NewOccupational Categories Recommended for the Field of Public Health

(Still pending, August 1997)

(5) Environmental Science Technician andTechnologist (e.g., Air Pollution Technicians,VectorControl Workers)

Assists Environmental Scientists and Specialists andother environmental health professionals in thecontrol, elimination, and/or prevention of environmental health hazards.

(6) Occupational Safety and HealthSpecialist (e.g., Industrial Hygienists, OccupationalHealth Specialists, Radiologic Health Inspectors,Safety Inspectors)Reviews, evaluates, and analyzes workplace environments and exposures and designs programs andprocedures to control, eliminate, ameliorate, and/orprevent disease and injury caused by chemical,physical, biological, and ergonomic risks to workers.

(7) Occupational Safety and Health Techni-cian and TechnologistCollects data on workplace environments andexposures for analysis by Occupational Safety andHealth Specialists. Implements programs andconducts evaluation of programs designed to limitchemical, physical, biological, and ergonomic risksto workers.

(8) Health Educator (e.g., Public HealthEducator, Community Health Educator, SchoolHealth Educator)Designs, organizes, implements, communicates,provides advice on and evaluates the effect ofeducational programs and strategies designed tosupport and modify health-related behaviors ofindividuals, families, organizations, and communities.


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(9) Public Health Policy AnalystAnalyzes needs and plans for the development ofhealth programs, facilities, and resources; analyzesand evaluates the implications of alternative policiesrelating to health care.

(10) Health Service Manager/Health ServiceAdministratorPlans, organizes, directs, controls, and/or coordi-nates health services, education, or policy in estab-lishments such as hospitals, clinics, public healthagencies, managed care organizations,industrial andother types of businesses, or related entities.

(11) Public Health and Community SocialWorker (e.g., Community Organizer, Outreach andEducation Social Worker, Public Health SocialWorker)Identifies, plans, develops, implements, and/orevaluates programs designed to address the socialand interpersonal needs of populations in order toimprove the health of a community and promote thehealth of individuals and families.

(12) Mental Health and Substance AbuseSocial Worker (e.g., Alcoholism Worker, ClinicalSocial Worker, Community Health Worker, CrisisTeam Worker, Drug Abuse Worker, Marriage andFamily Social Worker, Psychiatric Social Worker,Psychotherapist Social Worker)Provides services for persons having mental, emo-tional, or substance abuse problems. May providesuch services as individual and group therapy, crisisintervention, and social rehabilitation. May alsoarrange for supportive services to ease patients’return to the community.

NOTE: Social Worker occupations proposed (#11 and #12)are distinct from, and in addition to, social worker occupa-tions already proposed, including “Medical SocialWorker”; “Child, Family, and School Social Worker”; and“Social Worker, other.”

(13) Psychologist, Mental Health Provider(e.g., Clinical Psychologist, Counseling Psychologist,Marriage Counselor Psychologist, Psychotherapist)Diagnose and treat mental disorders by usingindividual, child, family, and group therapies. Maydesign and implement behavior modification pro-grams. (Requires doctoral degree.)

NOTE: Psychologist occupation proposed (#13) is distinctfrom, and in addition to, Psychologist occupations alreadyproposed, including “School Psychologist”; “Industrial/Organizational Psychologist”; and “Psychologists, exceptMental Health Providers.”

(14) Alcohol and Substance AbuseCounselor, including Addiction Counselor (e.g.,Substance Abuse Counselor, Certified SubstanceAbuse Counselor, Certified Alcohol Counselor,Certified Alcohol and Drug Counselor, CertifiedAbuse and Drug Addiction Counselor, Drug AbuseCounselor (Associates Degree or higher), DrugCounselor (Associates Degree or higher), AlcoholicCounselor (Associates Degree or above)Assesses and treats persons with alcohol or drugdependency problems. May counsel individuals,families, or groups. May engage in alcohol and drugprevention programs.

(15) Mental Health Counselor (e.g., ClinicalMental Health Counselor, Mental Health Counselor)Emphasizes prevention and works with individualsand groups to promote optimum mental health. Mayhelp individuals deal with addictions and substanceabuse; family, parenting, and marital problems;suicidal tendencies; stress management; problemswith self-esteem; and issues associated with aging,and mental and emotional health. Excludes psychia-trists, psychologists, social workers, marriage andfamily therapists, and substance abuse counselors.

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• Public Health Physician (e.g., GeneralPreventive Medicine/Public Health, Occu-pational Medicine, Epidemiologist, PhysicianExecutive, Clinician)

• Public Health Nurse (e.g., OccupationalNurse, School Nurse, Community HealthNurse, Nurse Practitioner, Clinician)

• Public Health Dentist (e.g., Dental PublicHealth Clinician)

• Public Health Dental Worker (e.g.,Dental Hygienist, Dental Assistant)

• Public Health Veterinarian

• Public Health Nutritionist (e.g., Commu-nity Nutritionist, Registered Dietician,Nutrition Scientist, Clinician)

• Public Health Pharmacist

Appendix C

• Public Health Laboratory Scientist(e.g., Microbiologist, Chemist, Physicist,Entomologist)

• Public Health Laboratory Technicianand Technologist (e.g., Medical Labora-tory Technician, Medical Technologist,Histologic Technician and Technologist,Cytotechnologist)

• Public Health Attorney or HearingOfficer

• Health Information System/Computer Specialist

• Public Relations/Public Information/Health Communications/MediaSpecialist

• Biostatistician

Revision of the Federal Standard OccupationalClassification (SOC) System: Public Health Occupational

Categories Already Listed Under Pre-ExistingOccupational Subcategories

(e.g., Physician, Nurse, Dentist, Veterinarian, Attorney, Statistician)


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Appendix D:Descriptions of Selected Public Health Workforce Assessment Studies

Investigator(s) Study Objectives Methods Type of Information

Public HealthFoundation, 1992

Provide informationon workforce engagedin public health activitieswithin Statehealth agencies

Analyze trends instaffing patterns

FTE data collected byoccupational categories inall 50 States by surveymailed to StateHealth Agency

Number and types ofvacancies byoccupational categories

Perceived workforcerecruitment problems

Environmental Health DataWorkshop(ASPH, L.J.Gordon, 1991)

Provide estimateof number of professionaland technical staffemployed inenvironmental health

Identify areas ofpersonnel shortages

Examine educational andtraining levels of environ-mental health workforce

Available data, estimates byworkshop participants

Number of personnel inenvironmental healthpositions

Level of formaleducation in field

Areas of personnelshortages inenvironmental health

Bureau of HealthProfessions, Report toCongress, 1992 & 1994

Provide detailed report onstatus of health personnel inthe United States

Available data, expertpanels and focus groups

Shortages of public healthpersonnel in specificcategories

National Association ofCity and County HealthOfficials (NACCHO), 1990& 1995

Gain a comprehensive,accurate description ofactivities, capacities, andneeds of local health depart-ments

Survey of localhealth departments

Estimates of numberof professionals inhealth departments

National Association ofState Mental HealthProgram Directors,1994 & 1996

Obtain comparabledata about mentalhealth systems

Survey of State MentalHealth Authorities

Staffing levels ofState-operated or State-funded mental healthprovider organizations

Information on minorityworkforce issues

Client/staff ratios

Recruitment, training, andstaff retention data

Salary levels

FTE physicians inState hospitals


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Descriptions of Selected Public Health Workforce Assessment Studies

Investigator(s) Study Objectives Methods Type of Information

The George WashingtonMedical Center,Center for HealthPolicy Research,(Solloway et al., 1996)

University of Texas, Schoolof PublicHealth, Center for HealthPolicy Studies(Kennedy et al., 1996)

An Update on HumanResources in Mental Health(Peterson et al., 1996)

Develop methodology andassess size and compositionof public health workforce in5 States

Examine changing patternsof public health practice andlink workforce to theessential public healthservices. Identify educa-tional and training needs ofpublic health personnel aswell as barriers to meetingneeds

Recommend approaches toaddress educational trainingneeds of State public healthworkers

Estimate size of professionalpublic health workforce inTexas

Describe workforce composi-tion

Identify personnel shortagesby occupation as well asperceived education andtraining needs

To update information fromprevious Mental Health,United States reports

To add information ondisciplines incorporated inthe work groups since 1990

To present comparableinformation on the size andcharacteristics of each of theeight disciplines

Using personnel data fromStates, organizationalcharts were used toidentify workers by jobtitle, organizational unit,and department. Job titleswere matched to workforcetypology developed bythe Bureau of Healthprofessions.

Study also conducted sitevisits, key-informantinterviews, and focusgroups and examined 3training and educationmodels to identify educa-tion and training needsand barriers.

Two-stage mailed survey;first stage surveyedemployers of professionalpublic health workers;second stage focused onindividual employees

Utilized methodologydeveloped by APHAWorkgroup in mid- 1980’sthat classifies workforceby 3 criteria: type of worksetting, type of workperformed, and type ofposition

Data sources include:AMA’s Physician Charac-teristics and Distribution inthe United States (1996);the 1996 membershiprecords of the APA; the1994 APA MembershipDirectory Survey; the1988-89 APA ProfessionalActivities Survey; NASWmembership; ANA’snational certificationprogram

Classification in publichealth workforce inthese 5 States

Level of formal education ortraining in the field of publichealth

Training and educationalneeds of workforce in the 5States

Methods of deliveringeducational and trainingprograms to public healthpersonnel

Estimate of supply of publichealth professionals in Texas

Identified shortage areas

Assessment and identifica-tion of employee perceivededucation and training needs

Classification of publichealth workforce by workactivity

Assessment of capacity andgeographicdistribution of workforce

Number of personnel in eightselect disciplines andprofessional activities

Level of education

Information on minorityworkforce issues

Recruitment, training, andstaff retention data

(continued)

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Appendix E:Competencies for Providing Essential Public Health Services

Essential Service #1: Monitor health status to identify community health problems.

Competencies:

Analytic Skills• Define a problem• Determine appropriate use of data and statistical methods for problem identification and resolution and

program planning, implementation, and evaluation• Select and define variables relevant to defined public health problems• Evaluate the integrity and comparability of data and identify gaps in data sources• Understand how the data illuminate ethical, political, scientific, economic, and overall public

health issues• Understand basic research designs used in public health• Make relevant inferences from data

Communication Skills• *Communicate effectively both in writing and orally (unless a handicap precludes one of these forms

of communication)• Present accurately and effectively demographic, statistical, programmatic, and scientific information

for professional and lay audiences• Solicit input from individuals and organizations• Advocate for public health programs and resources• Lead and participate in groups to address specific issues• Use the media to communicate public health information

Policy and Development/Program Planning Skills• Collect and summarize data relevant to an issue

Basic Public Health Sciences Skills• Define, assess, and understand the health status of populations, determinants of health and illness,

factors contributing to health promotion and disease prevention, and factors influencing the use ofhealth services

• Apply the basic public health sciences, including behavioral and social sciences, biostatistics, epidemi-ology, environmental public health, and prevention of chronic and infectious diseases and injuries

New• Understand risk assessment and risk communication skills• Understand how to use public health software packages such as Epi-Info to track, analyze, and

present findings of community health problems(continued)

(These lists of organizational competencies for providing essential public health services were done by the Competency-Based Curriculum Work Group of the Subcommittee on Public Health Workforce, Training, and Education. The WorkGroup began with the universal competencies developed by the Faculty/Agency Forum, divided them into the 10essential services of public health framework, and added new competencies. Those marked with a * are universalcompetencies that have been modified.)


30

• Design and operate a surveillance system• Understand analytic skills for survey development and administration• Understand the role and importance of vital statistics• Understand computer/information technology applications• Know existing sources of data• Describe problems in terms of time (persistence), magnitude/severity (scope), dispersion/location

(place), and co-occurrence/co-morbidity• Demonstrate ethical (including sensitive, confidential) conduct in practice, research, data collection and

storage, and program management• Effectively function in culturally diverse settings, assess cross-cultural relations, adapt professional

behavior to unique needs, assess and promote cultural competence of employee/organization


31

Essential Service #2: Diagnose and investigate health problems and health hazards in the community.

Competencies:

Analytic Skills• Define a problem• Determine appropriate use of data and statistical methods for problem identification and resolution, and

program planning, implementation, and evaluation• Select and define variables relevant to defined public health problems• Evaluate the integrity and comparability of data and identify gaps in data sources• Understand how the data illuminate ethical, political, scientific, economic, and overall public

health issues• Understand basic research designs used in public health• Make relevant inferences from data



for professional and lay audiences• Solicit input from individuals and organizations• Lead and participate in groups to address specific issues• Use the media to communicate public health information

Policy and Development/Program Planning Skills• Collect and summarize data relevant to an issue• State policy options• Articulate the health, fiscal, administrative, legal, social, and political implications of each policy option• State the feasibility and expected outcomes of each policy option

Cultural Skills• Understand the dynamic forces contributing to cultural diversity• Interact sensitively, effectively, and professionally with persons from diverse cultural, socioeconomic,

educational, and professional backgrounds and with persons of all ages and lifestyle preferences• Identify the role of cultural, social, and behavioral factors in determining disease, disease prevention,

health promoting behavior, and medical service organization and delivery• Develop and adapt approaches to problems that take into account cultural differences



• Understand research methods in all basic public health sciences(continued)

Appendix E



32

• Apply the basic public health sciences including behavioral and social sciences, biostatistics, epidemiol-ogy, environmental public health, and prevention of chronic and infectious diseases and injuries

New• Understand environmental health issues and environmental morbidity factors• Establish ties with nontraditional public health providers such as school health clinics and occupational

safety office in industry• Utilize risk assessments (i.e., identifying hazardous exposure and health effects)• Apply laboratory science skills• Understand study design, including outbreak/cluster investigation• Facilitate interview (including cultural competence) and qualitative survey methods• Utilize public relation skills• Know existing network of consultants and technical assistance and community-based assets to collect

and analyze community health data• Understand relevant legal and regulatory information• Identify the scientific underpinnings and ascertain strength of evidence from literature, including

effectiveness of interventions• Prepare and interpret data from vital statistics, census, surveys, service utilization, and other relevant

special reports


33

Essential Service #3: Inform, educate, and empower people about health issues.

Competencies:


of communication)• *Present accurately and effectively demographic, statistical, programmatic, and scientific information

for professional and lay audiences (i.e., risk communication)• Solicit input from individuals and organizations• Advocate for public health programs and resources• Lead and participate in groups to address specific issues• *Use the media and advanced technologies to communicate public health information

Cultural Skills• Understand the dynamic forces contributing to cultural diversity• Interact sensitively, effectively and professionally with persons from diverse cultural, socioeconomic,



New• Understand psychosocial and behavioral theories (e.g., health belief model)• Establish measurable goals/objectives• Understand how public and private agencies within a community operate• Understand risk assessment and health risk assessment methodologies• Translate education information into compelling sound “bites”• Know how to use the legal and political system to effect change• Understand different theories on education and learning

Appendix E



34

Essential Service #4: Mobilize community partnerships to identify and solve problems.

NOTE: Competencies needed to identify and solve problems are included in essential services #1, 2, and 5.Therefore, the competencies listed below reflect those needed to mobilize community partnerships.

Competencies:

Communication Skills• *Communicate effectively and persuasively both in writing and orally (unless a handicap precludes one of these forms of communication)• Present accurately and effectively demographic, statistical, programmatic, and scientific information for professional and lay audiences• Solicit input from individuals and organizations• Advocate for public health programs and resources• Lead and participate in groups to address specific issues• Use the media to communicate public health information




New• Establish ties with nontraditional health providers (such as businesses, managed care organizations

and other health care providers, schools, other government agencies, volunteer, and nonprofit organiza-tions, advocacy groups, community groups, hospitals, physicians, insurers, faith and church groups)

• Understand the existing network of consultants and technical assistance and community-based assetsto collect and analyze community health data

• Utilize leadership, team building, negotiation, and conflict resolution skills to build communitypartnerships

• Foster community empowerment, involvement, and power sharing whenever possible in the design,implementation, and research aspects of programs and systems


35

Essential Service #5: Develop policies and plans that support individual and community health efforts.

Competencies:

Communication Skills• Use the media and advanced technologies to communicate public health information

Policy and Development/Program Planning Skills• *Collect and summarize data relevant to an issue and test its reliability• State policy options• Articulate the health, fiscal, administrative, legal, social, and political implications of each policy option• State the feasibility and expected outcomes of each policy option• *Utilize current techniques in decision analysis• Write a clear and concise policy statement• Develop a plan to implement the policy, including goals, outcome and process objectives, and imple-

mentation steps• Translate policy into organizational plans, structures, and programs• Identify public health laws, regulations, and policies related to specific programs• Develop mechanisms to monitor and evaluate programs for their effectiveness and quality




Financial Planning and Management Skills• Develop and present a budget• Manage programs within budgetary constraints• Develop strategies for determining budget priorities• Monitor program performance• Prepare proposals for funding from external sources• Apply basic human relations skills to the management of organizations and the resolution of conflicts• Manage personnel• Understand the theory of organizational structure and its relation to professional practice

New• Utilize and integrate strategic planning processes, including assessment methodology and modeling

when developing policies or community-health plans• Conduct cost-effectiveness, cost-benefit, and cost-utility analyses

Appendix E



36

Essential Service #6: Enforce laws and regulations that protect health and ensure safety.

Competencies:


of communication)• *Present accurately and effectively demographic, statistical, programmatic, and scientific information

for professional and lay audiences (i.e., risk communication)• *Use the media and advanced technologies to communicate public health information

Policy and Development/Program Planning Skills• *Collect and summarize data relevant to an issue, including adequate interpretation of historical experi-

ences, activities, and outcomes• *Identify, interpret, and implement public health laws, regulations, and policies related to

specific programs

Cultural Skills• Interact sensitively, effectively, and professionally with persons from diverse cultural, socioeconomic,

educational, and professional backgrounds and with persons of all ages and lifestyle preferences

New• Utilize creative methods for achieving enforcement and regulation of laws that protect health• Collaborate with other public agencies and organizations (e.g., law enforcement)• Manage and monitor the enforcement process (including enforcement personnel, compliance, and

development of inspection indicators)• Understand risk assessment and health risk assessment methodologies


37

Essential Service #7: Link people to needed personal health services and ensure the provi-sion of health care when otherwise unavailable.

Competencies:

Analytic Skills• Define a problem• Make relevant inferences from data

Policy and Development/Program Planning Skills• Collect and summarize data relevant to an issue• State policy options• Articulate the health, fiscal, administrative, legal, social, and political implications of each policy option• State the feasibility and expected outcomes of each policy option• Decide on the appropriate course of action• Write a clear and concise policy statement• Develop a plan to implement the policy, including goals, outcome and process objectives, and imple-

mentation steps• Translate policy into organizational plans, structures, and programs• Develop mechanisms to monitor and evaluate programs for their effectiveness and qualityCultural Skills• Understand the dynamic forces contributing to cultural diversity• Interact sensitively, effectively, and professionally with persons from diverse cultural, socioeconomic,





Financial Planning and Management Skills• Develop and present a budget• Manage programs within budgetary constraints• Develop strategies for determining budget priorities• Monitor program performance• Prepare proposals for funding from external sources• Apply basic human relations skills to the management of organizations and the resolution of conflicts• Manage personnel• Understand the theory of organizational structure and its relation to professional practice

(continued)

Appendix E



38

New• Negotiate contracts for personal health services• Identify health needs of special and vulnerable populations• Utilize case management skills to coordinate care• Coordinate public health and medicine for optimal care• Provide or ensure provision of comprehensive personal health services, including primary and specialty

medical and dental care and clinical preventive services• Prepare and implement emergency response plans


39

Essential Service #8: Assure a competent public health and personal health care workforce.

Competencies:

Analytic Skills• Determine appropriate use of data and statistical methods for problem identification and resolution and

program planning, implementation, and evaluation

Policy and Development/Program Planning Skills (policy = privileging, licensing, quality assurance,credentialing, and accreditation of health professionals and health professions education)• Collect and summarize data relevant to an issue• State policy options• Articulate the health, fiscal, administrative, legal, social, and political implications of each policy option• State the feasibility and expected outcomes of each policy option• Decide on the appropriate course of action• Write a clear and concise policy statement• Develop a plan to implement the policy, including goals, outcome and process objectives, and imple-

mentation steps• Translate policy into organizational plans, structures, and programs

Cultural Skills• Interact sensitively, effectively, and professionally with persons from diverse cultural, socioeconomic,

educational, and professional backgrounds and with persons of all ages and lifestyle preferences• Develop and adapt approaches to problems that take into account cultural differences

Basic Public Health Sciences Skills• Understand the historical development and structure of State, local, and Federal public health agencies

Financial Planning and Management Skills• Understand the theory of organizational structure and its relation to professional practice

New• Persuasively express to organizational leaders the value and need for training and education• Know and use contemporary learning technologies• Understand different theories on education and learning


Appendix E


40

Essential Service #9: Evaluate effectiveness, accessibility, and quality of personal andpopulation-based health services.

Competencies:

Analytic Skills• Evaluate the integrity and comparability of data and identify gaps in data sources• Understand how the data illuminate ethical, political, scientific, economic, and overall public

health issues• *Understand basic research methodologies used in public health and health services research• Make relevant inferences from data



for professional and lay audiences• Solicit input from individuals and organizations• Advocate for public health programs and resources

Policy and Development/Program Planning Skills• Collect and summarize data relevant to an issue• Identify public health laws, regulations, and policies related to specific programs• Develop mechanisms to monitor and evaluate programs for their effectiveness and quality• Understand analytic skills for survey development and administration






• Understand research methods in all basic public health sciences• Apply the basic public health sciences, including behavioral and social sciences, biostatistics, epidemi-

ology, environmental public health, and prevention of chronic and infectious diseases and injuries• Understand the historical development and structure of State, local, and Federal public health agencies

(continued)


41

Financial Planning and Management Skills• Monitor program performance

New• Understand analytic skills for survey development and administration• Monitor quality of personal health services provided• Conduct cost-effectiveness, cost-benefit, and cost-utility analyses

Appendix E



42

Essential Service #10: Research for new insights and innovative solutions to health problems.

Competencies:

Analytic Skills• Define a problem• Determine appropriate use of data and statistical methods for problem identification and resolution and

program planning, implementation, and evaluation• Select and define variables relevant to defined public health problems• Evaluate the integrity and comparability of data and identify gaps in data sources• Understand how the data illuminate ethical, political, scientific, economic, and overall

public health issues• Understand basic research designs used in public health• Make relevant inferences from data

Communication Skills• *Use the media to communicate and disseminate results of research findings






• Understand research methods in all basic public health sciences• Apply the basic public health sciences, including behavioral and social sciences, biostatistics, epidemi-

ology, environmental public health, and prevention of chronic and infectious diseases and injuries• Understand the historical development and structure of State, local, and Federal public health agencies

New• Identify specific research methodologies relevant to each of the previous nine essential services• Conduct collaborative research across multiple disciplines• Understand budget processes in order to lobby for resources to investigate innovative approaches to

health problems


43

Organizations:

Academy of General DentistryAerobics and Fitness Association of AmericaAlcohol and Drug Problems AssociationAlliance for Aging ResearchAlliance for HealthAmateur Athletic Union of the United StatesAmerican Academy of Child and Adolescent PsychiatryAmerican Academy of Family PhysiciansAmerican Academy of NursingAmerican Academy of OphthalmologyAmerican Academy of Orthopedic SurgeonsAmerican Academy of Otolaryngology, Head and Neck Surgery, Inc.American Academy of Pain ManagementAmerican Academy of Pediatric DentistryAmerican Academy of PediatricsAmerican Alliance for Health, Physical Education, Recreation and DanceAmerican Art Therapy AssociationAmerican Association for Clinical ChemistryAmerican Association for Dental ResearchAmerican Association for Health EducationAmerican Association for Marriage and Family TherapyAmerican Association for Respiratory CareAmerican Association for the Advancement of ScienceAmerican Association of Certified OrthoptistsAmerican Association of Colleges of NursingAmerican Association of Colleges of Osteopathic MedicineAmerican Association of Colleges of PharmacyAmerican Association of Dental SchoolsAmerican Association of Family and Consumer ServicesAmerican Association of Health PlansAmerican Association of Homes for the AgingAmerican Association of Occupational Health NursesAmerican Association of Pathologists’ AssistantsAmerican Association of Public Health DentistryAmerican Association of Public Health PhysiciansAmerican Association of Retired Persons

American Association of School AdministratorsAmerican Association of SuicidologyAmerican Association of University Affiliated ProgramsAmerican Association on Mental RetardationAmerican Cancer Society, Inc.American College Health AssociationAmerican College of AcupunctureAmerican College of CardiologyAmerican College of Clinical PharmacyAmerican College of Emergency PhysiciansAmerican College of GastroenterologyAmerican College of Health Care AdministratorsAmerican College of Health Care ExecutivesAmerican College of Nurse-MidwivesAmerican College of NutritionAmerican College of Obstetricians and GynecologistsAmerican College of Occupational and Environmental MedicineAmerican College of PhysiciansAmerican College of Preventive MedicineAmerican College of RadiologyAmerican College of Sports MedicineAmerican Correctional Health Services AssociationAmerican Council on Alcoholism, Inc.American Council on ExerciseAmerican Counseling AssociationAmerican Dental AssociationAmerican Dental Hygienists’ AssociationAmerican Diabetes AssociationAmerican Dietetic AssociationAmerican Federation of TeachersAmerican Geriatrics SocietyAmerican Heart AssociationAmerican Highway Users AllianceAmerican Hospital AssociationAmerican Indian Health Care AssociationAmerican Institute for Preventive MedicineAmerican Kinesitherapy AssociationAmerican Liver FoundationAmerican Lung AssociationAmerican Meat InstituteAmerican Medical AssociationAmerican Medical Student AssociationAmerican Nurses Association

Appendix F:HEALTHY PEOPLE 2000 Consortium


44

American Occupational Therapy AssociationAmerican Optometric AssociationAmerican Orthopedic Society for Sports MedicineAmerican Osteopathic Academy of Sports MedicineAmerican Osteopathic AssociationAmerican Osteopathic Health care AssociationAmerican Pharmaceutical AssociationAmerican Physical Therapy AssociationAmerican Podiatric Medical AssociationAmerican Psychiatric AssociationAmerican Psychiatric Nurses AssociationAmerican Psychological AssociationAmerican Public Health AssociationAmerican Red CrossAmerican Rehabilitation AssociationAmerican Rehabilitation Counseling AssociationAmerican Running and Fitness AssociationAmerican School Food Service AssociationAmerican School Health AssociationAmerican Society for Clinical NutritionAmerican Society for Gastrointestinal EndoscopyAmerican Society for MicrobiologyAmerican Society for Nutritional SciencesAmerican Society for Parenteral and Enteral NutritionAmerican Society for Pharmacology and Experimental TherapeuticsAmerican Society of Addiction MedicineAmerican Society of Health System PharmacistsAmerican Society of Human GeneticsAmerican Society of OcularistsAmerican Speech-Language-Hearing AssociationAmerican Spinal Injury AssociationAmerican Statistical AssociationAmerican Thoracic SocietyAmerican Trauma SocietyAmerican Veterinary Medical AssociationAquatic Exercise AssociationArthritis FoundationAsian and Pacific Islander American Health ForumAsociacion Nacional Pro Personas MayoresASPO/Lamaze AssociationAssociation for Applied Psychophysiology and BiofeedbackAssociation for Hospital Medical EducationAssociation for Professionals in Infection Control and EpidemiologyAssociation for the Advancement of Automotive MedicineAssociation for the Care of ChildrenAssociation for Worksite Health Promotion

Association of Academic Health CentersAssociation of American Indian PhysiciansAssociation of American Medical CollegesAssociation of Community Health Nursing EducatorsAssociation of Food and Drug OfficialsAssociation of Maternal and Child Health ProgramsAssociation of Occupational and Environmental ClinicsAssociation of Pediatric Oncology NursesAssociation of Rehabilitation NursesAssociation of Schools of Allied Health ProfessionsAssociation of Schools of Public HealthAssociation of State and Territorial Chronic Disease Program DirectorsAssociation of State and Territorial Dental DirectorsAssociation of State and Territorial Directors of Health Promotion and Public Health EducationAssociation of State and Territorial Directors of NursingAssociation of State and Territorial Health OfficialsAssociation of State and Territorial Public Health Laboratory DirectorsAssociation of State and Territorial Public Health Nutrition DirectorsAssociation of State and Territorial Public Health Social WorkersAssociation of Teachers of Preventive MedicineAssociation of Technical Personnel in OphthalmologyAssociation of Women’s Health, Obstetric, and Neonatal NursesAsthma and Allergy Foundation of AmericaBlack Congress on Health, Law, and EconomicsBlue Cross and Blue Shield AssociationBoy Scouts of AmericaBrain Injury Association, Inc.Business RoundtableCamp FireCardiovascular Credentialing InternationalCatholic Health Association of the United StatesCenter to Prevent Handgun ViolenceChamber of Commerce of the United States of AmericaCoalition for Consumer Health and SafetyCollege of American PathologistsConsortium of Social Science AssociationsCouncil for Responsible NutritionCouncil of Medical Specialty SocietiesEmergency Nurses AssociationEmployee Assistance Professionals AssociationEnvironmental Council of the StatesEye Bank Association of America

45

Federation of American Societies for Experimental BiologyFederation of Behavioral, Psychological, and Cognitive SciencesFood Marketing InstituteFuture Homemakers of AmericaGeneral Federation of Women’s ClubsGerontological Society of AmericaGirl Scouts of the United States of AmericaGrocery Manufacturers of AmericaHealth Industry Manufacturers AssociationHealth Insurance Association of AmericaHealth Ministries AssociationHealth Sciences Communications AssociationHealthier People NetworkHealthy Mothers, Healthy BabiesInstitute for Child Health PolicyInstitute of Food TechnologistsInternational Hearing SocietyInternational Lactation Consultant AssociationInternational Life Sciences InstituteLa Leche League InternationalLearning Disabilities Association of AmericaMarch of Dimes Birth Defects FoundationMaternity Center AssociationMidwives Alliance of North AmericaMigrant Clinicians NetworkMothers Against Drunk DrivingNational 4-H CouncilNational AIDS FundNational PTANational Alliance for the Mentally IllNational Alliance of Black School EducatorsNational Alliance of Nurse PractitionersNational Alliance of Senior Citizens, Inc.National Asian and Pacific American Families Against Substance AbuseNational Association for Family and Community EducationNational Association for Home CareNational Association for Human DevelopmentNational Association for Music TherapyNational Association for Public Health Statistics and Information SystemsNational Association for Public Worksite Health PromotionNational Association for Sport and Physical EducationNational Association of Biology TeachersNational Association of Childbearing Centers

National Association of Children’s Hospitals and Related InstitutionsNational Association of Community Health CentersNational Association of CountiesNational Association of County and City Health OfficialsNational Association of Elementary School PrincipalsNational Association of Governor’s Councils on Physical Fitness and SportsNational Association of NeighborhoodsNational Association of Neonatal NursesNational Association of Optometrists and Opticians, Inc.National Association of Pediatric Nurse Associates and PractitionersNational Association of RSVP DirectorsNational Association of School NursesNational Association of Secondary School PrincipalsNational Association of Social WorkersNational Association of State Alcohol and Drug Abuse DirectorsNational Association of State Boards of EducationNational Association of State Mental Health Program DirectorsNational Association of State Nutrition Education and Training CoordinatorsNational Association of State School Nurse ConsultantsNational Athletic Trainers’ AssociationNational Black Nurses AssociationNational Board of Medical ExaminersNational Civic LeagueNational Coalition Against Sexual AssaultNational Coalition of Hispanic Health and Human Services OrganizationsNational Commission Against Drunk DrivingNational Committee to Prevent Child AbuseNational Community Pharmacists AssociationNational Conference of State LegislaturesNational Consumers LeagueNational Council for AdoptionNational Council for International HealthNational Council of Community HospitalsNational Council of La RazaNational Council on Alcoholism and Drug DependenceNational Council on Patient Information and EducationNational Council on the Aging

Appendix F


46

National Dairy CouncilNational Education Association Health Information NetworkNational Environmental Health AssociationNational Family Planning and Reproductive Health AssociationNational Federation for Specialty Nursing OrganizationsNational Federation of State High School AssociationsNational Food Processors AssociationNational Health CouncilNational Health Lawyers AssociationNational Hispanic Council on AgingNational Institute for Fitness and SportsNational Kidney FoundationNational League for NursingNational Lesbian and Gay Health AssociationNational Medical AssociationNational Mental Health AssociationNational Minority AIDS CouncilNational Minority Health AssociationNational Nurses Society on AddictionsNational Organization for WomenNational Organization on Adolescent Pregnancy, Parenting and PreventionNational Osteoporosis FoundationNational Pediculosis AssociationNational Pest Control AssociationNational Recreation and Park AssociationNational Restaurant AssociationNational SAFE KIDS CampaignNational Safety CouncilNational School Boards AssociationNational Strength and Conditioning AssociationNational Stroke AssociationNational Wellness Institute, Inc.National Women’s Health NetworkNetwork of Employers for Traffic SafetyNursing Network on Violence Against WomenOncology Nursing SocietyOpticians Association of AmericaOral Health AmericaPartnership for PreventionPeople’s Medical SocietyPharmaceutical Researchers and Manufacturers of AmericaPhysicians for a Violence-Free SocietyPlanned Parenthood Federation of AmericaPoison Prevention Week CouncilPopulation Association of America

Prevent Blindness AmericaProduce for Better Health FoundationProduce Marketing AssociationPublic Health InstituteRoad Runners Club of AmericaSalt InstituteSalvation ArmySexuality Information and Education Council of the U.S.Society for Academic Emergency MedicineSociety for Adolescent MedicineSociety for Healthcare Strategy and Market DevelopmentSociety for Hospital Epidemiology of AmericaSociety for Nutrition EducationSociety for Public Health EducationSociety of Behavioral MedicineSociety of General Internal MedicineSociety of Prospective MedicineSociety of State Directors of Health, Physical Education and RecreationState Family Planning AdministratorsThe ArcThe International Health, Racquet and Sportsclub AssociationThe Sugar AssociationThe United States Conference of MayorsThink First FoundationUnitarian Universalist Seventh Principle ProjectUnited States Eye Injury RegistryUnited Way of AmericaVHA, Inc.Visiting Nurse Association of AmericaWashington Business Group on HealthWellness Councils of AmericaWestern Consortium for Public HealthWomen’s Sports FoundationWound, Ostomy and Continence Nurses SocietyYMCA of the USA

State Agencies:Public HealthMental HealthSubstance AbuseEnvironment

47

Appendix G:The Faculty/Agency Forum Competencies by Discipline

In addition to the Universal Competencies, competencies were developed for the following specific disci-plines by the Public Health Faculty/Agency Forum:

Public Health Administration

Epidemiology and Biostatistics

Behavioral Sciences

Environmental Public Health

For details refer to:Sorensen, Andrew A., and Ronald G. Bialek, eds. 1993. The public health faculty/agency forum:

Linking graduate education and practice. Gainesville, FL: Florida University Press.


48

49

Appendix H:Competencies Reviewed by

the Competency-Based Curriculum Work Group

Competency Set Lead Organization Date

Universal Competencies The Public Health Faculty/Agency Forum 1989

Competencies for Education in Association of Teachers of Maternal & 1993 Maternal and Child Health Child Health

Association of Schools of Public HealthMCH Council

Public Health Leadership Competencies for State The National Public Health Leadership Draft Regional Programs Development Network version

1996

Community-Based Public Health Competencies Johns Hopkins University School of Health 1996

A Competency-Based Framework for Professional The National Commission for Health 1996 Development of Certified Health Education Specialists Education Credentialing, Inc.

Addiction Counselor Competencies Curriculum Review Committee of the 1995Addiction Training Center Program

Educating Environmental Health Science and Protection Association of Schools of Public Health 1991 Professionals: Problems, Challenges, Larry J. Gordon and Recommendations

Competency Objectives for Dental Public Health American Public Health Association: 1990Dental Section


50

51

CO-CHAIRS

Jo Ivey Boufford, M.D.Acting Assistant Secretary for HealthU.S. Department of Health and Human Services

Audrey F. Manley, M.D., M.P.H.Acting Surgeon GeneralU.S. Department of Health and Human Services

MEMBERS

Lisa Simpson, M.B., B.Ch.Acting AdministratorAgency for Health Care Policy and Research

E. Richard Brown, Ph.D.PresidentAmerican Public Health Association

Allan Rosenfield, M.D.PresidentAssociation of Schools of Public Health

Jack Dillenberg, D.D.S., M.P.H.PresidentAssociation of State and Territorial Health Officials

David Satcher, M.D., Ph.D.DirectorCenters for Disease Control and Prevention

Harold Reheis, P.E.PresidentThe Environmental Council of the States

David A. Kessler, M.D.Commissioner of Food and DrugsFood and Drug Administration

Ciro Sumaya, M.D., M.P.H.T.M.AdministratorHealth Resources and Services Administration

Michael H. Trujillo, M.D., M.P.H.DirectorIndian Health Service

Mary des Vignes-Kendrick, M.D., M.P.H.PresidentNational Association of County and City Health Officials

Luceille FlemingPresidentNational Association of State Alcohol and Drug Abuse Directors

Stuart B. Silver, M.D.PresidentNational Association of State Mental Health Program Directors

Edwin Pratt, Jr.Past PresidentNational Association of the Local Boards of Health

Appendix I:Public Health Functions Steering Committee and Working Group

Subcommittee on Public Health Workforce, Training, and Education:Competency-Based Curriculum Work Group

Distance Learning Systems Work GroupWorkforce Composition Work Group

PUBLIC HEALTH FUNCTIONS STEERING COMMITTEE

MEMBERS (MARCH 1997)


52

Harold E. Varmus, M.D.DirectorNational Institutes of Health

Maurice Mullet, M.D.Chairman of the BoardPublic Health Foundation

Honorable Richard S. SchweikerChairPartnership for Prevention

Nelba R. Chavez, Ph.D.AdministratorSubstance Abuse and Mental Health Services Administration

PUBLIC HEALTH FUNCTIONS

WORKING GROUP

MEMBERS (MARCH 1997)

CO-CHAIRS

David Satcher, M.D., Ph.D.DirectorCenters for Disease Control and Prevention

Claude Earl Fox, M.D., M.P.H.Deputy Assistant Secretary for Health(Disease Prevention and Health Promotion)

MEMBERS

Raymond Seltser, M.D.Center for Primary Care ResearchAgency for Health Care Policy and Research

Katherine S. McCarter, M.H.S.Acting Executive DirectorAmerican Public Health Association

Michael K. Gemmell, C.A.E.Executive DirectorAssociation of Schools of Public Health

Cheryl Beversdorf, R.N., M.H.S., C.A.E.Executive Vice PresidentAssociation of State and Territorial Health Officials

Edward Baker, M.D., M.P.H.DirectorPublic Health Program Practice OfficeCenters for Disease Control and Prevention

Charles GollmarActing Director, Office of Program Planning and EvaluationCenters for Disease Control and Prevention

Jeffery R. Harris, M.D., M.P.H.Associate Director for Policy, Planning, and EvaluationCenters for Disease Control and Prevention

Gary Hogelin, M.A.Assistant Director for Policy and PlanningOffice of Surveillance and AnalysisCenters for Disease Control and Prevention

Ray M. Nicola, M.D.Associate Director, Division of Public HealthPublic Health Program Practice OfficeCenters for Disease Control and Prevention

Reverend Samuel NixonDirector, Affiliate Relations DepartmentCongress of National Black Churches

Robbie RobertsExecutive DirectorThe Environmental Council of the States

Peter Rheinstein, M.D.Director, Medicine Staff, Office of Health AffairsFood and Drug Administration

Ronald CarlsonAssociate Administrator for Planning Evaluation and LegislationHealth Resources and Services Administration

Douglas S. Lloyd, M.D., M.P.H.Associate Administrator for Public Health PracticeHealth Resources and Services Administration

53

Audrey H. Nora, M.D.Director, Maternal and Child HealthHealth Resources and Services Administration

Stephen B. Permison, M.D.Deputy Director, Quality Assurance DivisionBureau of Health ProfessionsHealth Resources and Services Administration

Neil H. SampsonActing Director, Division of Associated Dental and Public Health ProfessionsBureau of Health ProfessionsHealth Resources and Services Administration

CDR Susanne Caviness, Ph.D.Chief, Patient Registration, Quality ManagementIndian Health Service

Nancy RawdingExecutive DirectorNational Association of County and City Health Officials

Edwin Pratt, Jr.Past PresidentNational Association of Local Boards of Health

John GustafsonExecutive DirectorNational Association of State Alcohol and Drug Abuse Directors

Robert Glover, Ph.D.Executive DirectorNational Association of State Mental Health Program Directors

William Harlan, M.D.Associate Director for Disease PreventionNational Institutes of Health

Eric Goosby, M.D.DirectorOffice of HIV/AIDS Policy

Roscoe M. Moore, Jr., D.V.M., Ph.D., D.Sc.Associate DirectorOffice of International and Refugee Health

Valerie WelshOffice of Minority Health

Thomas KringActing Deputy Assistant Secretary for HealthOffice of Population Affairs

RADM Stephen B. CorbinChief of StaffOffice of the Surgeon General

Susan Blumenthal, M.D.Deputy Assistant Secretary on Women’s HealthOffice on Women’s Health

Jud RichlandExecutive DirectorPartnership for Prevention

Christine G. Spain, M.A.Director, Research, Planning and Special ProjectsPresident’s Council on Physical Fitness and Sports

Ronald Bialek, M.P.P.Executive DirectorPublic Health Foundation

Duiona Baker, M.P.H.Senior Policy AnalystOffice of Policy and Program CoordinationSubstance Abuse and Mental Health Services Administration

STAFF

Kristine Gebbie, Dr.P.H., R.N.Senior Advisor, Public Health FunctionsOffice of Disease Prevention and Health Promotion

Nicole CumberlandOperations Coordinator, Public Health FunctionsOffice of Disease Prevention and Health Promotion

Appendix I


54

COMPETENCY-BASED CURRICULUM

WORK GROUP

CO-CHAIRS

Dick LincolnPublic Health Program Practice OfficeCenters for Disease Control and Prevention (until October 1996)Association of Schools of Public Health

Neil H. SampsonBureau of Health ProfessionsHealth Resources and Services Administration

MEMBERS

Raymond SeltserCenter for Primary Care ResearchAgency for Health Care Policy and Research

Catherine KordekAmerican Public Health Association

Wendy KatzAssociation of Schools of Public Health

Alison WojciakAssociation of Schools of Public Health

Jane C. NelsonCenter for Public Health PracticeEmory University School of Public Health

Mary HaackGeorge Washington Center for Health Policy

Michelle SollowayGeorge Washington Center for Health Policy

Rosemary DuffyBureau of Health ProfessionsHealth Resources and Services Administration

Alexander F. RossHealth Resources and Services Administration

Rick BothwellDivision of Clinical and Preventive ServicesIndian Health ServiceLee BoneDepartment of Health and Policy ManagementJohns Hopkins School of Public Health/Kellogg Community-Based Public Health

Jeanne WehageDepartment of Health Policy and ManagementJohns Hopkins School of Public Health

Jerre JensenPublic Health Training Network

Elaine AuldSociety for Public Health Education

Janice TaylorState of Washington Department of Health

Susanne RohrerCenter for Substance Abuse Treatment SubstanceAbuse and Mental Health Services Administration

Major Bruno PetrucelliWalter Reed Army Institute of ResearchDivision of Preventive MedicineU.S. Department of Defense

Susan ConrathInternal Environments DivisionU.S. Environmental Protection Agency

STAFF

D.W. ChenBureau of Health ProfessionsHealth Resources and Services Administration

Nicole CumberlandOffice of Disease Prevention and Health Promotion

SUBCOMMITTEE ON PUBLIC HEALTH WORKFORCE, TRAINING , AND EDUCATION

55

DISTANCE-BASED LEARNING SYSTEMS

WORK GROUP

CHAIR

Dennis McDowellDivision of Media and Training ServicesPublic Health Program Practice OfficeCenters for Disease Control and Prevention

MEMBERS

Lynn KazemekasCenter for Information DisseminationAgency for Health Care Policy and Research

James G. HillDirector, Office of Rural HealthAmerican Psychological Association

Tom KubisynAssistant Executive DirectorPolicy and Advocacy in the SchoolsAmerican Psychological Association

Scott BeckerAssociation of Schools of Public Health

Nona GibbsPublic Health Program Practice OfficeCenters for Disease Control and Prevention

Robert FatulaTelevision Design and Development BranchFood and Drug Administration

Gary GermanDivision of Human Resource ServiceFood and Drug Administration


Pam VockeSurveyor Training Improvement TeamHealth Care Financing Administration


Ronald MerrillHealth Resources and Services Administration

Alexander RossHealth Resources and Services Administration

Neil H. SampsonBureau of Health ProfessionsHealth Resources and Services Administration

Alan Lee MyersTraining OfficerIndian Health Service

Michael WeisbergNational Library of Medicine

Rita KelliherPublic Health Foundation

Steve SeitzPublic Health AdvisorCenter for Substance Abuse PreventionSubstance Abuse and Mental Health Services Administration

Lisa NelsonU.S. Environmental Protection Agency

Ruth SalingerOffice of the SecretaryU.S. Department of Health and Human Services

STAFF

Jerre JensenSenior AdvisorPublic Health Training Network

Nicole Cumberland (Part-time)Office of Disease Prevention and Health Promotion

Appendix I


56

WORKFORCE WORK GROUP

CHAIR

Douglas S. LloydHealth Resources and Services Administration

MEMBERS

Carolyn ClancyAgency for Health Care Policy and Research

Karen VanLandeghemAssociation of Maternal and Child Health Programs

Wendy KatzAssociation of Schools of Public Health

David ManningAssociation of State and Territorial Health Officials

Mary HaackGeorge Washington Center for Health Policy



Madeleine GoldeNational Association of Social Workers

Jim BaxendaleNational Association of State Alcohol and Drug Abuse Directors

Bruce EmeryNational Association of StateMental Health Program Directors

Valerie WelshOffice of Minority Health

Kay EilbertPublic Health Foundation

Duiona BakerSubstance Abuse and Mental Health Services Administration

Richard HouseSchool of Public HealthUniversity of North Carolina at Chapel Hill

STAFF

Alexander F. RossHealth Resources and Services Administration

Nicole CumberlandOffice of Disease Prevention and Health Promotion

57

REFERENCES

Addiction Training Center Program Curriculum Review Committee. 1995. Addiction counselorcompetencies.

American Association of Public Health Dentistry, Health Policy and Program Management andAdministration Group. 1990. Competency objectives for dental public health. Journal of Public HealthDentistry 50 (5):338-344.

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Peterson, B.D, H.A. Pincus, J. Kohout, G.M. Pion, et al. 1996. An update on human resources in mentalhealth. In R.W. Manderscheid and M.A. Sonnenschein (eds.). Mental health, Untied States, 1996.SMA96-3098. Washington, DC: Government Printing Office.

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These sources were not cited directly in the report or appendices but were found to be helpful and canbe used by readers as further sources of information on public health workforce issues.

Gebbie, K.M. 1996. What currently employed public health nurses need to know. New York: ColumbiaSchool of Nursing.

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