Methods

In consultation with MCHB and an advisory committee assembled for this project, major state and local agencies and organizations serving the MCH population were chosen as the target of this assessment of training needs. As a means of obtaining input from these employers of MCH professionals, a needs assessment form was developed to assess the importance of and need for supporting training in specific skill and content areas and the preferred modalities for training. During the summer of 2000, the needs assessment forms were distributed to the following MCH-related agencies: all State Medicaid offices; a 20% random sample of local health departments (Local); all State and Territory Maternal and Child Health (MCH) agencies; all State and Territory Children with Special Health Care Needs (CSHCN) agencies; all HRSA/MCHB Regional Offices; and, key informants selected by the National Office of the March of Dimes. While the HRSA Regional Offices and March of Dimes key informants were included in the information-gathering phase, the data collected from these groups are not included in this report, as the responses were not believed to necessarily be representative of their respective organizations or agencies. Therefore, all results presented in this report reflect the following four respondent categories: local health departments and State MCH, CSHCN and Medicaid agencies.

Response Rate and Limitations

Needs assessment forms were mailed to 871 agencies, the majority to local health departments. State MCH and CSHCN agencies had the highest return rates among the respondent categories, at 79.3% and 54.4% respectively. Medicaid agencies followed closely at 53.6%. Local agency response rates were significantly lower (23.7%). Overall, 274 forms were returned, representing a 31.5% response rate. This overall response rate largely reflects that of the Local agencies, which composed 80 percent of the original target respondents. The low response rate (24%) from Local health department agencies represents a major limitation to this study. Although the response rate is not atypical of mailed surveys and would be difficult to increase without a substantial investment, the Local health respondents may not be representative of local health departments. The MCH agency response rate probably does reflect a close representation of MCH agencies in general. The response for State CSHCN agencies was lower than that of MCH agencies and was more variable across the regions. Regions III, IV and IX were conspicuous in their low response and generalizing these results to those regions should be undertaken with due caution. Similarly, lower response rates from Medicaid offices in Regions VIII, IX, and X limits generalizability to those areas.

Overview of Graduate Education Needs

Regardless of agency type, i.e., state MCH, CSHCN, Medicaid or local health department, having employees with graduate education in MCH was perceived to be of value. The percentage of agencies perceiving a benefit from having graduate level trained employees ranged from a low of 73.3% among Medicaid directors to a high of 95.5% of State MCH Directors (Figure 1). More than one-half of the MCH, CSHCN and Local agencies reported that they either had a hard time or were unable to find qualified applicants who possessed the critical skills they needed (Table 6).

Respondents were asked to rate the importance of graduate-level skills and competencies. Leadership, systems development, management, administration, analytic, policy and advocacy skills were all overwhelmingly perceived to be important (Table 5). Compared to Local health agencies, the three state-level agencies perceived graduate-level clinical skills to be less important (Table 5). Agency respondents indicated MCH epidemiology, health care administration and management as among their top rated critical unmet need areas for MCH professionals with graduate education (Tables 8 and 9). In the clinical area, the critical unmet need areas included genetics, dentistry and health education for MCH agencies; medicine, dentistry and nursing for CSHCN agencies; nursing, nutrition and health education for Local agencies; and, dentistry, health education and nursing for Medicaid agencies (Tables 7 and 9).

Several factors were reported as preventing staff from pursuing graduate education (Table 12). The cost of graduate education programs, the loss of income while in school, and the time required for completion of the program were reported to be the most prohibitive barriers to graduate education by all responding agencies.

Overview of Continuing Education Needs

Appreciable unmet need for more continuing education for MCH personnel was identified (Figure 2). Moreover, state and local agencies report limited capacity to meet the training needs of either their staff or the staff of other agencies (Table 47). Program managers and program staff were perceived to be in greatest need for continuing education (Tables 13 and 50). Program management and administration skill areas were the most important CE themes for program managers and include program planning, development, implementation, management and evaluation, needs assessment, performance management, data analysis and interpretation, personnel management, team building and policy development (Table 31). For program staff, the most important CE topics tended to be more direct service and program performance oriented and include cultural competency, family centered care, families as partners, clinical skills, and program evaluation, performance and management (Table 32). For agency directors, leadership, systems development and administrative CE themes emerged across all agencies, including health care financing, policy development, interagency and systems-level collaboration, managing change and performance, team building, negotiations, personnel management, and working with families, communities, the public, and legislative bodies (Table 30).

Respondents indicated that it would be useful for MCH personnel at nearly all staff levels and agency types to learn more about the programs, policies and access and referral procedures of Medicaid agencies and for the personnel of those other agencies to learn more about those same items for MCH-related agencies. Co-knowledge of data bases and needs assessments were also viewed as useful. Finally, the future emerging topics for continuing education for all agencies included skills in technical writing (e.g., grant writing), communications, systems development, organization change, cost analysis, and advanced leadership.

The number of reported continuing education programs currently being provided is modest (Table 49). Further, the routine assessment of training needs is very limited, which makes it difficult for agencies to accurately document their needs and plan accordingly to meet them (Table 48).

Having in-state, on-site and small conferences as a means for continuing education was of interest to the respondents and comprised their first preference (Tables 43-45). These preferences seem to be compatible with the reported barriers to seeking CE, i.e., time away from work, lack of staff to cover functions while away, and cost (Table 46). While there are appreciable interest, capacity and preference for other types of CE modalities, including Internet and Web-based training, the reported preference for small conferences might reflect a desire for interaction among colleagues and educators as part of continuing education activities. Taken together, these responses may reflect a desire for local training opportunities that allow participants to get out of the office (thereby eliminating constant interruptions) for short periods of time to learn together.

Recommendations:

The following recommendations are based on the findings of this needs assessment, a review of the previous 1992 AMCHP assessment of MCH graduate and continuing education needs, and the authors’ nearly two decades of experience in providing graduate and continuing education in the MCH field. The recommendations are presented in order of priority, although the top five are all seen as critical.

Recommendation #1: Continue to support MCH graduate education in public health and clinical skill areas, using multiple funding support mechanisms

Substantial demand for employees with graduate education was in evidence among all agency types queried. More than 70 percent of all the agencies perceived having employees with graduate education as a benefit with 96 percent of MCH agencies so responding (Figure 1). For all agencies, more than one-third of current staff members were viewed as able to use or benefit from graduate education (Table 11).

More than 80 percent of all respondents in State MCH, State CSHCN, and Local agencies perceived public health leadership and systems development as among the most important graduate education topics and over 75 percent of all agencies perceived graduate education in program management, administration and core public health skills as important (Table 5). Among the specific core public health skills areas, a MCH professional with graduate education in MCH epidemiology was indicated to be the most critical unmet need area by state MCH (96%), State CSHCN (67%), Local (55%), and Medicaid (57%) agencies (Table 8).

Given these findings, it is recommended that MCHB continue to support MCH graduate education in public health and might make additional dollars available for tuition remission and stipends in order to allow more students to pursue the MPH degree in MCH without excessive cost burdens and significant loss of income. Further, MCHB might explore partnerships with state MCH/CSHCN programs to offer graduate fellowships to current MCH professionals interested in pursuing the MPH, with the condition that the graduate return to their home state and program. This would provide security to the employee as well as an incentive to the agency to grant the employee educational leave. The MCH Bureau might also offer graduate fellowships to entry-level students. These might also include a required two or more year placement in a MCH/CSHCN-related agency upon graduation.

There also remains a large unmet need for professionals with graduate education in clinical skill areas. For MCH agencies, the highest unmet critical need areas for clinical graduate education were genetics (61.4%), dentistry (47.7%), health education (45.4%) nutrition (44.2%) and nursing (42.3%). For CSHCN agencies, the higher unmet clinical need areas were medicine (64.7%), dentistry (57.1%), nursing (55.5%), physical therapy (50%) and early childhood education (50%). Nursing was the highest clinical area of unmet need for Local agencies, followed by nutrition (46.4%) and health education (45.1%). Dentistry (61.9%), health education (50%) and nursing (45%) were the most prominent unmet clinical need areas for Medicaid agencies (Table 7). Multiple approaches might be considered by MCHB to address these needs, including tuition and stipend support for graduate education and graduate fellowships tied to conditions of working a specified period in a state or local MCH, CSHCN or related agency. Joint degree programs, e.g., MPH/MD, MPH/MSN and MPH/MSW, represent another viable approach to increase the availability of clinicians cross-trained to address a broad range of needs of the MCH population.

Recommendation #2: Expand continuing education in the areas of leadership, administration, management, core public health, and clinical skills and support innovative continuing education approaches targeted at program managers and staff using on-site and small conferences.

A need for continuing education was reported by more than 90 percent of respondents from all agencies (Figure 2). Program managers were identified by over 58 percent of respondents as having the greatest unmet need. More than 67 percent of program staffs were perceived to have a need for continuing education (Table 13). Leadership, management, administration and core public health skills were among the most important CE topics requested and were among the topics suggested to receive CE training dollars. The importance of specific CE topics differed by staff levels.

Leadership and system-based skills (i.e., systems development, interagency collaboration, policy issues, advocacy) were deemed as important for directors. More than 80 percent of those responding viewed program management skills and core public health skills (i.e., program development/implementation/evaluation, personnel management, performance measures, data analysis) as important CE topics for managers. For program staff, over 70 percent of all respondents indicated more direct service and program performance topics (i.e., cultural competency and family-centered care) as an important area for continuing education (Tables 14-32). Finally, well more than a majority indicated that CE on other agency’s services, programs, policies, and data would be useful (Tables 33-42).

Many of the emphasized CE topic areas are currently addressed by several MCHB-funded CE efforts, e.g., the MCH Leadership Skills Training Institute, although the demand for training continues to exceed the capacity of this program. The ongoing demand for CE in these leadership and management topics suggests that current successful efforts be continued and even expanded to allow more staff to participate and that additional, alternative CE approaches also be explored. As an example of an alternative approach to address current CE needs in the areas of leadership, administration and management, MCHB might support the further development of regional or state leadership academies and identify groups of experts to provide specific skills training in several states (i.e., a traveling leadership academy). Several states (e.g., Illinois, Arkansas) have already organized successful public health leadership academies and more could be designed as certificate programs with MCHB supporting the skeletal structure in an effort to enhance the skills of MCH professionals in a variety of settings within several states.

The major barriers to current employees pursuing continuing education are time away from work, inadequate staffing to cover absence from work, and the cost of CE programs. Over 70 percent of all respondents indicated time away from work as a barrier for continuing education. The cost of continuing education and lack of adequate staff to cover for employees out were perceived as barriers by more than 59 percent of all respondents (Table 46). At the same time, the preferred modality for CE was “instate” and ”small conference”. More than 70 percent of the State MCH and State CSHCN respondents indicated “in-state conference” as the preferred mode of continuing education compared to more than half of local and Medicaid respondents. Over 60 percent of all respondents prefer a “small conference”. More than 68 percent of State MCH, Local, and Medicaid respondents indicated a preference for on-site workshops, while only 55 percent of State CSHCN respondents preferred this mode of continuing education (Table 45).

Given these identified barriers and preferred modalities for CE training, MCHB might consider funding several entities or individuals to develop itinerant continuing education programs that could be ‘taken on the road’ and offered locally in multiple states throughout a region. These could be supported along with or in favor of the more traditional CE model of funding one entity to provide one CE conference in one state or one region. Current grantees of CE training funds might be provided incentives to work together on a particular topic, optimizing particular talents that exist across universities rather than setting them up as competitors. For example, given the importance of cultural competence training, it is conceivable that faculties at more than one MCH-funded training program that would be interested in jointly developing a traveling continuing education program. Bringing together faculties from different universities and different specialties, e.g., public health and clinical, could further enrich the perspectives brought to training.

Recommendation #3: Explore the development of a national MCH training policy analysis and development center to serve as a focus for assessing training needs on a regular basis, to serve as a clearinghouse for training activity information, and to foster the development of a national or regional MCH CE brokerage model.

Less than one-half of the responding agencies routinely assessed the training needs of their own staffs or others (Table 48). A comparison of the results of this needs assessment with the 1992 AMCHP assessment indicate that some training needs may have declined (e.g., the need for graduate degree trained nurses), some may have stayed the same (e.g., the need for program development and management training), and some have emerged (e.g., the need for systems development training). These apparent changes in training needs over time suggest that regular, systematic assessments of training needs and appraisals of the impact of training support efforts are advisable to assure that current training efforts are appropriately targeted and to assess the degree to which trends may partly reflect the effectiveness or insufficiency of past state and national training initiatives. Moreover, the results of these periodic assessments should be routinely analyzed and compiled in such a manner as to facilitate their use in MCHB’s strategic planning and performance measurement activities. Accordingly, MCHB might consider establishing and supporting a national MCH graduate and continuing education training policy analysis and development center to advise MCHB on training-related efforts and serve as a training resource for state Title V and related agencies. Such an entity could provide several important and needed services, including the regular national assessment of training needs and the provision of guidance to states and localities on the conduct and analysis of ongoing training needs assessments. Moreover, the proposed center could assist in the evaluation of these efforts and in the promotion of federal/state/ training partnerships.

Another specific function of this proposed center might be the development and maintenance of a continuing education clearinghouse. Benefits of a MCHB-funded clearinghouse for CE were perceived by 85% of MCH, 60% of CSHCN, 67% of Local, and 71% of Medicaid agencies (Table 52). These responses indicate strong support for the creation of a national MCH training clearinghouse that in one place would organize information on existing training programs and offerings funded by MCHB. Such information would include details about graduate and CE programs, including contact information, targeted audience, cost, content, objectives, location, dates, and agenda of each training session. The clearinghouse aspect of the proposed center support the efforts of existing funded grantees in marketing their educational programs.

In order to assist MCHB in targeting CE efforts to meet specific state and local needs for desired CE content and preferred CE modalities, while fostering the development of training teams composed of the best trainers from multiple schools and organizations, the proposed center might also be used to explore the development of a national or regional CE brokerage model, whereby a single entity would bear responsibility for identifying experts on selected topics and then deploying them to several states over the course of a year. The broker would handle logistics, including soliciting topic requests from states (beginning with those identified most frequently through this survey); matching experts to topics; and arranging the schedule of CE sessions, topics and sites. For example, once critical CE topics are selected for a region, the CE broker would be charged with identifying one or more persons to develop a CE program on each topic. The persons selected would be asked to offer the CE program on-site or in-state in several states over the course of a year for a negotiated package fee. The broker would also arrange the scheduling and pay the travel and expenses of the speakers.

Recommendation #4: Require state Title V agencies to conduct assessments of their needs for graduate education, continuing education, and technical assistance, as part of the 5-year and annual update needs assessments.

In order to assist MCHB in obtaining ongoing and current information to plan for graduate education, continuing education, and technical assistance efforts, State Title V agencies might be encouraged, as part of their comprehensive five-year and annual update needs assessments, to conduct and report on assessments of the graduate and continuing education needs of their state’s MCH/CSHCN professionals both within and outside the agency. This would allow for MCHB to better identify unmet needs, as well as determine when needs have been met, so that resources can be directed at the most pressing problems.

The MCH Bureau invests considerable funds in both continuing education and technical assistance for MCH, CSHCN and related programs, though tends to organize them separately. State assessments of continuing education needs, coupled with the self-assessment of technical assistance needs that states conduct each year, would be expected to reveal substantial overlap between the two. It is not unusual during a continuing education program for participants to ask questions specific to their work to the point that the education program borders on a technical consultation. Similarly, technical assistance visits may evolve into continuing education sessions as trainees ask for more detailed explanations, historical perspectives or guidance in adapting new skill areas. State assessments might reveal needs for more coordinated approaches to technical assistance and continuing education. Such approaches would also be consistent with the results contained in this report (Table 45) that indicate a greater desire for on-site short courses (a step closer to a technical assistance model) versus large national or regional conferences (the typical continuing education approach).

Recommendation #5: Explore and promote alternative graduate and continuing education models, e.g., distance learning.

The major barriers to current employees pursuing graduate education are cost of the program, loss of income while completing the program, ability to take time off work, and time to complete the program (Table 12). Over 60 percent of respondents from State MCH, CSHCN, and Local agencies indicated the barriers above to be of the greatest consequence to graduate education. Distance to the program followed the above barriers in terms of importance across agencies. For Medicaid respondents, the percentages were slightly lower, but the trends in perceived barriers mirrored those of other agencies with over 50 percent of the Medicaid respondents indicating cost of program, loss of income while in school, ability to take time off work, and time required to complete program as barriers to graduate education. In order to address these barriers, the MCH Bureau should continue and might further expand its promotion of alternative graduate educational models (e.g., weekend, work/school, and partial distance-based programs), ideally with regional access for professionals in all states. Support of on-site or on-line certificate graduate-level programs may also be considered.

Barriers to continuing education also include time away from work, cost, lack of adequate staff for coverage, and travel restrictions (Table 46). More than 70 percent of all respondents perceived time away from work as a barrier. Over 60 percent of State MCH and CSHCN agency respondents and more than 35 percent of Local and Medicaid perceived travel restrictions as barriers. While preference for on-site continuing education is evident, there are also appreciable interest, capacity and preference for distance learning at both state and local levels (Tables 43-44). This offers an alternative CE training approach that might be further promoted and supported by MCHB.

Recommendation #6: Sponsor academic/practice partnerships to developcross training of MCH-related faculty and expand technical assistance and continuing education opportunities.

Given the existing need for well-trained MCH professionals with diverse skills, states might benefit from longer-term, on-site consultation and involvement of MCH-related faculty. This might be accomplished in a manner similar to that used by CDC to assign epidemiologists to states. Graduate training programs (both in the clinical and public health areas) would also benefit from having their faculty gain MCH agency practice experience. The MCH Bureau could consider funding sabbaticals for faculty in MCH programs in Schools of Medicine, Public Health, Dentistry, Nursing, Social Work and other MCH-related fields in order that these experts could spend time with one or more states. These sabbatical, possibly ranging from 6 months to more than one year, would allow faculty to provide more intensive continuing education and technical assistance on a set of relevant topics, while at the same time gaining valuable practice-based experience. Finally, interagency personnel actions (IPAs) might also be used to allow faculty to take sabbaticals or work-leave to work with MCHB or its regional offices.

CONTENTS INCLUDED IN THIS PUBLICATION:

Executive Summary
Purpose of Needs Assessment
Methods
Study Limitations
Results
Respondents and Response Rate
Graduate Education Needs and Barriers
Continuing Education Needs
Modalities for Continuing Education
Barriers to and Capacity for Continuing Education
Priorities for Continuing Education
Discussion
Graduate Education Conclusions
Continuing Education Conclusions
Recommendations