Health-Related Services Provided by Public Health Educators Hans H. Johnson, EdD 1 Craig M. Becker, PhD 1 This study identifies the health-related services provided by public health educators. The investigators, with the help of practicing public health educators, created the list of health-related services. Respondents received questionnaires in 2001 and 2007. Thus, this study determined the changes in health-related services provided over a 6-year period. Respondents ranked up to five health-related services by the amount of time spent delivering each health-related service. The list of health-related services presented in a 2001 survey and a 2007 survey were identical. As in 2001, this list in the 2007 survey captured the breadth of health-related services provided, with one exception. In 2007, several participants wrote-in emergency preparedness/bioterrorism. The types of health-related services provided did not change over the 6-year period; however, the ranking of these services did change. Most notably, nutrition education and involvement with physical activity moved up in the ranking in 2007. Keywords: public health educator practice; health educator services Throughout the 20th century, Americans experienced an unprecedented increase in life expectancy (56%) and decline in age-adjusted death rate (74%). The leading causes of death also shifted from infectious diseases to chronic diseases because of effective treatments that allowed people to recover and maintain their quality of life (Becker & Loy, 2004; Guyer, Freedman, Strobino, & Sondik, 2000). Later in the 20th century, the Centers for Disease Control and Prevention (CDC) developed a list of the 10 greatest public health achievements. Included in this list were accomplishments such as safety, control of diseases, safer food and water, recognition of health hazards, and vaccinations (CDC, 1999). Health educators and health education and promotion are vital to the practice of public health. Indeed, 3 of the 10 essential public health services match the health educator responsibilities and competencies (CDC, 2008; National Commission for Health Education Credentialing, Inc. [NCHEC], 2006): inform and educate, evaluate, and research. Several of the remaining seven essential public health services are certainly within the domain of a public health educator s practice: diagnosing and solving community health problems, mobilizing community partnerships, developing policies and plans that support individual and community health efforts, and linking people to health services (NCHEC, 2006). Many people attribute health improvement during the 20th century as a natural consequence of a more affluent or advanced society. These improvements are, however, the consequences of significant contributions by the many hard-working professionals that comprise our public health workforce. Public health professionals recognize and understand the role and contributions of the medical community for treatment and cure of diseases. Integral, however, with these advancements has been the grassroots force that has implemented preventive health services, the health educator (Sheinfeld Gorin & Arnold, 2006). Often the work of health educators is unseen because of its behind-the-scenes nature. For instance, the falling 1 East Carolina University, Greenville, NC, USA Health Promotion Practice September 2011 Vol. 12, No. 5, 723-733 DOI: 10.1177/1524839910362961 2011 Society for Public Health Education Authors Note: Please address correspondence to Hans H. Johnson, EdD, Department of Health Education and Promotion, East Carolina University, Greenville, NC 27858; e-mail: johnsonh@ ecu.edu. 723
incidence of infant mortality, heart disease, and stroke reflect the work of public health educators. Health educators have also contributed greatly in the areas of increased physical activity, safety laws such as smoking bans, seat-belt use, and recommendations on appropriate nutrition (McKenzie, Pinger, & Kotecki, 2007). When responding to the question, What do health educators do? varying processes are typically enumerated such as performing needs assessment and planning and evaluating health education programs (Becker & Loy, 2004; Johnson, Glascoff, Lovelace, Bibeau, & Tyler, 2005; NCHEC, 2006; U.S. Department of Labor, Bureau of Labor Statistics, 2008; Wilson & Dunn, 2005). However, when it comes to health-related services provided by health educators, the professional literature is essentially silent. This situation is also true for many of the textbooks commonly used in university classrooms (Bensley & Brookins-Fisher, 2009; Cottrell, Girvan, & McKenzie, 2009; Greenberg, 2004; Kreuter, Lezin, Kreuter, & Green, 2003; Minelli & Breckon, 2009). This study describes the range of health-related services provided by public health educators in North Carolina Health Departments as well as the change in these services over a 6-year period. METHOD Purpose This study gathered information on the health-related services delivered by public health educators and investigated if these services had changed over a 6-year period. Specifically, this study assessed the practices of public health educators in 2001 and 2007 to determine similarities and differences with regard to the services provided. Procedure Following conversations with the state director of health education, regional health education consultants, and practicing health educators, a draft of the questionnaire was developed. The collaborating partners reviewed the questions for clarity and a revised questionnaire was pilot tested with graduate health education students and four practicing North Carolina public health educators in one local health department. This process provided estimates of time required to complete the questionnaire in addition to a critique of the questionnaire s content and the clarity of questions. The University and Medical Center Institutional Review Board approved the questionnaire and cover letter (study approval number UMCIRB 99-0087). Health educators received identical questionnaires in 2001 and 2007. A list of current public health educators, supplied by the North Carolina Division of Public Health, identified potential respondents. Health educators received the questionnaire via posted mail in 2001. In 2007, health educators received the questionnaire via email. Responses were confidential. An identifying number tracked responses in 2001. Computer software allowed tracking of email in 2007. Follow-up occurred over a 2-month period, re-mailing in 2001 and re-emailing in 2007. Ranking of Services The investigators, with the help and review of practicing public health educators, created the following list of health services: Chronic diseases (heart/lung disease, cancer, stroke, diabetes, hypertension, Breast & Cervical Cancer Program [BCCP], chronic venous hypertension [CVH]), Environmental health, Family planning, Food and drug safety, Medical support services (clinical services, immunizations), HIV/AIDS and other sexually transmitted diseases and infections (STDs/STIs), Infectious diseases other than HIV/AIDS or STDs/ STIs, Injury prevention, Maternal and infant health (unintended pregnancy, prenatal care, parenting, infant death), child health, mental health, Nutrition, Occupational health and safety, Oral health, Physical activity, School health, Substance abuse (alcohol and other drugs), and Tobacco. Respondents ranked up to five services, 1 for the service they spent most time on, 2 the next, and so on. The question contained space for write in, or other responses. Determination of Demographic Variables The investigators selected the following variables as having the greatest potential for affecting the delivery of services by public health educators: 724 HEALTH PROMOTION PRACTICE / September 2011
Gender. The investigators were interested in the types of services delivered by female and male health educators. Age. The investigators were interested in the types of services delivered by younger health educators and older health educators. Race/ethnicity. The investigators were interested in the types of services delivered by Whites and non-whites. Education. Various Reports from the Institute of Medicine (1988, 2002a, 2002b, 2003, and 2004) challenged public health leadership to provide a formally trained and credentialed workforce. The investigators felt it important to document the degree to which individuals with formal health education training as well as certified health educators (CHEs) are delivering specific health education services. Experience. Insight into the types of health services delivered by beginning health educators and those health educators with more experience provides information to those responsible for training health educators, both at universities and continuing on-the-job training. Leadership. The leadership, guidance, and mentoring received by public health educators could be argued as an important contributing factor to the quality and success of health services they provide. The investigators felt it important to document the degree to which specific health services are delivered by individuals supervised by a health educator. This represents an advocacy issue for the hiring and promotion of formally trained health educators. Peer support in the agency. A reality of smaller local health departments is that fewer health educators are on staff, and in some cases, there is only a single health educator. The investigators felt it important to document health services delivered by smaller and larger local health departments with specific emphasis on those delivered by the single or lone health educators. Knowing this information has consequence not only for those responsible for the formal training of health educators but for continued access to consultation and technical assistance. Analysis The demographic variables and services provided used descriptive statistics for analysis. Dichotomous demographic variables used correlations and t-tests for analysis. Categorical variables used chi-square for analysis. RESULTS This study resulted in an overview of the services delivered by public health educators in 2001 and 2007 and changes in the service provided between 2001 and 2007. Results came from a survey of all health educators employed in local health departments in North Carolina in the spring and summer of 2001 and again in 2007. Participants returned questionnaires by mail in 2001 and email in 2007. In 2001, a total of 204 health educators returned questionnaires, for a response rate of 69.0%. In 2007, a total of 208 health educators returned questionnaires, for a response rate of 67%. Services Provided Table 1 presents the 10 highest ranked services (those ranked 1) in 2001 compared to the same services delivered in 2007. Chronic diseases, maternal and infant health, HIV/ AIDS and STDs/STIs, school health, and family planning showed a significantly less amount of time spent in 2007 compared to 2001. Physical activity and nutrition showed a significant increase in time spent in 2007 compared to 2001. Although not significant, tobacco prevention in 2007 compared to 2001 increased. Dependent Variables Tables 2 and 3 present variables related to the delivery of health services by public health educators that had significant differences. There was a significant increase in age in 2007 compared to 2001 and a significant difference in the overall ethnicity of the health educators in 2007 compared to 2001. The gender mix remained consistent over this time. The majority of health educators, in both years, were female. There was no significant difference in the education, experience, and the peer support variables in 2007 compared to 2001. There were significantly fewer public health educators supervised by a health educator in 2007 compared to 2001. Tables 4 and 5 present the significant results for services delivered in 2001. Tables 6 and 7 do the same for services delivered in 2007. The findings presented in Tables 4 through 7 are in response to the following question: What are the PRIMARY health areas on which your work focuses? Please rank up to 5 (in terms of the amount of time you spend on each), with 1 being the activity on which you Johnson, Becker / HEALTH-RELATED SERVICES PROVIDED BY PUBLIC HEALTH EDUCATORS 725
Table 1 Ten Highest Ranked Services (Ranked 1) in 2001 Compared to 2007 2001 (n = 204) 2007 (n = 196) Number Percentage Number Percentage Significance Chronic diseases 50 24.5 39 19.9.022** Maternal and infant health 42 20.6 22 11.2.024* HIV/AIDS and STDs/STIs 19 9.3 17 8.7.069* Tobacco prevention 12 5.9 20 10.2.381 School health 10 4.9 7 3.6.057* Family planning 10 4.9 7 3.6.094* Physical activity 9 4.4 23 11.7.092* Injury prevention 7 3.4 7 3.6.740 Child health 6 2.9 9 4.6.137 Nutrition 4 2.0 24 12.2.000*** NOTE: p values were derived from t test. *p <.1. **p <.05. ***p <.001. Table 2 Demographic Variables of Health Educators in 2001 and 2007 2001 2007 Significance Age Average 35.0 38.9.000*** Range 21-65 21-66 Median 32 37 Mode 28 28 n 201 181 Race/ethnicity 2001 2007 Number Percentage Number Percentage American Indian 6 3 2 1.1 Asian 1 0.5 0 0 Black/African American 38 18.7 53 27.9 Hispanic 1 0.5 3 1.6 Pacific Islander 0 0 0 0 White 155 76.4 123 64.7 Other 2 1.0 9 4.7 Total 203 100 190 100.014** NOTE: p values were derived from chi-square test. *p <.1. **p <.05. ***p <.001. spend the most time. Consequently, lower numbers in Tables 4 through 7 indicate the services health educators spent the most time providing. In 2001, males ranked services related to HIV/AIDS and STDs/STIs and infectious disease significantly higher than females. Females ranked services related to maternal and infant health significantly higher than males. With regard to age, the younger group of health educators ranked services related to family planning higher than did health educators more than 35 years of age. White health educators ranked services related to HIV/AIDS and STDs/STIs and tobacco significantly higher than minority health educators did, and minority health educators ranked services related to infectious 726 HEALTH PROMOTION PRACTICE / September 2011
Table 3 Demographic Variables of Health Educators in 2001 and 2007 2000 2007 Number Percentage Number Percentage Significance Gender Male 23 11.3 16 8.5 Female 180 88.7 173 91.5 Total 203 100.0 189 100.0.344 Education BS degree in health education Yes 115 59.3 97 52.7.119 No 79 40.7 87 47.3 Total 194 100.0 177 100.0 MA degree in health education Yes 61 73.5 53 61.6.069 No 22 26.5 33 38.4 Total 83 100 86 100 Experience Worked <2 years 54 26.7 39 20.7.166 Worked 2 years 148 73.3 149 79.3 Total 202 100 188 100 Worked <4 years 81 40.1 39 40.1.194 Worked 4 years 121 59.9 68 59.9 Total 202 100.0 107 100.0 Leadership: supervised by a health educator Yes 95 47.3 72 37.5.050* No 106 52.7 120 62.5 Total 201 100.0 186 100.0 Peer support in agency Only health educator 28 13.7 22 11.2.131 Two or more health educators 176 86.3 174 88.8 Total 204 100.0 196 100.0 NOTE: p values were derived from t test. *p <.1. **p <.05. ***p <.001. disease and maternal and child health significantly higher than White health educators did. Table 4 presents these findings. In 2001, health educators with formal training in health education ranked services related to medical support and HIV/AIDS and STDs/STIs significantly higher than health educators without formal health education training. Health educators with less experience ranked services related to chronic disease and school health significantly higher than did health educators with more experience, whereas health educators with more experience ranked tobacco, mental health, HIV/AIDS and STDs/STIs, and nutrition significantly higher than did health educators with less experience. Health educators not supervised by a health educator ranked services related to HIV/AIDS and STDs/STIs significantly higher than health educators supervised by a health educator. Health educators supervised by a health educator ranked services related to school health, infectious disease, and injury prevention significantly higher than health educators not supervised by a health educator. Health educators in health departments with more than one health educator ranked services related to injury prevention significantly higher than in health departments with one health educator. Table 5 presents these findings. In 2007, male health educators ranked services related to child health significantly higher than female Johnson, Becker / HEALTH-RELATED SERVICES PROVIDED BY PUBLIC HEALTH EDUCATORS 727
Table 4 Significant Results Among the 10 Highest Ranked Services Delivered in 2001: Age, Gender, and Ethnicity Variables Gender Age Ethnicity Male Female 35 years >35 years White Minority HIV/AIDS and other STDs/STIs n = 9 n = 66 n = 53 n = 22 M 1.9 2.8** 2.9 3.9** SD 1.3 1.3 1.4 1.2 Infectious disease (not HIV) n = 3 n = 6 n = 6 n = 3 M 1.3 3.2* 3.2 1.5* SD 0.6 1.5 1.3 0.6 Maternal and infant health n =6 n = 86 n = 68 n = 24 M 3.0 2.1* 2.3 1.8* SD 1.2 1.2 1.3 1.1 Family planning n = 50 n = 24 M 2.6 3.1* SD 1.2 1.2 Tobacco n = 53 n = 10 M 2.9 3.9** SD 1.4 1.2 NOTE: p values were derived from t test. M (SD) values have response rankings ranging from 1 to 5. *p <.1. **p <.05. ***p <.01. health educators. Female health educators ranked services related to family planning significantly higher than males and those 35 years old or younger focused more on HIV/AIDS and STDs/STIs than those older than 35 years. Those older than 35 years focused more on injury prevention and oral health. The only noted significant difference based on ethnicity was in food and drug safety, in that Whites had a stronger focus than minorities. Table 6 presents these findings. In 2007, there were fewer statistically significant differences. Those that had a health education bachelor s degree put less of a focus on oral and mental health than did those health educators without a bachelor s degree. Differences in experience were noted. Those with more experience put more of a focus into food and drug safety, medical support, and substance abuse than did those with less experience. The only other noted significant difference was that those who did not have a health educator as a supervisor had more of a focus on chronic diseases than did those who had a health educator as a supervisor. Table 7 presents these findings. An Additional Finding The first survey, in 2001, was conducted pre-9/11. On the 2007 survey, emergency preparedness/bioterrorism was a frequent write-in response. This was not the case in 2001. DISCUSSION The results of this study offer insight into the services provided by health educators in the public health practice setting. Participants ranked the services they provide according to the amount of time they spent delivering the service. The surveys used in 2001 and 2007 were identical. If the list of health services did not completely capture the services provided, participants added to the list. In both 2001 and 728 HEALTH PROMOTION PRACTICE / September 2011
Table 5 Significant Results Among the 10 Highest Ranked Services Delivered in 2001: Training, Experience, Leadership, Peer Support Variables Training Leadership Peer support Degree in Not health Experience Health Not health Only health education educator educator health >1 health education degree 2 years >2 years as supervisor supervisor educator educator Medical support Has BS None n = 7 n = 4 M 2.7 5.5** SD 1.7 1.1 Tobacco n = 25 n = 37 M 3.3 2.6*** SD 1.4 1.4 Chronic diseases n = 63 n = 40 M 1.8 2.6** SD 1.1 1.5 Mental health n = 5 n = 1 M 3.8 2.0** SD 0.4 0.0 HIV/STI n = 18 n = 6 n = 17 n = 58 n = 37 n = 38 M 2.4 3.5* 3.2 2.6* 3.9 2.4* SD 1.3 1.5 1.4 1.3 2.2 1.3 Nutrition n = 25 n = 50 M 3.5 3.1* SD 1.1 1.1 School health n = 18 n = 34 n = 25 n = 25 M 2.5 3.3* 2.6 3.4** SD 1.6 1.4 1.4 1.4 Infectious diseases n = 5 n = 4 M 1.8 3.5* SD 0.8 1.7 Injury prevention n = 20 n = 26 n = 10 n = 36 M 2.7 3.5* 4.0 2.9** SD 1.4 1.3 1.1 1.4 NOTE: p values were derived from t test. M (SD) values have response rankings ranging from 1 to 5. *p <.1. **p <.05. ***p <.01. 2007, almost 70% of the public health educators responded to the questionnaire. Thus, the researchers were able to pinpoint, over a 6-year period, changes in the delivery of services. The list of health educator services presented in the 2001 and 2007 surveys were identical. As in 2001, this list in the 2007 survey captured the breath of services provided, with one exception. In 2007, several participants Johnson, Becker / HEALTH-RELATED SERVICES PROVIDED BY PUBLIC HEALTH EDUCATORS 729
Table 6 Significant Results Among the 10 Highest Ranked Services Delivered in 2007: Age, Gender, and Ethnicity Variables Gender Age Race/ethnicity Male Female 35 Years >35 Years White Minority HIV/AIDS and other STDs/STIs n = 32 n = 29 M 2.5 3.2** SD 1.5 1.4 Injury prevention n = 18 n = 14 M 3.8 2.7* SD 1.4 1.5 Child health n = 5 n = 36 M 1.4 3.1*** SD 0.5 1.3 Family planning n = 5 n = 56 M 4.2 3.0* SD 0.8 1.3 Oral health n = 11 n = 4 M 3.6 2.0* SD 1.5 0.8 Food and drug safety n = 2 n = 1 M 2.8 4.1* SD 1.6 1.1 NOTE: p values were derived from t test. M (SD) values have response rankings ranging from 1 to 5. STDs/STIs = sexually transmitted diseases and infections. *p <.1. **p <.05. ***p <.01. wrote-in emergency preparedness/bioterrorism. This represents an evolving activity for public health educators. Health education preparatory and continuing education programs need to respond to this changing activity in the public health practice setting. The specific health-related services provided by public health educators is absent in the literature; thus this list becomes an important addition to describing the contributions of health educators. The types of demographic information collected in 2001 and 2007 were identical. The average age of health educators was up significantly in 2007. This is an interesting trend and deserving of further research. For example, are health educators staying in their positions longer or are there more advancement opportunities. A possible reason for the increase in age would be that more health educators are entering the profession with advanced degrees. In this study, however, the number of health educators with master s degrees dropped, though not significantly, from 2001 to 2007. This same trend was true for health educators with bachelor s degrees in health education. The percentage of health educators supervised by a health educator dropped significantly in 2007. This represents a worrisome trend and is deserving of further study. Health educators have advocated for the advancement of health education as a profession over the past few decades. Indeed this came to be with the inclusion of health education in the Bureau of Labor Statistic s Occupational Outlook Handbook (2008). Seemingly, in the public health setting, health education leaders now must advocate for the supervision of health educators by trained health educators. 730 HEALTH PROMOTION PRACTICE / September 2011
Table 7 Significant Results Among the 10 Highest Ranked Services Delivered in 2007: Training, Experience, Leadership, Peer Support Variables Training Leadership Oral health n = 9 n = 6 M 3.8 2.3* SD 1.3 1.5 Food and drug safety Degree Degree in not Experience Health Not health in health in health educator as educator education education 2 years >2 years supervisor supervisor n = 6 n = 2 M 2.5 5.0* SD 1.5 0.0 Chronic diseases n = 19 n = 37 M 3.4 2.4** SD 1.7 1.4 Mental health n = 11 n = 6 M 4.1 1.8*** SD 1.3 1.2 Medical support n = 6 n = 3 M 2.5 4.7** SD 1.0 0.6 Substance abuse n = 8 n = 4 M 2.5 4.5** SD 1.7 0.6 NOTE: p values were derived from t test. M (SD) values have response rankings ranging from 1 to 5. *p.1. **p.05. ***p.01. ****p.001. The racial and ethnic mix of public health educators between 2001 and 2007 changed. A greater number of minorities are becoming public health educators. This is a positive trend. It better ensures the delivery of services to a diverse population. The investigators selected seven demographic variables as having the greatest potential for affecting the delivery of health services by public health educators: gender, age, race and ethnicity, education, experience, leadership, and peer support in the agency. Table 8 summarizes findings as they relate to these variables. Going down through this list, one notes that the rankings in 2007 are completely different from the rankings in 2001. These shifting trends suggest that more information is needed to determine practice changes for health educators in the public health setting, but they should remind individuals providing health education preparatory and continuing education programs of the importance of keeping in touch with and understanding the public health education practice environment. Table 9 presents a review of the top-ranked health services in terms of the total time spent. Going down through the table one can see that the top 10 ranked Johnson, Becker / HEALTH-RELATED SERVICES PROVIDED BY PUBLIC HEALTH EDUCATORS 731
Table 8 Comparison of Health Educators Rankings: 2001 to 2007 in Terms of the Amount of Time Spent Delivering a Service 2001 2007 Gender HIV/AIDS and STDs/STIs More males Child Health more males Infectious diseases More males Family Planning more females Maternal and infant health More females Age ( 35 years and >35 years) Family planning More 35 years HIV/AIDS and STDs/STIs More 35 years Injury prevention More >35 years Oral health More >35 years Race and ethnicity (minority and White) HIV/AIDS and STDs/STIs More White Food and drug safety More White Infectious diseases More minority Maternal and infant health More minority Tobacco prevention More White Education (no health education degree and have health education degree) Medical support HIV/AIDS and STDs/STIs More with health education degree More with health education degree Oral health Mental health More no health education degree More no health education degree Experience ( 2 years and >2 years) HIV/AIDS and STDs/STIs More >2 years Food and drug safety More >2 years Nutrition More >2 years Medical support More >2 years School health More 2 years Substance abuse More >2 years Leadership (health education supervisor and no health education supervisor) HIV/AIDS and STDs/STIs School health Infectious diseases Injury prevention Peer support (peer support and no peer support) Injury prevention NOTE: *p.1 or greater. More no health education supervisor More with health education supervisor More with health education supervisor More with health education supervisor More peer support Chronic disease More no health education supervisor health services in 2001 and 2007 remained intact, with a shifting of services slightly up or down. For example, the total amount of time spent on tobacco prevention education from 2001 to 2007 remained constant and the total amount of time spent on HIV/AIDS and STDs/STIs education declined somewhat. Notably, the change in nutrition education and attention to physical activity were both significant, 732 HEALTH PROMOTION PRACTICE / September 2011
Table 9 Overview of the 10 Top-Ranked Health Services Ranked High to Low: 2001 to 2007 2001 2007 Chronic diseases Maternal and infant health HIV/AIDS and STDs/STIs Tobacco prevention School health and family planning Physical activity Injury prevention Child health Nutrition Infectious diseases Chronic diseases Nutrition Physical activity Maternal and infant health Tobacco prevention HIV/AIDS and STDs/STIs Child health School health, family planning, and injury prevention Infectious diseases with nutrition education representing the biggest change. The findings of this study are important to individuals providing preparatory and containing education programs. While preparing for this study, it was interesting to learn that although the processes of health education are well described and published, the services provided by health educators are not. Preparatory and continuing health education programs importantly stress these processes, such as gathering data, planning, and evaluation. Indeed, these processes are the foundation of the responsibilities and competencies of health educators and the certifying examination for health educators. However, in practice, health educators typically apply these processes to specific health content. The list of health educator services developed for this study, in both surveys, captured the range of service provided by public health educators. REFERENCES Becker, C., & Loy, M. (2004). Important competencies for future health and wellness professionals: An investigation of employer desired skills. American Journal of Health Education, 35, 228-233. Bensley, R., & Brookins-Fisher, J. (2009). Community health education methods: A practical guide (3rd ed.). Sudbury, MA: Jones and Bartlett. Centers for Disease Control and Prevention. (1999). Ten great public health achievements United States, 1900-1999. Morbidity and Mortality Weekly Report, 48(12), 241. Centers for Disease Control and Prevention. (2008). 10 essential public health services. Retrieved from http://www.cdc.gov/od/ ocphp/nphpsp/essentialphservices.htm Cottrell, R., Girvan, J., & McKenzie, J. (2009). Principles and foundations of health promotion and education (4th ed.). San Francisco, CA: Pearson Benjamin Cummings. Greenberg, J. S. (2004). Health education and health promotion: Learner-centered instructional strategies (5th ed.). New York, NY: McGraw-Hill. Guyer, B., Freedman, M. A., Strobino, D. M., & Sondik, E. J. (2000). Annual summary of vital statistics: Trends in the health of Americans during the 20th century. Pediatrics, 106, 1307-1317. Institute of Medicine. (1988). The future of public health. Committee for the Study of the Future of Public Health, Division of Health Care Services. Washington, DC: National Academies Press. Institute of Medicine. (2002a). The future of the public s health in the 21st century. Committee on Assuring the Health of the Public in the 21st Century. Washington, DC: National Academies Press. Institute of Medicine. (2002b). Who will keep the public healthy: Educating public health professional for the 21st century. Committee on Educating Public Health Professionals for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2003). Who will keep the public healthy: Workshop summary. Committee on Educating Public Health Professionals for the 21st Century. Washington, DC: National Academies Press. Institute of Medicine. (2004). In the nation s compelling interest: Ensuring diversity in the health- care workforce. Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce. Washington, DC: National Academies Press. Johnson, H., Glascoff, M., Lovelace, K., Bibeau, D., & Tyler, E. (2005). Assessment of public health educator practice: Health educator responsibilities. Health Promotion Practice, 6, 89-96. Kreuter, M., Lezin, N., Kreuter, M., & Green, L. (2003). Community health promotion ideas that work (2nd ed.). Sudbury, MA: Jones and Bartlett. McKenzie, J., Pinger, R., & Kotecki, J. (2007). An introduction to community health (6th ed.). Sudbury, MA: Jones and Bartlett. Minelli, M., & Breckon, D. (2009). Community health education: Settings, roles, and skills (5th ed.). Sudbury, MA: Jones and Bartlett. National Commission for Health Education Credentialing, Inc. (2006). A competency-based framework for health educators. Retrieved from http://www.nchec.org/aboutnchec/rc.htm#1 Sheinfeld Gorin, S., & Arnold, J. (2006). Health promotion in practice. San Francisco, CA: Jossey-Bass. U.S. Department of Labor, Bureau of Labor Statistics. (2008). Occupational outlook handbook, health educators on the Internet. Retrieved from http://www.bls.gov/oco/ocos063.htm Wilson, R., & Dunn, J. (2005). Assessment of the training needs of Kentucky public health educators. Health Promotion Practice, 6, 97-104. Johnson, Becker / HEALTH-RELATED SERVICES PROVIDED BY PUBLIC HEALTH EDUCATORS 733