The health and well-being of the MCH population in Hawaii require a highly skilled, diverse workforce. This means that ongoing public health training and education are needed to address the increasingly complex and broad scope of health issues for women, infants, children, and their families.

With 265 employees, the Family Health Services Division (FHSD) is the second largest division in the Hawaii State Department of Health (DOH). FHSD staff have varied professional experience and training. Few FHSD program staff have training in public health. The FHSD staff have program management experience or subject matter knowledge in their respective program areas and would benefit from more public health-specific skill building.

Public health and MCH training resources in Hawaii are limited. Hawaii has three relatively small university-level public health programs offering both graduate and undergraduate public health courses at the University of Hawaii (UH) and two private-sector colleges, Chaminade University and Hawaii Pacific University (HPU). UH and HPU offer master’s in public health and have an online MPH option. UH is the only university with a Ph.D. degree program. Chaminade University only offers an undergraduate public/community health program. None of the Hawaii academic institutions offer MCH-specific courses, and none have dedicated MCH faculty. All three programs are located on Oahu. Two FHSD staff are currently enrolled in the new UH online MPH program.

MCH LEND. The UH Medical School administers the MCH Leadership Education in Neurodevelopmental and Related Disabilities (LEND) grant, directed by pediatric faculty at the school. Several FHSD staff are LEND graduates and FHSD continues to encourage existing program staff to enroll in LEND, particularly the Children with Special Health Needs staff. LEND annually shares its curriculum calendar and invites Title V staff to participate in specific trainings to enhance skill building. In FY 2022, Title V also helped fund family incentives for LEND family focus groups conducted as part of the LEND research methods curriculum. Title V and LEND maintain its partnership primarily through a parent leader, Susan Wood, who serves as LEND faculty and FHSD's AMCHP parent representative.

Most workforce development opportunities for Title V staff are funded by federal grants supporting staff participation in national conferences, access to national MCH subject matter experts, current research, technical assistance (TA), and state peer networking. State-funded staff generally has limited access to these invaluable resources.

MCH Academic Pathways: In the past, the MCH Bureau funded a public health leadership MCH certificate program at the University of Hawaii (UHM) public health program that:

• Developed and implemented an academic and skill-building pathway to train MCH workforce/leaders and staff in public and private sector MCH programs, both here in Hawaii and throughout the Pacific and parts of Asia, and
• Created MCH research opportunities to highlight Hawaii’s unique Asian, Native Hawaiian, and Pacific Islander populations to better inform and support public health MCH practice.

Reinitiating this MCH leadership program in Hawaii is critical in light of growing MCH/Title V vacancies, difficulties in recruitment and retention, greater emphasis on workforce diversity, and emerging healthcare challenges. The UH Office of Public Health Studies is potentially interested in re-establishing an MCH program but has been impeded by position vacancies and difficulty recruiting MCH faculty.

Federal Workforce Support. In Spring 2023, FHSD met with the federal MCH Bureau Workforce Development Director, Lauren Ramos, to discuss issues relating to re-establishing an MCH program at UH. Hawaii shared information regarding workforce challenges, including the struggle to fill vacancies (particularly epidemiologists), the difficulty recruiting out-of-state due to high cost of living in Hawaii, and the struggle to find workable university partnerships (including those with UH and MCH Centers of Excellence (COE) in other states). Ms. Ramos suggested Hawaii could apply for a Catalyst Grant, a small grant available to accredited university public health programs to build MCH curriculum/programs. If federal funding is available, a new grant announcement is scheduled for release in Fall 2024. This would provide Hawaii enough time to convene partners to explore a submission.

MCH Academic-Practice Partnerships. In 2021, FHSD participated in a study conducted by the MCH Bureau on MCH academic and practice partnerships. Hawaii shared its experience regarding the value of these partnerships, including the limited availability of MCH resources at local universities. Through this experience, Hawaii learned about the Association of Teachers of MCH (ATMCH) mentoring program to assist university public health programs build an MCH track/curriculum. FHSD was able to connect UH faculty with the Association to establish a possible mentoring partnership.

Public Health Workforce Interests & Needs Survey (PH WINS). PH WINS is designed to help public health agencies understand workforce strengths, gaps, and opportunities to improve skills, training, and employee engagement. The survey is normally conducted every three years, with the last survey conducted in Fall 2021 (after a  COVID delay). The 2021 survey included: new modules on COVID, well-being, and an MCH module sponsored by the MCH Workforce Development Center (WDC). The Association of State and Territorial Health Officials (ASTHO) and the de Beaumont Foundation (dBF) conduct the survey. Working with the dBF PH WINS epidemiologist, FHSD secured specific workforce survey findings for its staff, with comparisons to the DOH and the U.S. national public health workforce. A presentation of results was shared with FHSD program managers. Key findings for FHSD follow.

Compared with the state and national government public health workforce, FHSD staff are:

• Older (58% are 51 years of age or more) and are more racially/ethnically diverse
• Less likely to have formal academic public health education and training (8% of FHSD staff had a degree in public health, compared to 14% nationally)
• Served longer at their current agency (13% served 21 years or more) and are more likely to retire within the next 5 years (65%)
• Much more likely to report a training need in Justice, Equity, Diversity, and Inclusion (44%). Nationally and for DOH, budget and financial management was the number one identified training need.

While most FHSD staff are satisfied with their job and supervisors (81% vs. 79% nationally), their perceptions of their organization are lower than those of the national workforce (51% vs 68% nationally).

This survey confirms that stress (32%) and burnout (32%) are related to intent to leave among the FHSD staff. Generally, 47% of FHSD staff reported their mental health was very good or excellent, with 19% reporting their mental health as poor/fair, roughly equivalent to overall Departmental rates.

The MCH survey module measured leadership development opportunities, organizational supports for leadership development, and readiness to lead. Among FHSD staff, rates were relatively low, ranging from 26% to 40%, pointing to areas of need and opportunity for further staff training.

MCH Workforce Development Center (WDC). In FY 2022, Hawaii was accepted into the  MCH WDC cohort. This was the third cohort Hawaii has joined. This year’s project focused on strengthening the Title V agency’s capability to address health equity by increasing staff knowledge and skills to integrate equity into public health practice. The project focus was informed by PH WINS survey data which confirmed that the primary training need for staff was health equity. Going forward, plans include coordination with the DOH Office of Health Equity for trainings; technical assistance to support staff learning/practice integration; workforce assessment; developing an FHSD land acknowledgment (that honors Hawaii's indigenous population); and development of adoptable health equity practices for individuals and programs.

COVID Impacts on Program Staff: Conditions have normalized considerably in 2022-2023 for program staff. Infection-acquired immunity and vaccinations have minimized the severity of COVID spread, although risk remains potentially high for those providing direct in-person services. Title V programs continued to be flexible, adapting/revising plans and operations in collaboration with community partners to address continuing and emerging economic and healthcare needs for families and youth. Resilience remains a key operating principle for FHSD staff.

While the state budget was significantly bolstered by federal relief funding and the strong rebound of the local visitor industry, state operations continue to be burdened by increasing staff vacancies, requirements for new funding opportunities, challenging personnel/procurement processes, and under-funded core public health infrastructure.

During COVID, FHSD conducted a quick survey of 30 program managers to assess their perceived needs and concerns. Managers reported that the high level of change, uncertainty, and resulting stress for management and staff was a major issue. Personnel (and other state systems) have varying degrees of ability to respond effectively to change. Despite the challenges experienced during the pandemic, nearly half of FHSD program managers reported in 2021 that the changes in service delivery due to COVID conditions helped to focus and strengthen overall program operations and partnerships. The top three program concerns reported in the survey were:

• Strengthening health equity efforts (73.9%)
• Staff capacity to address emerging needs/changes (73.9%)
• Staff morale/well-being (65.2%)

Plans for Employee Survey: FHSD had planned to conduct an employee survey to capture staff demographics and concerns coming out of COVID. The data would be used to assess staffing diversity, inform planning for succession needs, and create workforce training plans. Plans were delayed for the PH WINS survey results. The survey will be included in the Title V 2025 needs assessment scope of work, which will be contracted out to a qualified entity.

Title V Public Health Capacity: FHSD uses Title V as an opportunity to build public health capacity for program staff. From 2018-2020, Hawaii partnered with the University of Hawaii Office of Public Health Studies (OPHS) faculty to develop logic models for each of the Title V priorities, to assess program progress, achievement of short- and long-term outcomes, identification of barriers/challenges, as well as ensure the alignment of strategies with Title V measures.

Since 2021, continued TA for staff has been provided by Nancy Partika, RN, MPH, in conjunction with the Title V coordinator. Ms. Partika served as director and lead faculty for the former MCH Leadership Certificate program at OPHS from 2007-2011. Her TA supports building staff public health knowledge and skills, assists with the review of evidence research, and assistance with reviewing and updating logic models.

One Shared Future: To support the FHSD staff, One Shared Future (OSF) was contracted to conduct resiliency training in Spring 2022 using a strengths-based approach to address workplace stress and help minimize burnout and staff turnover. OSF is a firm started by the former state Department of Human Services (DHS) director that supports public sector professionals in implementing positive organizational and community change. The resiliency series, comprised of seven 90-minute virtual sessions, were conducted in cohorts of 20-25 and held over six weeks to allow optimal group interaction, networking, and sharing. The DOH and Title V directors signed written invitations to staff supporting participation, expressing staff appreciation, and endorsing the importance of self-care. OSF also arranged for appearances by the Governor and DOH Director/Deputy to reinforce the messages of appreciation and self-care. Two cohorts were completed and more may be scheduled in the future.

National Resources: Title V continues to sponsor staff and community partners to attend national conferences or share in national presentations and webinars, including:

• The annual AMCHP conference
• The MCH Workforce Development Center trainings
• The CityMatch/MCH Epidemiology Conference

These TA opportunities help develop staff and community capacity and also provide an opportunity to share Hawaii’s MCH issues with other states and national centers.

Hawaii Public Health Training Hui: Another workforce development effort supported by FSHD is the Hawaii Public Health Training Hui (HPHTH) steering committee. The HPHTH was established to provide statewide leadership and coordination to meet public health training and TA needs. FHSD's Rural Health coordinator serves on the HPHTH steering committee. Training topics are based on surveys disseminated online to public and private health professionals, with guidance from the Western Region Public Health Training Center, which funds the Hui. Training sessions are recorded and posted on the HPHTH website https://www.hiphi.org/phth/.

Health Equity Training: In FY 2022, several trainings on health disparities, structural racism, and systemic inequities were sponsored by FHSD to help integrate an equity focus for MCH programs, including:

• The Early Childhood Comprehensive Systems grant sponsored a training by the Racial Equity Institute (REI), ‘Building a Practical Understanding of Structural Racism.’
• MCH Branch partnered with the Native Hawaiian Health Department, University of Hawaii Medical School, to present ‘Contextualizing Maternal Health in Hawaii,’ addressing the historical, cultural, and social determinants of health, which included findings from original research on implicit racial bias among local perinatal providers toward Native Hawaiians and Pacific Islander patients.

Trainings: FHSD programs also support training for the MCH workforce statewide. Several federal grants include workforce development as a key activity. In 2021, many of these events were switched from in-person to virtual, including:

• Maternal Infant Early Childhood Home Visiting grant supports regular trainings for the Hawaii Home Visiting Network.
• Early Childhood Comprehensive Systems (ECCS) grant supports training for providers on developmental screening tools and protocols, as well as other infant/toddler health and safety conferences.
• Hawaii Medicare Rural Hospital Flexibility Program grant is used to conduct training on healthcare quality improvement for healthcare professionals and operational and financial performance improvement for Critical Access Hospitals.
• The State Office of Rural Health sponsors numerous training projects, including the annual Healthcare Workforce Summit and telehealth training through Project ECHO telehealth learning network.
• The Child Abuse and Neglect (CAN) Prevention program sponsored several virtual trainings with national speakers addressing Adverse Childhood Experiences, Trauma-Informed Care, Toxic Stress, Protective Factors to Prevent CAN, and a miniseries of webinars on Fetal Alcohol Spectrum Disorders (FASD) during FASD Awareness Month.

• Sexual Violence/Domestic Prevention programs sponsor several trainings each year on healthy masculinity and interpersonal violence prevention in conjunction with Na Leo Kane (Hawaiian for the Voices of Males), a DOH-sponsored community collaborative to engage men and boys in violence prevention.
• A consortium of Title V programs supports the Parent Leadership Training Institute.

Conferences: Programs also sponsor annual conferences for providers to receive updates from national and local speakers on research, best practices, and data. Examples include:

• Annual DOH Rape Prevention and Education Sexual Violence Prevention Meeting, part of Sexual Violence Awareness Month
• Annual Safe Sleep Summit
• Hawaii State Rural Health Association Annual Conference
• Early Intervention Stakeholder Conference
• Hawaii Home Visiting providers meetings
• Hawaii Mortality Review Trainings
• WIC Services Branch annual staff meeting

Most meetings have returned to in-person and may offer virtual options for easier access.