Abstract
Both the clinical and public health workforces are vital to achieving the goals of the Patient Protection and Affordable Care Act (ACA), which aims to improve access to and quality of health care and to reduce costs. Achieving these goals presents significant challenges owing to the overall burden of chronic disease, social determinants of health, an aging population, a lack of population health literacy and numeracy, and other factors. Health education specialists (HESs) are well positioned to assist in the transition to a health care system that rewards health outcomes over services rendered and emphasizes disease prevention and health promotion. Because of new service models resulting from the ACA, HESs have increased opportunities to apply their competencies at the patient and population levels in health care settings, at worksites, and in health departments, communities, and schools. The national health education certification system organized in 1988 provides a strong evidence-based foundation for quality assurance in the field, with HES competencies being updated every five years. Public and private stakeholders must support initiatives to expand awareness about the role of health education specialists in the post–health reform era.
Relationship to Existing APHA Policy Statements
APHA has long recognized the role of health education professionals in improving health through education and advocacy, including their role in promoting healthy lifestyles and effectively navigating the health care system. Specifically, APHA Policy Statement 200911, Public Health’s Critical Role in Health Reform in the United States, declared that effective public health activities are essential to the health and well-being of individuals and communities to increase access to health services and avoid rising health care costs. Policy Statement 20109 identified the importance of health education, healthy behaviors, and health system operations as a strategy to confront health literacy issues. Policy Statement 201313 discussed the need for more comprehensive efforts to enumerate the public health workforce, and Policy Statement 20088 addressed the need for interprofessional education of health care and public health professionals to improve patient-centered health outcomes. Although Policy Statements 20088, 20109, and 201313 do not specifically address health education professionals, they emphasize need for further attention to health workforce development and training and guidelines to be considered in the health education professional framework. Policy Statement 7708, The Role of Health Professionals in Promoting Active Measures of Prevention, acknowledged that “a variety of health care professionals are qualified to deliver specific preventive services, particularly those services which result in a change of life-styles to promote health and well-being and prevent disease and injury.”
Problem Statement
The majority of health care spending and deaths in the United States are related to expensive, debilitating chronic diseases such as obesity, diabetes, high blood pressure, heart disease, and cancer, which can be reduced or modified through behavioral interventions.[1] The 2013 National Health Expenditure Accounts report by the Centers for Medicare & Medicaid Services (CMS) showed a 3.6% increase in health care spending in the United States, which stood at $2.9 trillion, or $9,255 per person per year.[2] By 2023, health expenditures financed by the federal, state, and local governments are projected to account for 48% of national health spending.[2] Racial, ethnic, and sexual minority populations are disproportionately affected by certain chronic conditions owing to health barriers caused by lack of education and socioeconomic, geographic, or other sociocultural factors.[3,4] In 2005, 113 million people were living with at least one chronic disease, a number that is projected to grow to 157 million by 2020, affecting especially those below the federal poverty line.[5] Given the aging population and associated disease-specific risk factors and social determinants, health care spending is expected to rise from $1.3 trillion in 2003 to $4.7 trillion in 2023.[6]
The Trust for America’s Health estimates that spending as little as $10 per person on proven preventive interventions to address chronic diseases could save more than $16 billion in five years.[7] For a variety of reasons, the public health and health care workforce is not adequately prepared to realize the vision of the Patient Protection and Affordable Care Act (ACA) of providing comprehensive team-based preventive services. First, by 2020, chronic and acute conditions will challenge health care and public health systems because more than 20% of the population will be 65 years or older, with those over 85 years representing the fastest-growing age group; these shifting patterns will require changes in health care delivery.[8–11]
Second, the public health workforce is aging.[12] The average public health worker is 47 years old, which is seven years older than the average age of the rest of the US workforce, and retirement rates are expected to soar in the coming years.[12] The ACA authorizes the creation of a commission (the National Health Care Workforce Commission) to develop a national strategy to address this issue, but Congress has not allocated funding for this group.[13]
Third, nearly 9 of 10 adults are incapable of accessing routine health information owing to limited health literacy and numeracy skills, which are essential for individuals in selecting health plans, choosing prevention or treatment options, and understanding and following medical directives.[14–18] Some 28.8% of adults are below a basic level of numeracy, 33.4% are at a basic level, 29.3% are at an intermediate level, and only 8.6% are at a proficient level.[15]
Fourth, the United States faces a shortage of family practice physicians, especially in certain geographic areas or among those who receive Medicaid. The American Academy of Family Physicians projects the need for an additional 4,475 new family practice residency training positions by the year 2025, and the Association of American Medical Colleges projects the need for an increase of 5,000 physicians annually as a result of the additional patients now insured through the ACA.[19,20] Even among those physicians currently available, large disparities exist as to geographic distribution and willingness to accept Medicaid as a payment form. The National Center for Health Statistics reported in 2011 that only two of three primary care physicians were willing to accept Medicaid.[21]
In addition, nurses (and individuals involved in the large number of competencies under that professional umbrella) are increasingly being used for their clinical skills. In 2012, the Health Resources and Services Administration (HRSA) reported that, with respect to care of young and elderly patients, nurse practitioners and physician assistants accounted for 18% of primary care clinicians who received bonus payments from Medicare, or 7.5% of the overall bonus payments issued under the CMS value-based payment system created as part of the ACA. In fact, 32% of Medicare beneficiaries that year received at least one service from a nurse performing clinical duties.[22] Although the shortage of US nurses has long been recognized, a 2014 HRSA study concluded that, nationally, the increase in the supply of registered nurses and licensed practical nurses between 2012 and 2025 is projected to outpace demand.[22] However, the report acknowledged that projected changes in the supply of and demand for nurses vary substantially by state and that supply and demand will continue to be affected by factors such as changes in health care reimbursement and service delivery models. Furthermore, it based its projection on a forecasting model requiring an assumption of supply and demand equilibrium in 2012.[23]
Thus, the opportunities and challenges presented by the ACA to focus on upstream prevention and management of chronic conditions demand a new framework for interprofessional health teams, one organized in a fashion that alleviates the patient load stress of the clinical staff and moves to more holistic team approach. A multidisciplinary team including clinical staff, health education specialists (HESs), and others such as community health workers (CHWs) can improve clinical outcomes, enhance patient satisfaction, and lower costs.[4,24] HESs have successfully addressed the unique needs of underserved populations by focusing on both proximal and distal stressors and enhancing protective factors.[25–27] The examples below illustrate these roles.
HESs already play a critical role in reducing health care costs and improving health outcomes in a wide variety of settings, including P–12 schools, universities, clinics, hospitals, worksites, military venues, health departments, and voluntary organizations. The Bureau of Labor Statistics reports that HESs work for government/public health agencies (23%), hospitals (21%), ambulatory health care services (17%), and other organizations (22%).[16] The US Department of Labor recognizes the HES field as a standard occupational classification (SOC 21-1091.00) and notes that health education specialists promote, maintain, and improve health by “provid[ing] and manag[ing] health education programs that help individuals, families, and their communities maximize and maintain healthy lifestyles. [They also collect] and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments. [They] may serve as [a] resource to assist individuals, other health professionals, or the community, and may administer fiscal resources for health education programs.”[28]
Specifically excluded from the SOC HES definition are the responsibilities of CHWs,[29] who are defined as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. The CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”[13]
Health education specialists and CHWs are important team members working in tandem with the clinical workforce and the community. HESs frequently have master’s or higher-level degrees that include a background in behavioral theory, education, public health, epidemiology, community organization, management, policy, and advocacy. As such, they are well suited to apply their knowledge and skills to work one to one with individuals or interact with groups in the classroom, community, worksite, or health care setting. Some roles include coordinating and integrating care, conducting community needs assessments, building bridges between patients and health/medical care organizations, identifying plans to reduce structural barriers to care, designing culturally competent and patient-centered programs to improve health outcomes,[30] and planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments.[16] APHA resolutions address health educators’ roles in promoting healthy lifestyles through patient education, health literacy, risk communication, school health, worksite health promotion, community-based participatory research, professional education and training, and collaborations with other members of the public health workforce.[13] The Department of Labor predicts that there will be a 19% increase in the demand for health educators from 2012 to 2022 as a result of increased attention to health-related issues.[16]
With its roots at the turn of the 19th century, health education is a mature profession with a discrete body of knowledge, defined multidisciplinary competencies, a certification system for individual workforce members, and a code of ethics.[17] Certified health education specialists (CHESs) and master certified health education specialists (MCHESs) are health education professionals who have met established health education competency standards set by the National Commission for Health Education Credentialing, as demonstrated by successful completion of the CHES or MCHES examination.[18]
The minimum criteria established for eligibility for the CHES examination are a bachelor’s, master’s, or doctoral degree and either an official transcript showing a major in health education (or any of its variants, such as community health education) or an official transcript that reflects at least 27 quarter hours of coursework with a grade of C or above and specific preparation addressing HES responsibilities and competencies.[31] Eligibility for the MCHES examination requires at least five years as a CHES; a master’s degree (or above) in health education, public health education, school health education, community health education, or a related field; or a master’s degree with 37 quarter hours of coursework addressing HES responsibilities and five years of documented experience working as an HES.[32] Continuing education credits are required for both the CHES and MCHES certifications.[33] The 2015 Health Education Specialist Job Analysis, which included seven areas of responsibility and 263 subcompetencies, provides a sound basis for CHESs, MCHESs, and other health education specialists to improve health outcomes.[18]
Whether an HES chooses to become certified or not, the awarding of a degree in health education is, in itself, a certification that the person has completed a rigorous, multidisciplinary curriculum accepted by the health education field. The Council on Education for Public Health certifies schools of public health and graduate programs in public health through extensive reviews of an institution’s curriculum, performance, and educational policies.[34] Similarly, most universities that offer programs geared toward health education specialists aiming for a career in school health (P–12) are certified through the Council for Accreditation of Educator Preparation.[35] Recognizing the voluntary certification process and the curriculum accreditation processes for health education specialists, the HES workforce is uniform in its preparation and ability to use evidence-based best practices for health interventions.
Evidence-Based Strategies to Address the Problem
In the post–health reform era, HESs are being called on to apply their expertise and their voices regarding evidence-based practice, particularly as the social determinants of health are increasingly being recognized at the federal, state, and local levels.[30,36–38] Historically, HESs have been employed in health care settings; however, with the advent of patient-centered medical homes and accountable care organizations, they have expanded opportunities to promote health and coordinate care.[30] Health educators are strengthening physician-directed teams by applying theories and models of behavior change (e.g., goal setting, action planning, tailored communication, motivational interviewing, coaching), strengthening quality care coordination between health care enterprises and community resources, and addressing population management and quality improvement.[38–41]
Chambliss et al. found that HESs who performed Medicare annual wellness visits and physician co-visits were cost effective under their practice’s fee-for-service payment system, improving documentation and patient care.[39] Clinical providers were better able to address issues related to third-party reimbursements, while HESs applied their nonclinical skills to individual and population health improvement.
In 2012, the American Diabetes Association revised its National Standards for Diabetes Self-Management Education and Support to include health educators as part of the official instructional team.[42] The National Board of Certified Diabetes Education Specialists allows MCHESs to sit for its certified diabetes education specialist examination, while the National Asthma Certification Board permits CHESs to sit for its asthma certification examination.[43,44]
Significant research has documented the success of chronic disease self-management programs in the areas of arthritis, diabetes, and heart disease, diseases likely to rise with an aging population. These diseases can cause pain, functional and social impairments, and loss of wages.[45,46] Well before health reform, there was great interest in such self-management programs, including significant efforts by the Centers for Disease Control and Prevention. Health behavior theories and constructs (e.g., improving self-efficacy) and social learning theory were used in creating these programs,[45–47] whose design and implementation underscore the specialized training of health education specialists. One national study of the Chronic Disease Self-Management Program showed significant improvements in health outcomes (e.g., fewer hospitalizations and emergency room visits), causing a ripple effect of cost savings and thus contributing to the goals of the ACA. In one review and synthesis of research examining self-efficacy-enhancing interventions for reducing chronic disability, all of the studies included supported the use of health education specialists to improve health outcomes.[47]
In 2011 and 2012, a study conducted by East Stroudsburg University showed how diabetes programs using HESs have a positive return on investment (ROI) and a positive impact on public health. In Philadelphia County, for example, an average cumulative savings of $43 million was achieved (relative to nonparticipating counties). In Lehigh Valley, patients enrolled in a diabetes education intervention had an ROI ranging from 478% to 764% for each dollar spent depending on their income level (based on recouping lost days at work).[48]
The Agency for Healthcare Research and Quality’s Asthma Return on Investment Calculator estimates that investment in asthma education will result in savings from decreased use of health care services and reduced absenteeism,[49] generating (1) an ROI of $9.84 per dollar invested for programs that cost $85 per participant (low-cost programs) or (2) an ROI of $1.52 per dollar invested in more comprehensive programs (e.g., repeat visits, provision of supplies/materials) with a higher cost of $1,559 per participant.
In another example, the Asthma Network of Western Michigan (ANWM) program includes 12 months of asthma case management by an educator to allow for adequate follow-up, reinforcement of asthma education, and the effects of seasonal changes. One ANWM case management study showed an average hospital charge reduction of $1,625 per participant. Total hospital charges decreased by $55,265 from the year before the study. Highly significant reductions also were observed in number of emergency department visits, number of hospitalizations, and length of time spent in the hospital. Finally, there was an overall decrease in facility charges.[49]
The Prevention Institute reported that, after clinical personnel at the St. John’s Well Child and Family Center in Los Angeles noticed patients with conditions ranging from cockroaches in their ears to chronic lead poisoning, HESs developed surveys about housing conditions that were made a part of all visits and standard collection of medical information. When it was clear that substandard housing was affecting the health of this large population, HESs organized coalitions with tenant rights organizations, the local housing authority, the district attorney, a human rights organization, and the public health department to address relevant social determinants, a process that led to improved housing and improved health outcomes.[50]
In summary, the ACA has expanded opportunities for health education professionals to develop outreach programs and literacy materials that help people enroll for and maintain health insurance coverage and fully utilize ACA benefits.[51] Health educators’ skills are being applied to identify underserved and underinsured populations; develop culturally and linguistically appropriate programs to help consumers understand and evaluate their coverage options; assist in the survey design, analysis, and quality improvement needed for retention of populations in health insurance programs; and train health providers in cultural competency.[51] In addition to insurance enrollment, health education professionals in elementary and secondary education are helping improve basic health literacy skills among both students and parents.[52,53] In the higher education sector, community colleges are exploring two-year degree programs in patient navigation with many foundational courses in health education.[54]
With respect to the ACA and worksite health promotion, the Department of Health and Human Services (DHHS) issued new rules in 2014 for employee wellness programs, rewarding employers and workers for meeting health goals.[55] While large employers have recognized the value of worksite wellness in terms of reduced sick time, decreased emergency room visits, and other cost savings, the new rule encourages participation by smaller employers. HESs are assuming expanded roles in educating employers about evidence-based programs for individuals as well as those at the population level that can ultimately influence insurance premiums.[56]
Another prominent role that health education professionals have assumed in connection with the ACA relates to the Prevention and Public Health Fund, which has provided grants at the state and local levels for policy, system, and environmental changes to reduce chronic disease risk (e.g., tobacco, physical activity, healthy eating). At the community level, health educators are developing new materials and strategies that are culturally/linguistically appropriate; designing surveys and collecting data; leading coalitions, managing health-related discussions, and building partnerships for community engagement; and leveraging their advocacy skills for policy and system changes that help make “the healthy choice the easy choice.”[57–60] The synergism of multiple evidence-based health education and health promotion approaches may result in a broader public health impact than a single intervention, particularly with regard to addressing the social and economic determinants of health.[61,62]
Opposing Arguments/Evidence
While there is promise and progress related to the role of health education professionals and their contributions to achieving the ACA’s goals, there is limited opposing evidence to suggest that the role of practicing HESs is controversial. In a commentary published some 15 years ago, Veach and Cissell argued that many health education specialists are not adequately prepared with the skills to provide health education.[63] However, as the health education profession has continued to refine and update its competencies and to integrate them into professional preparation and continuing education, this argument has diminished.[64,65]
Another opposing argument may be linked to a lack of awareness by employers and enumeration of the distinct occupation of health educators among individuals and communities.[66] The term “health educator” has been applied broadly to anyone providing health information, including nurses, social workers, and public relations/information specialists. Moreover, HESs, distinct from others who conduct health education in the context of broad responsibilities, are often not tracked in employment surveys designed to help assess the availability and pipeline of the health care workforce. APHA Policy Statement 201313 (Advancing Efforts to Enumerate and Characterize the Nation’s Public Health Workforce) recognizes that there is a lack of knowledge about the public health profession, as well as noting the lack of “a common language to describe its work [or] delineation of requirements that strengthen its capacity to do that work.”[13] Recent studies by the Association of State and Territorial Health Officials and the National Association of County and City Health Officials included limited estimates of the numbers of federal, private, and voluntary health educators.[67,68] According to APHA policy, “increased understanding about which types of workers can best address particular community population health needs might lead to deploying community health workers rather than certified health educators as the most appropriate resource. Conversely, use of CHES[s] in particular population-based health programs may fit the demand for service more appropriately in other situations.”[13]
Health education also has been cited as being at the top of a hierarchical pyramid according to which it is the least effective intervention in influencing the health of a population, whereas policy/system change, at the base of the pyramid, can yield the most impact on population health.[61] This model fails to recognize the role of health education at each level of the pyramid and the interdependence of blended hierarchies of feasible and politically viable strategies.[62] For example, community-based public health education and health communications are required to educate decision makers and the electorate in creating political support for passing, funding, and enforcing policies and structural changes in tobacco control and other areas. Indeed, eminent epidemiologist Geoffrey Rose aptly noted that “[p]olitical decisions are…complex and mostly hidden from public scrutiny.... Anything which stimulates more public information and debate about health issues is good, not just because it may lead to healthier choices by individuals but also because it earns a higher place on the political agenda. In the long run, this is probably the most important achievement of health education.”[69]
Action Steps
The proposed action steps outlined below are feasible to undertake and are culturally responsive to all groups, including underrepresented and underserved populations. Specifically, APHA:
- Urges Congress to authorize funding for the National Health Care Workforce Commission to provide a national strategy health care providers can use in achieving the goals of the ACA.
- Urges DHHS and its agencies (including the National Institutes of Health, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration) and private groups (including the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the Robert Wood Johnson Foundation, and the de Beaumont Foundation) to include health education specialist as a distinct occupation in workforce data collection and surveys related to health issues.
- Urges DHHS and its agencies to provide funding for quantitative and qualitative research on the role of health education specialists in improving individual, community, and population-based health literacy and health numeracy; reducing health disparities; improving access to and use of health services; improving patient engagement in health care decision-making; and efficiently assisting primary care clinical providers.
- Urges DHHS and its agencies to expand the use of health education specialists in its approaches to health promotion and prevention. Such expanded recognition should include mention of health education specialists alongside other public health workers in requests for proposals and associated guidance documents.
- Urges the Institute of Medicine to convene a roundtable that addresses the role of health education specialists in improving the nation’s health literacy and numeracy via recommendations for future research, professional preparation/curricula, workforce development, and practice.
- Calls for professional preparation schools and programs for health care providers, public health personnel, and allied health workers to strengthen their curriculum with information on the role of health education specialists as part of the health workforce in the post–health reform environment.
- Encourages health education professionals and local, state, and federal agencies to collaborate in expanding the public health taxonomy, consistent with the Department of Labor’s standard occupational classification.
References
1. Centers for Disease Control and Prevention. Chronic disease overview. Available at: http://www.cdc.gov/chronicdisease/overview/. Accessed January 25, 2016.
2. Centers for Medicare and Medicaid Services. National health expenditure data, 2014. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Accessed January 25, 2016.
3. Centers for Disease Control and Prevention. Health disparities and inequalities report—United States. Available at: http://www.cdc.gov/mmwr/pdf/other/su6203.pdf. Accessed January 25, 2016.
4. Fredriksen-Goldsen KI, Kim H-J, Barkan SE, Muraco A, Hoy-Ellis CP. Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. Am J Public Health. 2013;103:1802–1809.
5. Bodenheimer T, Chan E, Bennett H. Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job? Health Aff (Millwood). 2009;29:64–74.
6. DeVol R, Bedroussian A, Charuworn A, et al. An Unhealthy America: The Economic Burden of Chronic Disease. Santa Monica, CA: Milken Institute; 2007.
7. Trust for America’s Health. Prevention for a healthier America: investments in disease prevention. Available at: http://www.healthyamericans.org/reports/prevention08/. Accessed January 25, 2016.
8. National Institute on Aging. Global health and aging. Available at: http://www.nia.nih.gov/sites/default/files/global_health_and_aging.pdf. Accessed January 25, 2016.
9. Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Press; 2008.
10. Frank JC, Altpeter M, Damron-Rodriguez J, et al. Preparing the workforce for healthy aging programs: the Skills for Healthy Aging Resources and Programs (SHARP) model. Health Educ Behav. 2014;41(suppl 1):19S–26S.
11. White S, Bennett I, Cordell T, Baxter SL. Health literacy of America’s adults: results from the 2003 National Assessment of Adult Literacy. Available at: https://nces.ed.gov/pubs2006/2006483.pdf. Accessed January 25, 2016.
12. Northwest Public Health. Public health’s aging workforce, aging leaders. Available at: http://www.northwestpublichealth.org/web-specials/aging-leaders. Accessed January 25, 2016.
13. American Public Health Association. Policy statement database. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database. Accessed January 25, 2016.
14. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.
15. Health Literacy and Numeracy: Workshop Summary. Washington, DC: National Academies Press; 2014.
16. US Department of Labor, Bureau of Health Statistics. Occupational employment and wages, 2014: health educators. Available at: http://www.bls.gov/oes/current/oes211091.htm. Accessed January 25, 2016.
17. Livingood WC, Auld EM. Lessons learned from health education certification. J Public Health Manage Pract. 2001;7:38–45.
18. National Commission for Health Education Credentialing. Health credentialing FAQs. Available at: http://www.nchec.org/credentialing/healthedfaqs/. Accessed January 25, 2016.
19. American Academy of Family Physicians. Family physician shortage could end with targeted policies that value primary care. Available at: http://www.aafp.org/media-center/releases-statements/all/2014/familiy-physician-shortage-end-value-primary-care.html. Accessed January 25, 2016.
20. Kaiser Health News. Are there enough doctors for the newly insured? Available at: http://khn.org/news/doctor-shortage-primary-care-specialist/. Accessed January 25, 2016.
21. Hing E, Decker S, Jamoom E. Acceptance of new patients with public and private insurance by office-based physicians: United States, 2013. Available at: http://www.cdc.gov/nchs/data/databriefs/db195.pdf. Accessed January 25, 2016.
22. Pauly M, Naylor M, Weiner J. Primary care shortages: it’s more than just a head count. Available at: http://www.inqri.org/sites/default/files/INQRI%20Brief%20FINAL1.pdf. Accessed January 25, 2016.
23. Health Resources and Services Administration. The future of the nursing workforce: national and state level projections, 2012–2025. Available at: http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf Accessed. Accessed January 25, 2016.
24. Schroeder SA. We can do better—improving the health of the American people. N Engl J Med. 2007;357:1221–1228.
25. American Public Health Association. Reduction of bullying to address health disparities among LGBT youth. Available at: http://apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/23/09/31/reduction-of-bullying-to-address-health-disparities-among-lgbt-youth. Accessed January 25, 2016.
26. Dohrenwend BP. The role of adversity and stress in psychopathology: some evidence and its implications for theory and research. J Health Soc Behav. 2000;41:1–19.
27. Meyer IH, Frost DM. Minority stress and the health of sexual minorities. In: Handbook of Psychology and Sexual Orientation. Oxford, England: Oxford University Press; 2012:252–266.
28. Bureau of Labor Statistics. Standard occupational classification: health educators. Available at: http://www.bls.gov/soc/2010/soc211091.htm. Accessed January 25, 2016.
29. Bureau of Labor Statistics. Standard occupational classification: community health workers. Available at: http://www.bls.gov/soc/2010/soc211094.htm. Accessed January 25, 2016.
30. Goodman J, Hanson C, Auld ME, Sherry C, Strack R, Mathis J. Affordable Care Act: Opportunities and Challenges for Health Education Specialists. Washington, DC: Society for Public Health Education; 2013. Available at: http://www.sophe.org/Sophe/PDF/ACA-Opportunities-and-Challenges-for-Health-Educators-FINAL.pdf. Accessed January 25, 2016.
31. National Commission for Health Education Credentialing. CHES exam eligibility. Available at: http://www.nchec.org/ches-exam-eligibility. Accessed January 25, 2016.
32. National Commission for Health Education Credentialing. MCHES exam eligibility. Available at: http://www.nchec.org/mches-exam-eligibility. Accessed January 25, 2016.
33. National Commission for Health Education Credentialing. Continuing education: pursue your education. Available at: http://www.nchec.org/continuing-education. Accessed January 25, 2016.
34. Council on Education for Public Health. Accreditation criteria: schools of public health. Available at: http://ceph.org/assets/SPH-Criteria-2011.pdf. Accessed January 25, 2016.
35. Council for Accreditation of Educator Programs. About accreditation. Available at: http://caepnet.org/accreditation/about-accreditation/what-is-accreditation. Accessed January 25, 2016.
36. Koh HK. The public health journey: the meaning and the moment. Health Educ Behav. 2013;40:635–639.
37. Fielding JE. Health education 2.0: the next generation of health education practice. Health Educ Behav. 2013;40:513–519.
38. Gastmyer CL, Pruitt BE. The impact of the Affordable Care Act on health education: perceptions of leading health educators. Health Promot Pract. 2013;15:349–355.
39. Chambliss M, Lineberry S, Evans W, Bibeau D. Adding health education specialists to your practice. Fam Pract Manage. 2014;21:10–15.
40. Luquis RR, Paz HL. Attitudes about and practices of health promotion and prevention among primary care providers. Health Promot Pract. 2014;16:745–755.
41. Strawbridge LM, Lloyd JT, Meadow A, Riley GF, Howell BL. Use of Medicare’s diabetes self-management training benefit. Health Educ Behav. 2015;42:530–538.
42. Haas L, Maryniuk M, Beck J, et al. National standards for diabetes self-management education and support. Diabetes Educ. 2012;38:619–629.
43. National Certification Board for Diabetes Education. Discipline requirement. Available at: http://www.ncbde.org/certification_info/discipline-requirement/. Accessed January 25, 2016.
44. National Asthma Education Certification Board. Get certified. Available at: http://www.naecb.com/get_certified.php. Accessed January 25, 2016.
45. Marks R, Allegrante J, Kate L. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I). Health Promot Pract. 2005;6:37–43.
46. Marks R, Allegrante J, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part II). Health Promot Pract. 2005;6:148–156.
47. Ory MG, Ahn S, Jiang L, et al. Successes of a national study of the Chronic Disease Self-Management Program. Med Care. 2013;51:992–998.
48. Cardelle A. Return on investment analysis: a tool for policy advocacy. Paper presented at: APHA annual meeting, Boston, MA, November 2013.
49. Hoppin P, Stillman L, Jacobs M. Asthma: a business case for employers and health care purchasers. Available at: http://asthmaregionalcouncil.org/wp-content/uploads/2014/02/2010_Business_Case_Employers_Health_Care_Purchasers.pdf. Accessed January 25, 2016.
50. Canton J, Cohen L, Mikkelsen L, Panares R, Srikantharajah J, Valdovinos E. Community-Centered Health Homes: Bridging the Gap Between Health Services and Community Prevention. Oakland, CA: Prevention Institute; 2011.
51. Society for Public Health Education. Role of health education specialists. Available at: https://www.sophe.org/NHEW2013_toolkit_final.pdf. Accessed January 25, 2016.
52. Carroll LN, Smith SA, Thomson NR. Parents as Teachers Health Literacy Demonstration Project: integrating an empowerment model of health literacy promotion into home-based parent education. Health Promot Pract. 2014;16:282–290.
53. Golden SD, Moracco KE, Feld AL, Turner KL, DeFrank JT, Brewer NT. Process evaluation of an intervention to increase provision of adolescent vaccines at school health centers. Health Educ Behav. 2014;41:625–632.
54. Association of Schools and Programs of Public Health. Future of Public Health Initiative. Available at: http://www.aspph.org/educate/models/community-colleges-and-public-health/SPH. Accessed January 25, 2016.
55. US Department of Labor. Fact sheet: Affordable Care Act and wellness programs. Available at: http://www.dol.gov/ebsa/newsroom/fswellnessprogram.html. Accessed January 25, 2016.
56. Michaels CN, Greene AM. Worksite wellness: increasing adoption of workplace health promotion programs. Health Promot Pract. 2013;14:473–479.
57. Becker KL. Conducting community health needs assessments in rural communities: lessons learned. Health Promot Pract. 2014;16:15–19.
58. Chin MH, Goddu AP, Ferguson MJ, Peek ME. Expanding and sustaining integrated health care-community efforts to reduce diabetes disparities. Health Promot Pract. 2014;15(suppl 2):29S–39S.
59. Earle-Richardson G, Scribani M, Wyckoff L, Strogatz D, May J, Jenkins P. Community views and public health priority setting: How do health department priorities, community views, and health indicator data compare? Health Promot Pract. 2014;16:36–45.
60. Blonstein AC, Yank V, Stafford RS, Wilson SR, Rosas LG, Ma J. Translating an evidence-based lifestyle intervention program into primary care: lessons learned. Health Promot Pract. 2013;14:491–497.
61. Frieden T. A framework for public health action. Am J Public Health. 2010;100:590–595.
62. Green L, Kreuter M. Letter to the editor: evidence hierarchies versus synergistic interventions. Am J Public Health. 2010;100:1824–1825.
63. Veach CC, Cissell WB. Role modeling: a dilemma for the health education specialist. Health Educ Behav. 1999;26:621–622.
64. Gilmore GD, Olsen LK, Taub A, Connell D. Overview of the National Health Educator Competencies Update Project, 1998–2004. Am J Health Educ. 2005;36:363–372.
65. Doyle EI, Caro CM, Lysoby L, Auld ME, Smith BJ, Muenzen PM. The National Health Educator Job Analysis 2010: process and outcomes. Health Educ Behav. 2012;39:695–708.
66. Marketing the Health Education Profession to Employers: Knowledge, Attitudes and Hiring Practices of Health Educators. Syracuse, NY: Hezel Associates; 2007.
67. Association of State and Health Territorial Health Officials. Workforce and leadership development. Available at: http://www.astho.org/programs/workforce-and-leadership-development/. Accessed January 25, 2016.
68. National Association of City and County Health Officials. Local health department workforce. Available at: http://www.naccho.org/topics/infrastructure/profile/upload/NACCHO_WorkforceReport_FINAL.pdf. Accessed January 25, 2016.
69. Rose G. The Strategy of Preventive Medicine. New York, NY: Oxford University Press; 1992.