Pampuri O, Czabanowska K, Hysa B, Roshi E, Burazeri G. Public health leadership competency level among health professionals in a South Eastern European country (Original research). SEEJPH 2015, posted: 10 February 2015. DOI 10.12908/SEEJPH-2014-40 1 ORIGINAL RESEARCH Public health leadership competency level among health professionals in a South Eastern European country Orjola Pampuri 1 , Katarzyna Czabanowska 2,3 , Bajram Hysa 4 , Enver Roshi 1,4 , Genc Burazeri 2,4 1 Institute of Public Health, Tirana, Albania; 2 Department of International Health, CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; 3 Institute of Public Health, Faculty of Health Sciences, Jagiellonian University, Medical College, Krakow, Poland; 4 Faculty of Public Health, University of Medicine, Tirana, Albania. Corresponding author: Orjola Pampuri, Institute of Public Health; Address: Rr. “Aleksander Moisiu”, No. 88, Tirana, Albania; Telephone: +355672066183; E-mail: o.pampuri@yahoo.com Pampuri O, Czabanowska K, Hysa B, Roshi E, Burazeri G. Public health leadership competency level among health professionals in a South Eastern European country (Original research). SEEJPH 2015, posted: 10 February 2015. DOI 10.12908/SEEJPH-2014-40 2 Abstract Aim: The aim of this study was to describe the current and the required leadership competency level of health professionals in Albania, employing a recently established international instrument. Methods: A nationwide cross-sectional study was conducted in Albania in July-December 2014 including a representative sample of 267 health professionals (162 men and 105 women; mean age: 44.7±10.3 years; overall response rate: 89%). A structured questionnaire was administered to all health professionals aiming at self-assessing the current level of leadership competencies and the required (desirable) level of leadership competencies for their current job position. The questionnaire included 52 items grouped into eight subscales/domains. Answers for each item of the tool ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). An overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both the current and the required leadership competency levels. Wilcoxon signed ranks test was employed to compare the overall scores and the subscale scores of the current and the required level of leadership competencies among health professionals. Results: Mean value of the overall summary score for the 52 items of the instrument was significantly lower for the current leadership competency level compared with the required leadership competency level (138.4±11.2 vs. 159.7±25.3, respectively; P<0.001). Most of the subscales’ scores were significantly higher for the required than for the current leadership competency level. Conclusion: Our study provides useful evidence about the current and the required level of leadership competencies among health professionals in transitional Albania. Findings of this study may help policymakers in Albania to identify the gap between the required and the current level of leadership competencies among health professionals. Furthermore, findings of this study should be expanded in the neighbouring countries of the South Eastern European region and beyond. Keywords: Albania, competency level, health professionals, public health leadership, South Eastern Europe. Acknowledgement: The authors thank colleagues and partners from the LEPHIE project and the members of the ASPHER’s WGIGP. Conflicts of interest: None. Pampuri O, Czabanowska K, Hysa B, Roshi E, Burazeri G. Public health leadership competency level among health professionals in a South Eastern European country (Original research). SEEJPH 2015, posted: 10 February 2015. DOI 10.12908/SEEJPH-2014-40 3 Introduction To date, there have been developed a few competency frameworks in order to assess public health leadership and medical leadership competencies (1-4). These instruments have basically included the key principles and concepts of leadership (5,6). Establishment and refinement of these tools is due to the urgent need to develop strong leadership skills and competencies among public health professionals at large (7). Hence, these leadership frameworks are deemed useful for professional training and continuous medical education in particular, but also for continuous professional development in general (5,6). Competencies in the area of public health leadership are regarded as a crucial element for the performance and activities of health professionals operating at all levels of health care services (public health, primary health care services, as well as hospital care) in different settings and cultures (7). A key driver in improving leadership within public health is that the nature of the challenges faced by such professionals is evolving. Developing effective leadership is essential as many European countries are putting health systems under significant financial pressures and forcing them to deliver more with diminishing resources (8). Notwithstanding the current progress towards development of leadership competencies in the area of medicine and public health, the existing frameworks are – on the face of it – too generic and not satisfactorily detailed for a proper assessment of the leadership competency level of health professionals operating in different levels of health care. It has been convincingly argued that a proper identification and assessment of the level of leadership competencies is a basic prerequisite for adjustment of the educational curriculum and training models for health professionals in different European countries (7). For this very reason, fairly recently, it has been developed a specific public health leadership competency framework with the aim to significantly foster the competency-based European public health leadership curriculum (7). As acknowledged earlier, this competency framework was designed in the context of the Leaders for European Public Health (LEPHIE) Erasmus Multilateral Curriculum Development Project, supported by the European Union Lifelong Learning Programme (7). The information about public health leadership is scarce for Albania, a former communist country in Southeast Europe, which is characterized by a rapid political and socioeconomic transition associated with deleterious health effects (9,10). The particularly rapid process of transition in Albania over the past twenty five years has been associated with an intensive process of migration, both internal (from rural areas to urban areas of the country) and external (mainly to the neighbouring countries including Greece and Italy) (11). This has also affected the workforce, at least to some extent. Indeed, regardless of the international financial crisis, the relatively poor economic situation and the lack of rapid economic expansion due to limited domestic resources continue to encourage Albanian adults to emigrate (12). In 2013, it was established in Albania a national School of Public Health under the auspices of the University of Medicine. Nevertheless, the curriculum of both undergraduate and postgraduate public health programs does not sufficiently promote leadership skills and competencies for future health professionals in Albania. The new leadership competency framework was cross-culturally adapted in Albania in May 2014 in a sample of health professionals operating at different levels of health care services (13). Pampuri O, Czabanowska K, Hysa B, Roshi E, Burazeri G. Public health leadership competency level among health professionals in a South Eastern European country (Original research). SEEJPH 2015, posted: 10 February 2015. DOI 10.12908/SEEJPH-2014-40 4 In this context, the aim of our study was to describe the current and the required leadership competency level of health professionals in Albania, employing this recently established international instrument, which was previously validated. Methods A cross-sectional study was conducted in Albania in July-December 2014 targeting a nationwide representative sample of 300 health professionals working at different health institutions all over the country (primary health care services, regional hospitals, University Hospital Centre “Mother Teresa”, Institute of Public Health, and Health Insurance Fund). Of 300 targeted health professionals, 33 individuals refused to participate. The study sample consisted of 267 health professionals (162 men and 105 women; mean age: 44.7±10.3 years; overall response rate: 89%). A structured questionnaire was administered to all health professionals aiming at self- assessing the current level of leadership competencies and the required/desirable level of leadership competencies for their current job position. As reported previously, the questionnaire consisted of 52 items grouped into eight competency domains (subscales) including (7): i) systems thinking; ii) political leadership; iii) collaborative leadership: building and leading interdisciplinary teams; iv) leadership and communication; v) leading change; vi) emotional intelligence and leadership in team-based organizations; vii) leadership, organizational learning and development, and; viii) ethics and professionalism As explained elsewhere, each domain (subscale) of the instrument corresponds to one educational session within public health leadership curriculum (7,14). Answers for each item of each subscale of the instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). An overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both, the current level of competencies and the required level of competencies. The instrument was previously validated (cross-nationally adapted in the Albanian context) in a sample of 53 health professionals in Tirana in May 2014 (13), after a careful process of translation and back-translation of the original English version of the leadership competency questionnaire, following strict methodological rules (15). Furthermore, the questionnaire included demographic information (age and sex of health professionals), place of work (urban areas vs. rural areas), type of diploma obtained (dichotomized into: health sciences vs. other diploma), years of working experience, as well as current job position (trichotomized into: high, middle and low managerial level). Measures of central tendency and dispersion (mean values and standard deviations) were used to describe the distribution of age and working experience among male and female participants. Conversely, absolute numbers and their respective percentages were used to describe the distribution of place of work, diploma obtained and the job position of health professionals. Cronbach’s alpha was used to assess the internal consistency for both the current level of competencies and the required level of competencies (16,17). On the other hand, Wilcoxon signed ranks test was used to compare the overall scores and the subscale scores of the current level of competencies and the required level of competencies among health professionals included in this study. Pampuri O, Czabanowska K, Hysa B, Roshi E, Burazeri G. Public health leadership competency level among health professionals in a South Eastern European country (Original research). SEEJPH 2015, posted: 10 February 2015. DOI 10.12908/SEEJPH-2014-40 5 Results Mean age in the male sample of health professionals (N=162) was 44.9±10.6 years, whereas in females (N=105) it was 44.4±9.9 years (Table 1). About 75% of health professionals were working in urban areas and 25% in rural areas of Albania. Around 87% (N=233) of participants had received a diploma in health sciences (medicine, public health, nursing, pharmacy, or dentistry), whereas 13% (N=34) had other backgrounds (law, economics, social sciences, or engineering). Overall, mean working experience was 19.6±10.1 years. About 21% (N=55) of health professionals were working in high-level managerial positions compared with 32% (N=84) who were operating in low-level positions. Table 1. Baseline characteristics in a nationwide representative sample of health professionals in Albania, in 2014 Variable Men (N=162) Women (N=105) Total (N=267) Age (years) 44.9±10.6 * 44.4±9.9 44.7±10.3 Place of work: Urban areas Rural areas 111 (68.5) † 51 (31.5) 90 (85.7) 15 (14.3) 201 (75.3) 66 (24.7) Diploma: Health sciences Other 142 (87.7) 20 (12.3) 91 (86.7) 14 (13.3) 233 (87.3) 34 (12.7) Working experience (years) 20.0±10.4 19.0±9.6 19.6±10.1 Job position: High managerial level Middle managerial level Low managerial level 33 (20.4) 70 (43.2) 59 (36.4) 22 (21.0) 58 (55.2) 25 (23.8) 55 (20.6) 128 (47.9) 84 (31.5) * Mean values ± standard deviations. † Numbers and column percentages (in parentheses). The internal consistency of the overall scale (52 items) was Cronbach’s alpha=0.86 for the current competency level and Cronbach’s alpha=0.96 for the required competency level (Table 2). For the current competency level, Cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.49) and the “leadership, organizational learning and development” subscale (0.55) and the highest for the “political leadership” domain (0.94). Similarly, for the required competency level, Cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.65) and the highest for the “political leadership” domain (0.91). Mean value of the overall summary score for the 52 items of the instrument was significantly lower for the current competency level compared with the required competency level (138.4±11.2 vs. 159.7±25.3, respectively; P<0.001) (Table 3). All the subscales’ scores were significantly higher for the required competency level than for the current competency level, except for the “emotional intelligence and leadership in team-based organisations” and “leading change” domains (Table 3). Pampuri O, Czabanowska K, Hysa B, Roshi E, Burazeri G. Public health leadership competency level among health professionals in a South Eastern European country (Original research). SEEJPH 2015, posted: 10 February 2015. DOI 10.12908/SEEJPH-2014-40 6 Table 2. Internal consistency of the leadership competency instrument administered in a representative sample of health professionals in Albania (N=267) Domain (subscale) Cronbach’s alpha Current competency level Required competency level Overall scale (52 items) 0.86 0.96 Systems thinking (7 items) 0.82 0.78 Political leadership (8 items) 0.94 0.91 Collaborative leadership: building and leading interdisciplinary teams (5 items) 0.89 0.85 Leadership and communication (7 items) 0.62 0.87 Leading change (6 items) 0.64 0.77 Emotional intelligence and leadership in team-based organizations (6 items) 0.83 0.83 Leadership, organizational learning and development (7 items) 0.55 0.79 Ethics and professionalism (6 items) 0.49 0.65 Table 3. Summary score of each domain (subscale) of the leadership competency instrument for the current and the required competency level of Albanian health professionals (N=267) Domain (subscale) Mean values ± standard deviations P-value * Current competency level Required competency level Overall scale (52 items) 138.4±11.2 159.7±25.3 <0.001 Systems thinking (7 items) 21.1±2.8 21.8±3.4 <0.001 Political leadership (8 items) 20.1±5.0 20.9±5.4 <0.001 Collaborative leadership: building and leading interdisciplinary teams (5 items) 11.7±2.9 12.9±3.6 <0.001 Leadership and communication (7 items) 16.5±2.2 17.9±4.3 <0.001 Leading change (6 items) 17.1±2.1 16.7±3.2 0.005 Emotional intelligence and leadership in team-based organizations (6 items) 18.1±2.4 17.3±3.6 <0.001 Leadership, organizational learning and development (7 items) 16.5±2.1 17.7±3.6 <0.001 Ethics and professionalism (6 items) 17.2±2.0 17.6±2.7 0.018 * Wilcoxon singed ranks test. Discussion This study provides useful evidence about the level and distribution of leadership competencies among health professionals in transitional Albania, based on a recently established international instrument, which was previously validated (cross-culturally adapted) in the Albanian context. This measuring international instrument exhibited satisfactory internal consistency especially for assessment of the required (desirable) leadership competency level. During the previous Pampuri O, Czabanowska K, Hysa B, Roshi E, Burazeri G. Public health leadership competency level among health professionals in a South Eastern European country (Original research). SEEJPH 2015, posted: 10 February 2015. DOI 10.12908/SEEJPH-2014-40 7 validation exercise, the tool had also displayed a high stability over time (i.e., a high test- retest reliability for the overall scale and for each of the subscales of the instrument) (13). Main findings of this survey include a higher self-perceived level of the required leadership competencies than the current (existing) level of leadership competencies among health care professionals in post-communist Albania. Interestingly, most of the subscale scores were significantly higher for the required competency level compared with the current competency level in this nationwide representative sample of health professionals in Albania. Findings of this study may help policymakers in Albania to identify the gap between the required and the current level of leadership competencies among health professionals. As already reported elsewhere, the public health leadership competency-based curriculum was established in the framework of the LEPHIE project (7). Similarly, as Czabanowska et al. point out that a starting point is to identify the competency capacities of future leaders in relation to population health and well-being and apply the study results to inform education, training and culture change throughout the workforce (14), we considered that the description of the competencies supports the curriculum design and it can be used as a self-assessment instrument for students and public health professionals, helping them to reflect and identify gaps in their knowledge, skills and competencies (7). The teaching of leadership is still not common in public health training programmes around the world and seems particularly rare in countries experiencing intensive public health reforms. There is a need for substantial investment in leadership training for public health professionals (18). In conclusion, we provide important evidence about the level and distribution of the leadership competency level among health professionals in Albania, a country embarked in the long journey towards accession into the European Union. Our survey informs about both the self-perceived leadership competency level and the required/desirable level of leadership competencies for the respective job positions of health care professionals in Albania. Findings of our survey should be expanded further in large representative samples of health care professionals in the neighbouring countries in the Western Balkans and beyond. Similar to Albania, this type of survey will help to identify potential gaps in the level of existing leadership competencies and the required/desirable level of leadership competencies, which will ultimately inform the public health curricula about necessary content adjustments. References 1. Maintenance of Certification Competencies and Criteria. 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