Why do health educators obtain and continue to hold the CHES credential?
Abstract: Academically trained health education specialists have had the opportunity to become credentialed as CHES since 1989. This study was designed to find out why health education specialists decide to obtain the CHES credential, and why do those who obtain the credential decide to continue to be certified. The study population consisted of 3,191 current holders of the CHES credential. Forty-two percent of those invited to participate in the study completed usable questionnaires. The results showed different reasons for why they initially obtained the CHES credential and why they continued to hold it. Several obstacles for maintaining their CHES credential were also identified.
Article Type: Survey
Authors: McKenzie, James F.
Seabert, Denise M.
Pub Date: 09/22/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Fall, 2009 Source Volume: 24 Source Issue: 4
Accession Number: 307670892
Full Text: INTRODUCTION

Since 1989, health education specialists meeting education eligibility requirements have had the opportunity to become Certified Health Education Specialists (CHES), a credential offered by the National Commission on Health Education Credentialing, Inc. (NCHEC). The certification is awarded after passing an examination that covers the seven Areas of Responsibility for Health Educators (NCHEC, SOPHE, & AAHE, 2006). Between 1989 and 2007, 14,622 health education specialists had obtained the CHES credential. As of April 1, 2008, of the 14,622 who had obtained the credential 7,566 (51.7%) held a current CHES credential. It was recently reported that in 2006 62,000 individuals held jobs with the title of health educator (Bureau of Labor Statistics [BLS], 2009). Thus, one might assume in that year a little more than one-eighth (12.2%) of those who were practicing as health education specialists held the CHES credential. It should be noted that not all individuals who worked as health education specialists in 2006 had received the necessary formal education that qualified them to take the certification examination. In fact, three different studies (Sondag, Taylor, & Goldsmith, 1993; Bajracharya, 1999; Hezel Associates, 2007 [Also see Gambescia et al., 2009]) have found that someone other than a health education specialist performed many of the responsibilities identified as part of the role of the health educator. Even so, a number of those who are eligible to take the examination have not chosen to do so. So why is it that some health education specialists decide to obtain the CHES credential? And second, why do those who obtain the CHES credential decide to continue to be certified? The purpose of this study was to answer these two questions. Having the answers to these questions could help NCHEC and the health education profession to better (1) market the credential to those eligible for the credential and not yet certified, and (2) assist those who are certified in maintaining the credential.

METHODS

Because the purpose of this study was to determine why health education specialists with the CHES credential choose to be certified and maintain it, the study was designed as a cross-sectional survey of those who held the CHES credential at the time of the study was conducted in April 2008.

ARRANGEMENTS FOR THE STUDY

The process to gain approval for conducting the study was begun via an informal discussion between the principal investigator and the Executive Director of NCHEC. Based upon that discussion, a written description of the study and a formal request to complete the study was forwarded to the Executive Director for distribution to the Board of Commissioners (BOC) of NCHEC for review. It was then during a conference call of the BOC, Executive Director, and principal investigator that formal approval was received. The research protocol was then submitted to and approved by the Institutional Review Board at Ball State University.

PARTICIPANTS

The study population consisted of all the individuals included in the NCHEC database who 1) were considered current holders of the CHES credential, 2) obtained the credential between January 2003 and December 2007, and 3) had a current email address on file with NCHEC. These inclusion/exclusion criteria yielded a study population of 3,929 individuals. The years 2003 to 2007 were used because of the completeness of information available about the individuals in the NCHEC database, specifically the ability to contact the individuals via email. Email addresses were missing for many of those certified between 1989 and 2002.

DATA COLLECTION

Because of the size of the study population, the availability of the email addresses of those in the study population, and the ease of administering a questionnaire via the Internet, the investigators decided to invite all who were eligible for the study to participate. Thus, a census was used instead of a sample. To increase the response rate, two days prior to sending the letter of invitation, the potential participants were sent an email message notifying them that they had been selected to participate in the study and that in a few days they would be receiving an official email letter of invitation to participate. The letter of invitation had multiple purposes. It not only invited participation but also included directions on how to participate and an informed consent statement. If those in the study population wanted to participate, they were instructed to click on a link in the letter and the questionnaire, created using the online survey service of Zoomerang[TM], was loaded into their browser. Based upon the directions included in the letter of invitation it was assumed that if the recipients linked to the online questionnaire and completed it, they were consenting to participate in the study. When the participants completed the questionnaire, they were asked to click the submit button and the Zoomerang[TM] software automatically stored the data in a password protected database for later analysis. In addition, the letter of invitation offered the results of the survey, and if the participants opted to do so, an opportunity to enter a drawing in which five participates were randomly selected to win a NCHEC desk clock. To receive the results the participants had to send a separate email to the principal investigator. Approximately one week after the email letters of invitation were sent, a reminder email was distributed to all invited to participate.

DATA COLLECTION INSTRUMENT

The data were collected with a 13-item original instrument. The investigators developed the initial draft of the checklist with input from NCHEC's staff. Content validity for the checklist was created using the process outlined by McKenzie, Wood, Kotecki, Clark and Brey (1999). After the initial draft of the questionnaire was created, a jury of experts comprised of individuals who were current members of two of NCHEC's Division Boards (1-Professional Development, and 2-Certification of Health Education Specialists) were invited to review the instrument. Once the jurors agreed to participate, they were asked to complete two separate reviews of the instrument. The first was a qualitative review (i.e., wording and question changes) and the second was a quantitative review (i.e., how essential the questions were for the instrument). Based upon the quantitative review, a content validity ratio (CVR) was calculated for each questionnaire item using a modification of a formula developed by Lawshe (1975). In the current study, items rated either as a "3" (essential) or "2" (useful) were included in the calculation of the CVR. Lawshe's formula only uses the "essential" items in calculating the CVR. Items that met minimum values of the content validity ratio for significance of p<.05, for twelve jurors (CVR=.56) were included in the final instrument.

RESULTS

Between January 2003 and December 2007, 4,473 individuals became CHES certified. Of that number, 3,658 (81.8%) held "current" CHES status when this study was conducted. Of those 3,658 current CHES, 259 (7.1%) had either not provided NCHEC with an email address or had asked that their contact information not be shared by NCHEC. Thus, those 259 individuals were not eligible for this study. Therefore, 3,399 individuals were sent invitations to participate. Of those 3,399 who were sent email invitations to participate, 208 (6.1%) emails "bounced back" indicating the email addresses were no longer valid. Thus, 3,191 individuals actually received the invitation. Of that number, 1,461 (45.8%) visited the Zommerang[TM] site where the questionnaire was located. Of those 1,461, 115 (3.6%) did not complete any questions, six (<1.0%) completed some questions but not enough to be useful for analysis, while the remaining 1,340 (42.0%) completed all or most the questionnaire. Only these 1,340 questionnaires were included in the data analysis.

Table 1 presents a summary of selected demographic variables of the respondents. As can be seen in the table, about two-thirds (n=916, 68.3%) of the respondents had at least a master's degree at the time they completed the questionnaire, and just over half (n= 683, 51.0%) held at least a master's degree at the time they took the CHES examination. The mean number of years the participants had worked in the health education/promotion profession was 5.78 years. Additionally, of the 1,340 respondents, over three-fourths (n=1,034, 77.2%) were currently working in a health education/promotion setting, and 53 (4.0%) had no work experience in health education/promotion. There were a number of respondents (n=307, 22.9%) who did not respond to the question regarding their work setting. These may be the same ones (n=306, 22.8%) who indicated they were not working in health education at the time the study was conducted. However of those who were working in health education, there was a good distribution of health education specialists from the various work settings with the greatest number of respondents working in governmental health agencies (n=277, 20.7%) and the fewest number (n=40, 3.0%) working in K-12 schools.

Table 2 includes information about why the respondents initially became CHES certified and why they continued to be certified. In the instrument, questions about this information were asked in two different ways. First, respondents were asked to check all responses that applied. Thus, respondents could express multiple reasons. Second, in a follow-up question the respondents were asked to identify their primary reason for both why they initially sought certification and why they continued to be certified. As can be seen in Table 2, there were six responses that were selected by at least 25% of the respondents when asked reasons why they sought initial certification. The response selected most often (n=980, 73.1%) was "to show others that I am competent to practice health education," followed closely (n=928, 69.3%) by "to improve my chances of getting a job." However, when the respondents were asked to identify the primary reason for seeking initial certification these same two items were identified but the order of response was reversed. That is, "to improve my chances of getting a job" was selected more often (n=464, 34.6%) than "to show others that I am competent to practice health education" (n=404, 30.1%). There were 31 (2.8%) respondents who used the "other" response. Some of the reasons listed here were: "it was required/recommended by my employer," "for professional advancement," "to be more credible," and "it is one of the few certifications offered in public health." [Note: At the time the participants of this study earned their CHES, the Certified in Public Health (CPH) credential for which some CHES would be eligible was not available.]

As noted in Table 2, four items dealing with why the CHES continued to be certified were select ed by at least half of the respondents. The statement receiving the greatest number of responses was "to show others that I am competent to practice health education" (n=963, 71.9%). When asked to identify the primary reason for continuing to be certified "to show others that I am competent to practice health education" continued to be identified most often (n=386, 28.8%). Three other responses were selected by at least 10% of the respondents. They included: "to assist with upward mobility within the profession" (n=259, 19.3%), "to improve my chances of getting a job" (n=217, 16.2%), and "to support the health education profession" (n=137, 10.2%). There were 59 (4.4%) respondents who used the "other" response. The most common theme of the "other" responses was "it helps me stay current." Other reasons included were: "it is required for my job," "to keep my professional options open," "to defend my credibility," and "it seems wasteful to earn the credential and not maintain it."

To determine if any significant associations/relationships existed between the responses to primary questions on the questionnaire and the demographic variables, analysis of variance (ANOVA) and chi-square tests were used. To get meaningful results for the chi-square analyses, some of the data categories were collapsed in order to reduce the number of expected "low count" cells. However, no meaningful way of collapsing the data categories of the demographic question dealing with "current practice setting" could be determined to reduce low count cells. Thus, most of these analyses are not reported.

When the primary reason for initially becoming CHES certified and the demographic variable "highest level of education at the time the CHES examination was taken" were subjected to a chi-square analysis a significant association was found ([chi square]=110.50, df=16, p<.001). For this analysis the variable "highest level of education at the time the examination was taken" was collapsed into three categories: 1) within 90 days of completing a degree, 2) completed bachelor's degree, and 3) completed graduate degree. To determine in which subgroups the statistically significant associations existed, adjusted residuals were calculated. The adjusted residual is similar to a post-hoc test in that it makes it possible to determine which subgroups within a chi-square test are statistically significant. An adjusted residual of 2.0 or greater signifies statistical significance for that specific category (Bewick, Cheek, & Ball, 2004). After looking at the patterns of actual counts versus the expected counts for obtaining initial certification, the expected counts were most different for those within 90 days of completing their degree and those with a graduate degree at the time they took the examination. More specifically, those within 90 days of completing their degree had higher than expected counts for 1) "because a professor recommended I do so," 2) "to improve my chances of getting a job," 3) "to show others I am competent to practice health education," and 4) "for personal gratification and pride." Individuals with a graduate degree at the time they took the examination had higher than expected counts for 1) "for personal gratification and pride," 2) "to support the health education profession," and 3) "to serve as a role model to other professionals." The only response that had higher counts than expected for those who held a bachelor's degree at the time they took the examination was "to show others that I am competent to practice health education."

Similar analyses were conducted between primary reasons for continuing to be CHES certified and demographic variables. Significant associations were found between the primary reasons for continuing to be certified and two demographic variables: the "highest level of education completed" ([chi square]=19.07, df=7, p=.008), and whether or not the respondents "currently worked in a health education/promotion setting" ([chi square]=54.00, df=7, p<.001). The adjusted residuals for "the highest level of education completed" revealed that the two groups that were examined, those with a bachelor's degree versus a graduate degree, had expected counts in opposite directions on two responses. On the response "to support the health education profession" those with a bachelor's degree had lower counts than expected, while those with graduate degrees had higher counts than expected. On the response "because it increases my sense of pride about the profession" just the opposite occurred. Those with a bachelor's degree had higher counts than expected, while those with graduate degrees had lower counts than expected. The adjusted residuals generated for the chi-square analysis between "the primary reason for continuing to be CHES certified" and "do you currently work in the health education/promotion setting" revealed that those working in a health education/promotion setting had higher than expected counts with "to assist with upward mobility within the profession" and "because it is required to keep my job." For those not working in a health education/promotion setting higher than expected counts were found with "to improve my chances of getting a job," and "for personal gratification and pride." When an ANOVA was run on the primary reasons for continuing to be CHES certified and the number of years worked in health education/promotion field a significant relationship existed ([F.sub.(7,1166)] =8.45, p<.001). Of the 28 pair-wise differences generated by the Tukey's post hoc test, eight were significant at the p<.05 level. Of the eight, five were found related to the response "to serve as a role model to other professionals." Those related were: 1) "to improve my chances of getting a job," 2) "to assist with upward mobility in the profession," 3) "to show others that I am competent to practice health education," 4) "to support the health education profession," and 5) "because it increases my sense of pride about the profession." The other three were related to response "for personal gratification and pride." They included: 1) "to improve my chances of getting a job," 2) "to assist with upward mobility in the profession," 3) "to show others that I am competent to practice health education." What these data indicate is those with a greater number of years experience in the health education/promotion field were more likely to maintain their certification in order to serve as a role model or for personal gratification and pride, while those with fewer years in the field did so to improve their chances of getting a job, to assist with upward mobility, and show others they are competent.

Table 3 includes data on the obstacles to maintaining the CHES credential. Like Table 2, data presented in Table 3 came from two different questions. The first question asked the respondents to check all items that applied, while the second question asked them to identify the primary obstacle to maintaining certification. As noted in the table, about one-eighth (n=174, 13.0%) of the respondents indicated that they had no obstacles in maintaining their certification. Six of the obstacles were marked by at least 25% of the respondents. Two obstacles--"costs associated with obtaining Continuing Education Contact Hours (CECHs)" (n=706, 52.7%) and "lack of or limited opportunities to obtain CECHs" (n=674, 50.3%)--were identified as obstacles by more than half of the respondents. When asked to identify the primary obstacle for trying to maintain their CHES credential "costs associated with obtaining CECHs" (n=380, 28.4%) and "lack of or limited opportunities to obtain CECHs" (n=252, 18.8%) again topped the list. Another 53 (4.0%) respondents identified "other" primary reasons. Within this "other" category, 11 (20.8%) dealt with lack of Category I CECHs opportunities available to them, while another 16 (30.1%) respondents had other concerns related to CECHs.

When analyses were run on the question dealing with "the greatest obstacle to maintaining the CHES credential" and the demographic variables, a significant association/relationship was found with whether or not the respondents currently worked in a health education/promotion setting ([chi square]=23.09, df=8, p=.003) and the number of years worked in the health education/promotion field ([F.sub.(1171)=3.36,] p=.001). The adjusted residuals showed that those who worked in a health education/promotion setting had a higher than expected count for "I do not have obstacles" for obtaining the needed CECHs, while those who did not work in the field had more obstacles. Specifically, those not working in the field had higher than expected counts for the two obstacles "costs associated with obtaining the CECHs" and "lack of support from my employer to maintain CHES." Of the 36 pair wise differences generated by the Tukey's post hoc test, three were significant at the p<.05 level. They included: 1) "I do not have any obstacles" and "The cost of the annual renewal fee," 2) "I do not have any obstacles" and "Cost associated with obtaining the CECHs," and 3) "I do not have any obstacles" and "Available continuing education opportunities are not applicable to my work." What this means is that those with a greater number of years of experience in the health education/promotion field were significantly less likely to have obstacles obtaining CECHs, while those with fewer years in the field found significantly greater obstacles with the cost of the annual renewal fee," "costs associated with obtaining CECHs," and finding "available continuing education applicable to their work."

The final question on the instrument asked the respondents "At this point in your career, do you anticipate maintaining your CHES credential the rest of your career?" Approximately two-thirds of the respondents (n=882, 65.1%) indicated that "yes" they would maintain the credential. Another 393 (29.3%) indicated they were "Not sure," and 59 (4.4%) said that "no" they would not maintain the credential. The 59 (4.4%) who said "No" were given the opportunity to indicate why they would not maintain it. Several of these 59 (4.4%) respondents listed more than one response. The greatest number of responses to this question was because of the "cost of maintaining the credential" (n=23, 38.9%). Other responses included: "don't need it or use it for my job" (n=12, 20.3%), "lack of recognition for the certification," (n=9, 15.2%), "not applicable to my long-term career plans (n=8, 13.6%), and "restrictions on or hard to get CECHs" (n=8, 13.6%). When the data about plans for maintaining the CHES for the rest of the career was compared with the demographic variables significant associations were found with whether or not the respondent "currently worked in a health education/promotion work settings" ([chi square]=51.10, df=2, p<.001) and the "health education specialist's work setting" ([chi square]=17.79, df=8, p=.023). Adjusted residuals for these chi-square calculations between plans for maintaining the CHES credential and whether or not the respondent worked in the health education/ promotion field showed that for those who worked in the field greater than expected counts were found for those who planned to maintain their certification and lower than expected counts were found if they were not sure or did not plan to continue their certification. Just the opposite was found for those not working in the field. That is, lower than expected counts were found for continuing their certification and higher than expected counts were found for not sure or did not plan to keep their certification.

When the adjusted residuals were examined for only those who worked in the health education/ promotion setting and their plans for maintaining the CHES credential the data showed that those who planned to keep their certification had higher than expected counts for both those who worked in worksite and higher education academic settings, and lower than expected counts if they worked in school health.

DISCUSSION

Though the CHES credential is considered a credential for the entry-level health education specialist, the majority (n=916, 68.3%) of those responding in this study had at least a master's degree, and just over half (n= 683, 51.0%) held at least a master's degree at the time they took the CHES examination. Because it was unknown what academic degrees had been earned by all (N=7,566) who had earned the CHES credential, it is impossible to determine whether or not this may be a response bias specific to this study or if the results do mirror the today CHES population. However, it may be that many sought the credential because it was the only credential available for community health education specialists at the time. Since August 2008 health education specialists (and individuals from other fields) who have earned a graduate level (Master's or Doctoral) degree from a school or program of public health that is accredited by the Council on Education of Public Health (CEPH) are eligible to sit for the National Board of Public Health Examiners certification exam. If these individuals pass the exam they will have earned the Certified in Public Health (CPH) credential (National Board of Public Health Examiners, 2009). While the CHES and CPH credentials represent different content areas, time will tell if those eligible for both CHES and CPH will seek both or opt for one over the other.

When the answers to the question that asked the respondents to identify their primary reason for initially becoming certified were analyzed, it appears that most (n=922, 68.7%) did so with an "eye towards" some aspect of employment. Almost two-thirds of the respondents selected either "to improve my chances of getting a job" (n=464, 34.6%) or "to show others that I am competent to practice health education" (n=404, 30.1%), while another 54 (4.0%) responded by selecting "because it is required for my job." Although it is important to the profession to find that health education specialists feel the credential will be helpful for employment, only 54 (4.0%) respondents indicated that the primary reason for obtaining their certification was "because it was required for my job." This may be an indication that, like earlier studies, some employers still do not feel that individuals need to be academically trained in health education (Sondag, Taylor, & Goldsmith, 1993; Bajracharya, 1999) or hold the CHES credential (Hezel Associates, 2007 [Also see Gambescia et al., 2009]) to carryout the duties of a health education specialist. However, several years ago the health education profession as a whole indicated credentialing of both individuals, via certification, and professional preparation programs, via accreditation/approval, are important components of accountability and quality assurance for enhancing the profession (Allegrante et al., 2004).

When examining the data related to why those who obtain the CHES credential continued to be credentialed, it must be remembered that those invited to complete the questionnaire had been certified for six or fewer years, and the mean number of years worked in the health education profession was also less than six years. As such, it could be assumed that most of the respondents where still in the early years of their careers. Because many still may be early in their careers it maybe, at least in part, why the two answers with the greatest number of responses ["to show others that I am competent to practice health education" (n=386, 28.8%) and "to assist with upward mobility within the profession" (n=259, 19.3%)] were associated with employment, while those responses associated with promoting the profession ["to support the health education profession" (n=137, 10%), "because it increases my sense of pride about the profession" (n=79, 6%), and "to serve as a role model to other professionals" (n=27, 2%)] were selected many fewer times.

When asked about their obstacles to maintaining the credential most responses dealt with either the costs associated with or opportunities for obtaining Category I CECHs. While there are a number of different ways to get the CECHs (i.e., Attendance at Professional Meetings, Self-Study, Academic Preparation, Creative Endeavors, Professional Presentations, and Professional Service (NCHEC, 2009)), the costs vary depending on how and where the CECHs are obtained. Some are "free," such as when one earns CECHs for authorship of an article in a professional publication, while others may have either direct or indirect financial costs. An example of a direct cost is a specific charge for the CECHs, while examples or indirect costs are paying for a membership in an organization that offers CECHs or costs associated with travel to attend a professional meeting where CECHs are offered. While a number of employers do provide opportunities and support for professional development by paying for travel to professional meetings, there are many employers, especially small employers, who do not. Therefore, the costs associated with attending professional meetings, especially national meetings, are often prohibitive. This may be in part why a number of the respondents see the costs as obstacles to obtaining CECHs. However, it should be noted that there are a number of "free" CECHs offerings that have not been used that much by those seeking CECHs. In a recent revision of the NCHEC Web site, the section dealing with continuing education has been greatly enhanced to assist CHES identify and locate continuing education opportunities.

An encouraging result of this study was that only a small number of respondents (n=59, 4.4%) indicated that they would not maintain their CHES credential the rest of their career. This may be seen as an indication that most of the respondents feel that there are benefits to having the credential. However, it needs to be pointed out that there were almost one-third of the respondents (n=393, 29%) who were not sure they would maintain the credential over time. The reasons for this may be many including not knowing whether or not they will stay in the profession, and the cost versus the benefits of holding the credential.

DISCUSSION OF LIMITATIONS

This study was limited in several ways. First, not all individuals who held the CHES credential at the time the study was conducted were part of the survey population. The researchers had limited resources to use to collect data so it was decided to use Internet survey. Because of lack of availability of email addresses for many of the individuals certified before 2003, it felt there could be a good chance for response bias if an attempt was made to try collecting data from those certified between 1989 and 2002.

Second, the study was limited by the shortcomings of using an Internet survey to collect the data, including the "deleting" of an email from an un known sender. In addition, because email was used, the written word was the sole means of communication. Participants could not readily ask questions concerning the questionnaire or study.

Third, this study used a cross-sectional survey design with no comparison group. Using a comparison group could have strengthened the design of the study by providing some insight into whether or not the responses of those surveyed differed from those who had been certified at one time but let their certification lapse, and those who have never sought certification.

Finally, before leaving limitations we would like to comment on the response rate in this study. Some may see the response rate (42%) as a limitation to this study, or that there may be response bias. While the response rate was less than the 50%, which has been labeled as an "adequate" response for surveys (Babbie, 1999), a response rate of less than 50% may be acceptable depending on the survey population (Neutens & Rubinson, 2010). We think that this latter statement applies to the survey population (those currently holding the CHES credential) in this study for a couple of reasons. One is that they are an easily identifiable group of health education specialists and thus may be asked to respond to more surveys than those who are not so identified. And two, because of the newness/age (~ 20 years old) of the CHES credential little is known about those who hold the credential (McKenzie & Seabert, 2009) and researchers want to know more (e.g., Bonaguro, White, Duncan, Nicholson, & Smith, 2009). In addition, respondents are less likely to reply when they have no data or limited data to report. It may have been the case that many of the non-respondents: 1) were not working in the health education profession, 2) were not using the credential, or 3) had no problems maintaining their credential and thus nothing to report. Having stated this, the response rate obtained does leave one wondering if responses from non-respondents would have changed the results.

RECOMMENDATIONS

IMPLICATIONS FOR THE HEALTH EDUCATION PROFESSION

It is evident from this study that there are specific reasons for why certified health education specialists seek and maintain the CHES credential, and some obstacles that are faced by those who work to maintain their certification. Having this information should be useful to at least two different organizations. The first is NCHEC. It is recommended that several of the sub-groups within the NCHEC structure review the results of the study and examine their practices based upon the information. For example, NCHEC's Marketing Committee might be able to find information that would help them to target market the credential to both non-certified health education specialists and employers. Such information may lead to the creation of a new tag line for the credential or help with creating branding slogans. The Division Board of Professional Development (DBPD) may find information that may help reduce some of the obstacles (e.g., costs and limited opportunities for CECHs) faced by CHES in obtaining their CECHs. For example, publicizing the continuing education events that are "free or inexpensive" may help with the reported cost obstacle, while producing a similar listing showing the variety of ways of earning CECHs could help overcome the perceived "limited opportunities" obstacle. This could be done via targeted emails and a "featured listing" in the CHES Bulletin--the newsletter of NCHEC. And, the Division Board of Professional Preparation and Practice (DBPPP) may find the information useful in connecting in different ways with health education professional preparation programs to encourage more soon to be eligible graduates to take the certifying examination.

The second organization that should benefit from the results of this study is the Marketing the Profession Task Force of the Coalition of National Health Education Organizations (CNHEO). The information and data generated by this study should provide another "piece of the understanding" of the health education profession and may contribute to the profession-wide strategic marketing plan called for by Gambescia et al. (2009).

NEED FOR ADDITIONAL RESEARCH

As noted above the CHES credential is still relatively young, and thus there is still a need to find out more about those who hold the CHES credential. A similar study as the present study, but using one or more comparison groups would provide a better understanding of those health education specialists who hold the credential versus those who do not. It will also be useful to wait a number of years and replicate this study when the NCHEC database is larger to see if the reasons for seeking and maintaining the credential are the same. And finally, it might also be useful to conduct a regular "satisfaction survey" with those who hold the CHES credential so that they might be better served by NCHEC.

CONCLUSIONS

Based upon the results and within the limitations of this study, we have concluded that the reasons for initially obtaining the CHES credential and maintaining it over time are similar. They include: 1) "to improve my chances of getting a job," 2) "to show others that I am competent to practice health education," and 3) "to assist with my upward mobility within the profession." In addition, it does appear that that the amount of time a health education specialist has worked in the health education/promotion field does have an impact on the reasons to maintain the credential and the reported obstacles to obtaining CECHs. Finally, there is still much work to be accomplished in marketing the CHES credential to others in the profession, and those who hire health education specialists.

Acknowledgement:

The authors would like to thank the entire NCHEC staff, specifically Linda Lysoby, MS, CHES, CAE, Executive Director, Sandy Schaffer, Continuing Education Coordinator, and NCHEC's Board of Commissioners for their support and assistance in carrying out this study. In addition, the authors wish to thank James A. Jones, PhD, Assistant Director of Research Design and Analysis, University Computing Services, Ball State University, for his assistance in data analysis.

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James F. McKenzie, PhD, MPH, CHES, is a Professor in the Department of Physiology & Health Science at Ball State University. Denise M. Seabert, PhD, CHES, is an Associate Professor in the Department of Physiology & Health Science at Ball State University. Please address all correspondence to: James F. McKenzie, PhD, MPH, CHES, Department of Physiology & Health Science, Ball State University, Muncie, IN 47306. Tel: 765-285-8345. Fax: 765-285-3210. E-mail: jmckenzie@bsu.edu
Table 1. Selected Demographic Variables of Respondents (N=1,340)

Years worked in the health
education profession

  Mean                                    5.78 years
  Median                                  4.00 years
  Mode                                    2.00 years
  Range                                   38.00 years (0 to 38)

                                          n             %

Highest level of education completed
  Bachelor's degree                       384           28.7
  Master's degree                         820           61.2
  Specialist degree                       1             <0.1
  Doctoral degree                         95            7.0
  Other                                   39            2.9
  No response                             1             <0.1

Highest level of education completed
at the time of the CHES examination

  I did not hold a degree, I was within
  the 90-day period before earning my     217           16.2
  bachelor's degree
  Bachelor's degree                       425           31.7
  Master's degree                         622           46.4
  Specialist degree                       0             0.0
  Doctoral degree                         61            4.6
  Other                                   12            0.1
  No response                             3             <0.1

Work in ahealth education/health
promotion setting

  Yes                                     1034          77.2
  No                                      306           22.8

Health education/promotion work setting

  School health (K-12)                    40            3.0
  Community health agency                 193           14.4
  Governmental health agency              277           20.7
  Business/industry (worksite)            130           9.7
  Health care                             108           8.1
  Academic (Jr. college, college,         219           16.3
  or university)
  Other                                   66            4.9
  No response                             307           22.9

Table 2. Reasons for initial certification and
maintenance of certification

                                          Check all    Primary reason
                                          that apply

                                          n (%)        n (%)
I became CHES certified initially:

  - because it was a requirement          69 (5.1)     54 (4.0)
    for me to graduate.
  - because a professor recommended       615 (45.9)   94 (7.0)
    that I do so.
  - because it was an expectation of      95 (7.1)     18 (1.3)
    my alma mater.
  - to improve my chances of              928 (69.3)   464 (34.6)
    getting a job.
  - to show others that I am competent
    to practice health education.         980 (73.1)   404 (30.1)
  - for personal gratification            827 (61.7)   124 (9.3)
    and pride.
  - because it was required               93 (6.9)     54 (4.0)
    for my job.
  - to support the health                 640 (47.8)   69 (5.1)
    education profession.
  - to serve as a role model to           375 (28.0)   17 (1.3)
    other professionals.
  - other (please specify)                77 (5.7)     38 (2.8)
  - No response                           NA           4 (<0.1)

I continue to be CHES certified:

  - to improve my chances of              574 (42.8)   217 (16.2)
    getting a job.
  - to assist with upward mobility        696 (51.9)   259 (19.3)
    within the profession.
  - to show others that I am competent    963 (71.9)   386 (28.8)
    to practice health education.
  - because it is required to             103 (7.7)    52 (3.9)
    keep my job.
  - for personal gratification            711 (53.1)   111 (8.3)
    and pride.
  - to support the health education       716 (53.4)   137 (10.2)
    profession.
  - to serve as a role model to other     420 (31.3)   27 (2.0)
    professionals.
  - because it increases my sense of      552 (41.2)   79 (5.9)
    pride about the profession.
  - other (please specify)                90 (6.7)     59 (4.4)
  - No response                           NA           13 (<0.1)

Table 3. Obstacles to maintaining certification (N=1340)

                                               Check all    Primary
                                               that apply   reason

                                               n (%)        n (%)
What obstacles do you face in trying
to maintain your CHES credential?

  - I have none.                               174 (13.0)   NA
  - The cost of the annual renewal fee.        412 (30.7)   107 (8.0)
  - Costs associated with obtaining CECHs.     706 (52.7)   380 (28.4)
  - Lack of or limited opportunities           674 (50.3)   252 (18.8)
    to obtain CECHs.
  - Lack of support from my employer to        281 (20.9)   46 (3.4)
    maintain CHES.
  - Lack of time needed to obtain the CECHs.   413 (30.8)   114 (8.5)
  - Lack of knowledge about upcoming           445 (33.2)   98 (7.3)
    continuing education opportunities.
  - Available continuing education             166 (12.4)   23 (1.7)
    opportunities are not of interest to me.
  - Available continuing education             338 (25.2)   94 (7.1)
    opportunities are not applicable
    to my work.
  - other (please specify)                     106 (7.9)    53 (4.0)
  - No response                                NA           174 (13.0)
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