Training public health superheroes: five talents for public health leadership

Abstract

Background

Public health leaders have been criticized for their policy stances, relationships with governments and failure to train the next generation. New approaches to the identification and training of public health leaders may be required. To inform these, lessons can be drawn from public health ‘superheroes’; public health leaders perceived to be the most admired and effective by their peers.

Methods

Members and Fellows of the UK Faculty of Public Health were contacted via e-newsletter and magazine and asked to nominate their ‘Public Health Superhero’. Twenty-six responses were received, nominating 40 different people. Twelve semi-structured interviews were conducted. Thematic analysis, based on ‘grounded theory’, was conducted.

Results

Five leadership ‘talents’ for public health were identified: mentoring-nurturing, shaping-organizing, networking-connecting, knowing-interpreting and advocating-impacting.

Conclusions

Talent-based approaches have been effective for leadership development in other sectors. These talents are the first specific to the practice of public health and align with some aspects of existing frameworks. An increased focus on identifying and developing talents during public health training, as opposed to ‘competency’-based approaches, may be effective in strengthening public health leadership. Further research to understand the combination and intensity of talents across a larger sample of public health leaders is required.

Background

Public health leaders in the UK have been criticized for spending ‘too much of their time looking inwards, missing opportunities to translate important new science into robust policy’.¹ The recent failures to, persuade the government in the UK to institute minimum unit alcohol pricing and standardized packaging for tobacco products,^2,3 cause further concern for the impact and influence public health leaders will have upon policy decisions. Previous studies have also highlighted public health leaders' concerns about their ability to influence policy decisions,⁴ and of the need for public health leaders to be better prepared for the challenges of a ‘new era’, characterized by complex public health challenges.⁵

The public health profession needs to understand why this is the case, and to act to ensure public health leaders are more effective in the future.⁶ International literature on leadership suggests that at the heart of the most successful organizations are individuals who have been described as ‘Level 5 leaders’ who are a ‘paradoxical blend of personal humility and professional will’ and make the right decisions happen.⁷ Such leadership has also been recognized as being important in social sector organizations⁸ although in these contexts Level 5 leaders are described as having more diffuse and less clear executive power, relying on exemplary powers of persuasion, strong political currency and the building of strong coalitions based upon shared interests to exert influence.

This is pertinent in the UK, where in April 2013 the majority of public health professionals trained and employed in the National Health Service (NHS) were relocated to local government organizations. In a more politicized organizational context, public health professionals will need to develop new skills. Local government will also host public health trainees and have a role in professional development of senior public health specialists.⁹ New approaches to public health training and practice may be required, both in the UK and internationally as they develop their public health training programmes.

To inform these approaches, important lessons can be drawn from the traits of those public health leaders who are perceived to be the most effective and admired Level 5 leaders or public health ‘superheroes’ in the eyes of their peers. How have they made the right decisions happen for public health? And what can we learn from them to better identify, train and develop the public health Level 5 leaders of the future to strengthen their influence upon decisions that influence the public's health?¹

Methods

Members and Fellows of the UK Faculty of Public Health, the professional body responsible for public health training and accreditation, were contacted between March and April 2012 via the members e-newsletter and the magazine Public Health Today¹⁰ and asked to nominate their ‘Public Health Superhero’ who ‘particularly inspired or influenced’ their career or whom they particularly admired ‘because of their influence on the health of the public’ and ability to ‘make the right decisions happen’.¹⁰

Twenty-six responses to the advert were received, nominating a total of 40 different people: 2 people were nominated twice and some responders nominated more than one person (range 1–11). Nominations included two politicians and one literary author.

A convenience sampling approach¹¹ was utilized to arrange twelve semi-structured interviews with the responders about their nominated superhero. One interview (Interview 3, Table 1) involved two responders. All other interviews were conducted with the individual responders. The interviews covered 14 nominees from a range of public health fields and also from outside public health (Table 1).

Table 1

Public health superheroes areas of work and training

Interviewee characteristics					Nominated public health superhero characteristics
Interview number	Gender	Primary field(s)	Predominant level of work	Public health trained	Gender	Primary field	Predominant level of work	Public health trained
1	F	Generalist public healtha	Local	Yes	F	Generalist public health	International	Yes
2	M	Third sector/charity	National	No	M	Policy (injury prevention)	International	No
3	M, F	Generalist public health	Local	Yes, No	M	Generalist public health	Local	Yesa
4	M	Generalist public health	Local	Yes	M	Generalist public health	Local	Yesa
4	M	Generalist public health	Local	Yes	M	Generalist public health	Local	Yes
4	M	Generalist public health	Local	Yes	M	Generalist public health	Local	Yes
5	M	Generalist public health	Local	Yes	M	Generalist public health	International	No
6	M	Academic	National	Yes	M	Policy (government advisor)	National	Yes
7	M	Communicable disease control	Local	Yes	M	Policy (immunization)	National	Yes
8	F	Generalist public health	Local	Yes	F	Policy (government advisor)	National	Yes
9	M	Generalist public health	Local	Yes	M	Generalist public health	Local	Yes
10	F	Generalist public health	Local	Yes	M	Generalist public health	Local	Yes
11	F	Generalist public health	Local	Yes	M	General practitioner	Local	No
12	M	Generalist public health	Local	Yes	M	Generalist public health	Local	Yes
12	F	Communicable disease control	National	Yes	M	Paediatrician	Local	No

a

Generalist public health refers to a specialist competently working across nine key areas of public health.²⁹

b

Same superhero nominated by interviewees

Interviews were conducted by M.D. and D.S. (together) via the telephone or in person with participants between March and June 2012. All interviews were recorded following consent. Interviews ranged from 30 to 45 min in duration. Interviewees were asked for background information about their superhero and the context in which they worked with them (if at all). They were asked about their superhero's vision, approach to team building, influence on large-scale change and managing conflict. Open-ended questions reflecting on the current state of public health leadership and other effective public health leaders were also included. Interviews were transcribed and coded by one of the authors (M.D.). A thematic analysis,¹² based on ‘grounded theory’, was conducted by two of the authors (M.D. and D.S.). This approach enabled the generation of theory based on the interviewee's responses and ensured no pre-determination of the results based on existing theories of leadership.¹³

Results

Interviewees described significant achievements ascribed to the leadership of the public health superhero. Objective measures at a local level included reductions in cardiovascular mortality, reductions in teenage conception rates and improvements in life expectancy. Other measures of ‘large-scale change’ included the initiation, undertaking and dissemination of pioneering research, influencing public health policy in immunization, injury prevention, screening programmes, chronic disease, health inequalities, and training and education.

The five talents for public health leadership

Thematic analysis identified five ‘talents’ evident in our public health superheroes. These were mentoring-nurturing, shaping-organizing, networking-connecting, knowing-interpreting and advocating-impacting. Example quotations are provided in Appendix.

Mentoring-nurturing

Public health superheroes were characterized by their exceptional commitment to professional welfare, particularly in the form of ‘mentoring-nurturing’ colleagues and junior staff to be advocates for public health. This was achieved through articulating their strong sense of public health shared values, actively encouraging others to join the profession. Through mentoring and nurturing, public health superheroes created environments where individuals felt a pride to be practising public health. All public health superheroes used mentoring-nurturing as a means of building and fostering professional networks.

Shaping-organizing

Public health superheroes demonstrated exceptional skills in shaping and organizing the agenda for the benefit of the public health cause. Methods used to shape and organize included exceptional meeting administration, expert note taking, and the ability to use administrative techniques to influence internal agendas and external stakeholders. However, there was more to this than just making sure that things ran smoothly. Public health superheroes used their shaping-organizing talents to develop other talents, such as their professional networks. The ability to use shaping-organizing techniques to implement their overall vision was also exceptional. In this context, one superhero ‘took control’ of meeting minutes as a mechanism to implement her vision.

Networking-connecting

The ‘networking-connecting’ talent was used to maintain and develop links and relationships, between organizations and individuals at all levels. This included creating close links with a wide range of agencies and stakeholders, in particular the media. The ‘cultivation’ of long-term relationships in all of these settings was important for effective public health practice, particularly where public health advice went against ‘the status quo’.

Knowing-interpreting

Public health superheroes demonstrated exceptional abilities in ‘knowing-interpreting’ information to further the public health cause and enable others to act. There was an important distinction between the local- and national-level superheroes in this context; national-level leaders demonstrated depth of knowledge in a specific topic area or field, whereas local leaders demonstrated breadth across a wide range of public health areas. Crucially, knowing-interpreting talents were used to exert authority and as a mechanism to develop the power and authority necessary in a range of different settings.

Advocating-impacting

All superheroes excelled in some form or method of advocating-impacting; some excelled via writing for journals and opinion pieces, others via public speaking or media interviews, although not all superheroes were confident or polished communicators. A common theme across all the superheroes was that credibility was the key to being effective and that this was achieved predominantly through the ‘work done on the ground’. Interviewees described how advocacy varied in effectiveness. In three cases, the impact personally for the superhero resulted in a direct loss of the position or forced resignation.

Public health superheroes deemed successful by interviewees at advocating-impacting developed strong networks, within and across different organizational environments, to support any controversial advice.

Discussion

Main findings of this study

This study identified five predominant public health leadership talents: mentoring-nurturing, shaping-organizing, networking-connecting, knowing-interpreting and advocating-impacting.

What is already known?

Leadership traits versus leadership talents

Leadership studies and assessment tools have traditionally focussed on the ‘traits’ and ‘practices’ of leaders. Corresponding approaches to improving leadership have therefore focussed on identifying leadership traits through psychometric tools and focussed on strengthening the weaknesses identified.¹⁴ This traditional approach to strengthen weaknesses has been criticized, with studies arguing that the focus should be upon action to strengthen ‘personal talents’.^15,16 Talents differ to strengths in that they are related to naturally recurring patterns of thought, feeling or behaviour, which can be productively applied. Talents combine with knowledge, skills and time spent investing and developing skills and knowledge base to create an individual's strengths.¹⁷ Superheroes demonstrated this talent-based approach in their work. In one example, the superhero was described as having poor communication skills but he did not focus on this weakness, but concentrated on his other talents and structured his team accordingly so that communication was undertaken by more effective individuals. This talent-based approach to leadership has been applied and vindicated in other sectors, where effective leadership has been shown to be rooted in the effective use of disparate talents throughout the team, as opposed to within one individual.^15,16 Therefore, the key to developing strengths is to identify the most dominant talents within teams and individuals.¹⁷A focus on strengthening leadership talents may therefore provide an alternative approach to consider when identifying and developing public health leaders. Thus, we do not claim that the five talents that we identified are necessarily the best or even the only schema for describing public health leadership, although there is merit in exploring these further. However, we believe that they are a useful basis for strengthening public health leadership.

The difference between public health leadership ‘talents’ and existing leadership frameworks

Two commonly used frameworks for leadership development are the Leadership Practices Inventory (LPI)¹⁴ and The Gallup Organisations' individual leadership talents.¹⁸ We have attempted to map both of these to the public health leadership talents. The LPI identified five commonly used leadership practices. Our public health talents can be applied to each of the practices, although some talents mapped to more than one practice (Fig. 1). Mentoring-nurturing links to three of the five practices. This could reflect the strong emphasis of the LPI on emotional intelligence, upon which it had a strong basis.¹⁴

Fig. 1

Relationship between LPI¹² and public health leadership talents.

The Gallup leadership talents are categorized under four broader ‘theme’ headings. Fig. 2 shows the interaction with the public health leadership talents, with public health talents all mapping across at least two of the Gallup talent themes. For example, the relating stream is strongly associated with our ‘mentoring-nurturing’ and ‘networking-connecting’ talents. The ‘thinking’ stream is strongly associated with our ‘knowing-interpreting’ theme. Our ‘advocating-impacting’ theme is strongly associated with the ‘striving’ theme. ‘Impacting’ talents feature across all of our talents with the exception of ‘knowing-interpreting’.

Fig. 2

Relationship between Gallup talents and public health leadership talents.

It is important to emphasize that no individual is expected to possess every single leadership talent, it is rather the ‘combination and intensity’ of the talents and themes, which render a leader unique.¹⁸ There was significant interaction between the public health leadership talents. For example, ‘networking-connecting’ related to all of the other talents; as the means by which superheroes became aware of and developed colleagues by ‘mentoring-nurturing’; through utilizing networks to tap into the expertise of others for ‘knowing-interpreting’; for building confidence of others in meetings when ‘shaping-organizing’; and crucially, through providing the infrastructure to ‘advocate-impact’ on contentious or politically sensitive public health issues.¹⁹ Similarly, ‘knowing-interpreting’ had strong links to both ‘shaping-organizing’ and ‘advocating-impacting’. Through ensuring thorough preparation and organization, and relaying complex information to impact on public health decisions, these examples are not exclusive, and there were many more examples from our superheroes of where the talents interacted.

What this study adds

The Gallup talents were predominantly developed in the private sector, whereas our public health ones have been derived predominantly from the public sectors. More increasingly it has been noted by Collins and others that the types of power required to influence within different settings and in particular the social sector differs significantly.^8,19 In the UK, the Department of Health has acknowledged this in the recent Public Health Workforce Strategy by stating that ‘The changes to the public health system will bring a challenge for continued and stronger leadership. For those working in local government there will be a need for new skills in working with elected members, and possibly managing new services aligned to public health in that environment’.⁹ The King's Fund have gone further, proposing that leadership across the health and social care system should be based upon ‘ability to influence’, ‘working across boundaries’ and, crucially, in ‘persuading others of the right course of action’.²⁰ Interviewees referred to this in describing the power superheroes utilized to advocate-impact through adapting to differing contexts of power and authority, as one interviewee described it, a public health superhero is able to maintain influence regardless of ‘positional power’.

Implications for public health training

In the UK, Public Health Higher Specialist Training²¹ involves workplace-based training in a range of public health settings including local and national government, communicable disease control and academic public health departments.^21,22 Trainees are examined by two professional examinations, one focussed on public health knowledge, which occurs early in training, and one based on skills, undertaken at the mid-way point. Public health training in the USA and Canada is also currently structured around core competencies, including ‘leadership’.²³ The extent to which leadership skills and experience are actually developed in such training, however, is debatable. Furthermore, it is important to stress that not all those in public health training are expected to progress to a public health superhero status or that of a Level 5 Leader. Our public health talents provide a basis for strengthening talents to assist those in training to move to the next level of leadership.⁶

The UK training programme is likely to be more effective in developing some of the public health leadership talents relative to others (Table 2). For example, for talents such as ‘mentoring-nurturing’, there is a fair degree of luck in being allocated an effective training location and trainer, where there is a good interpersonal rapport. Similarly, ‘buddy’ type schemes for new trainees or newly qualified senior practitioners tend to be focussed on the more structural aspects of induction, as opposed to the shifts in leadership practice required and described in other sectors.²⁴ Workplace-based training may develop ‘shaping-organizing’, and to some degree ‘advocating-impacting’ through gaining understanding and experience of different decision-making processes within organizations. For ‘knowing-interpreting’, professional courses such as Masters in Public Health predominate, with subsequent testing via examinations. For ‘networking-connecting’, opportunities for development are less formal, and at individual level, although many of the superheroes were not naturally extrovert individuals, the talent was still prominent. There is, therefore, scope to provide training and simple advice to develop this talent. For example, there is currently no dedicated chapter covering networking ‘for’ public health in existing practice-based guides.²⁵

Table 2

Implications for training and development of public health talents

Talents	Current predominant training methods	Factors influencing talent development
Mentoring-nurturing	Brief courses for trainers on the theory of mentorship and preferred learning styles.	Training on coaching or a mentorship tends to be limited, with erratic or on-going support. Trainers may not attend relevant courses.Relies heavily on personal experience and interpersonal skills. Trainees may adopt styles of their trainers that they found personally helpful.There is a risk that good (but not outstanding) trainers will just train more of the same.Mentoring or ‘buddy’ schemes are helpful but mainly focus on help ‘finding the ropes’.There is limited scope for trainees to be line managers so that they can develop their mentoring/coaching skills.
Shaping-organizing	Workplace-based training, with pre-/post-meeting debriefs. Management theory taught via postgraduate courses and tested by examination.	Pre- and post-meeting brief/debriefs to teach ‘politics’ of public health tend to be more prominent within the early stages of training. In latter stages, trainees are expected to be more self-sufficient, but will miss out on support to enhance this Talent.Training can be limited by the seniority and experience of the trainer. However, current rotation through multiple public health organizations and working with trainers with different management styles will be of benefit.Courses on minute taking, setting agendas and delegation exist but are rarely accessed or the importance stressed of these skills for an effective leader.There are limited opportunities for trainees to manage budgets or to be line managers.
Networking-connecting	Mainly workplace-based training. Formal media training short courses, and interaction with media in the workplace.	Relies heavily on personal confidence and experiences, and not a formal component of public health training.Re-organization of public health systems can serve to disrupt networks.Exposure of public health trainees to ‘emerging leaders’ in other sectors may have been limited through lack of links to wider programmes at home and abroad.Can be improved through simple preparation, e.g. targeting key individuals, and peer methods.Networking materials should be part of day-to-day practice such as business cards and via use of social media to engage with other sectors.
Knowing-interpreting	Postgraduate courses on the knowledge and skills of public health, tested by examination.	The convenience of being able to teach and test knowledge rather than skills has meant that this Talent tends to predominate within training programmes.Emphasis is on knowing rather than interpreting, and the ‘power’ associated with being a ‘superhero’ is largely associated with the ability to ‘interpret’.Emphasis of current training is on technical appraisal of evidence, rather than on how to present information in a suitable language/format for public, policy makers, etc.Trainees would benefit from more opportunities to present at public meetings, to elected officials, the media and to senior leaders outside of public health.
Advocating-impacting	Workplace-based training.	Workplace experience and roles on wider committees are important. However, current training restricts the scope to advocate as mostly project/topic based.Public health has relatively poor record in dissemination, and scope for making impact is limited by ‘fire-fighting’ and time pressure to move onto next project.It is also limited by skills in how to disseminate and the resources to do it effectively.

For ‘networking-connecting’ and ‘advocating-impacting’, there is evidence that in the UK at least, constant re-organizations of the NHS (where public health has been housed from 1974 to April 2013) has had an impact upon the strong networks needed to influence policy,^26,27 which have included concerns regarding the ‘corporatisation’ of public health,⁴ and a growing distance between service-based public health and academia. In the USA, the Centers for Disease Control has supported a university-based National Public Health Leadership Institute (NPHLI) in an attempt to develop and maintain strong intergovernmental and intersectoral networks of leaders who share knowledge and jointly address public health problems.^28,29 Leaders involved in the scheme have benefited from learning and applying new coaching techniques, managing conflicts and crucially, through negotiating ‘win–win’ partnerships with other agencies to impact upon public health issues. The experiences of the NPHLI suggest similar approaches in the UK, and other countries may be applicable to assist the development of all of the public health talents described in Table 2. In the UK, the recent Public Health Workforce Strategy acknowledges this current gap through outlining an action for agencies ‘to co-design and develop leadership programmes that will create exceptional leadership capability, underpinned by initiatives that will create the conditions in which system or shared leadership can flourish’.⁹ The ‘co-design’ of these leadership programmes further underlines the importance of intergovernmental and intersectoral networks and also serves to reiterate the fact that not all public health superheroes come from within public health. Identifying Level 5 Leaders for public health from other sectors, understanding why and how they are effective and utilizing their resources for the public health cause is a priority.⁶

Limitations

Nominations of public health superheroes were accepted at their face value, in that the people nominated were deemed worthy of the label ‘superheroes’ or definition of a ‘level 5 leader’, which were included in the advert. We did not attempt to validate these achievements nor inquire whether other people had differing views of the nominee's merits. Furthermore, the adverts focus on ‘who inspired or influenced your career’ may explain the emergence of the ‘mentoring-nurturing’ talent. Our study also has a small sample size compared with the only other qualitative study on public health leaders conducted by Rowitz.^4,31 The fact that our public health ‘talents’ align with published evidence on a wider pool of leaders in other sectors is reassuring (Figs. 1 and 2).

Recommendations

An increased focus upon identifying and developing the public health talents identified in this paper may help to improve the identification and training of future public health leaders. For those involved in planning and providing public health training programmes, we propose a number of ways public health training programmes could strengthen the leadership talents (Table 2).

Networking-connecting emerges as one which is necessary to strengthen all of the other talents, but perhaps not sufficient for effective leadership in its own right. Furthermore, it is perhaps the least focussed on talent in current training programmes (Table 2). We recommend a strengthening of focus on this talent within public health training programmes through developing new ways to engage with emerging leaders and training programmes in other sectors, as in the NPHLI example, to share and disseminate good practice, and develop strong and long lasting multi-agency networks able to withstand system re-organization. To support this, training providers must create and encourage opportunities for high-level placement opportunities in home countries, and abroad. Exposure to different systems, decision-making processes and organizational cultures will help shift the focus of public health training from technical skills to the development of the public health leadership talents.

Our results have demonstrated that combination and intensity of the talents are important for effective public health leadership. However, further research to explore the association between the talents and corresponding ‘effectiveness’ of public health leaders beyond the basis of peer nomination is also required. We recommend this utilizes a larger international sample of public health leaders and established leadership profiling instruments, which will help to establish the exact degree of ‘combination and intensity’ of the talents required of an effective public health leader.

A focus upon strengthening public health leadership talents offers an alternative approach to try to ensure that the next generation of public health leaders avoid the criticisms levelled at their predecessors and are better equipped for the public health leadership required in the 21st century.

Authors’ contributions

M.D., D.S. and K.S. drafted the article. K.S., T.O. and K.Z. contributed to initial data interpretation and literature searching and contributed editorial comments. J.M. contributed to discussion for planning the research and of its findings. M.D., D.S. and K.S. designed and conducted the survey. M.D. and D.S. conducted the interviews from which the results are drawn and were responsible for data analysis.

Acknowledgements

This work was supported by the Worldwide Universities Network. Grant number: WUN RDF 2010.

Appendix: Example quotes [interviewee number]

Mentoring-nurturing	‘He was always had the welfare of, the professional welfare, the financial welfare, the personal welfare of his team members at his heart’.3 ‘He was very generous about giving us the credit for actually rather more than we had done, but I think it's actually quite unusual for someone in the position of seniority to be sharing the credit and minimising their own contribution rather than talking themselves up’.6
Shaping-organizing	‘She always took notes of everything, how to chair meetings, how to run an office, how to work with a secretary, how to follow things up, how to have regular one to one meetings with people’.8 ‘I mean she took her power through keeping hold of the strings, she always chaired meetings and she would more often than not would take the notes at meetings as well…. do the notes cause she then took control of the minutes’.8
Networking-connecting	‘He was a fantastic person who can network at various levels; network with the grassroots trainees, or network at the chief exec level… People didn't find him intrusive, people found him as someone who they should want to listen to … Building partnerships was the other thing was he was quite hard working at’.9 ‘[She] exhibited a lot of emotional intelligence, because it's very difficult managing very diverse sets of interests, you've got financial pressures in that environment, you've got very political decisions, you've got ethical decisions that you're making……what could have been an incredibly antagonistic difficult environment in terms of decision making felt incredibly collegiate’.1 ‘You need strong networks, you need people who believe in you, you need people who will support you if you're going to challenge the status quo, however carefully and politely and gently you're going to do that.’6
Knowing-interpreting	‘The breadth and depth of his knowledge [of his expert field] is just incredible, just incredible …When I'm talking about breadth and depth I'm talking about within the technical, defined field’7 ‘It was very much about deciding what your line was, taking your evidence based line, in as much as there's evidence around, making judgments, finding a sensible way though it, but if the Minister insists on doing something stupid then you will have a resignation point. And some of that comes down to his authority, because he's someone one wouldn't want to resign’.8
Advocating-impacting	‘He knew he would never get permission to commission that sort of report by going as it were overtly and asking, so he did it underhand…he did it in full knowledge of the likely consequences, but the consequences were helpful in my view in promoting the issues that he wanted to be promoted … and was very largely instrumental in putting the inequalities issue really in the middle of the public health agenda, and to my mind there isn't much more heroism than that’.4 ‘We also had major concerns about the probity of the government's approach to this…. we thought that was unethical, and contrary to the evidence, and he just didn't accept that…and he ended up ringing the [Chief Medical Officer] directly, and he's willing to take risks, you know, the CMO listened and nothing happened of course, not at the time, but he did have a longer term impact there because we've changed policy here’.3 ‘He concentrates on the doing rather than the telling, and sometimes you do have to invest quite a bit in the telling don't you in order to get buy-in from others’.3