Received: 7 April 2023 Revised: 6 July 2023 Accepted: 11 July 2023

DOI: 10.1111/phn.13229

P R O G R A M E VA L U AT I O N

Effectiveness of a web-based learning program for promoting

local healthcare planning competencies

Kyoko Yoshioka-Maeda PhD, RN, PHN1 Takafumi Katayama PhD2

Hitoshi Fujii PhD3 Misa Shiomi PhD, RN, PHN4 Noriko Hosoya PhD, RN, PHN5
Tatsushi Mayama MS6

1
Department of Community Health Nursing,
Division of Health Sciences and Nursing, Abstract
Graduate School of Medicine, The University
Objective: To determine the effectiveness of a web-based educational program
of Tokyo, Bunkyo-ku, Tokyo, Japan
2
Department of Statistics and Computer
regarding local healthcare planning by public health nurses (PHNs) in Japan.
Science, College of Nursing Art and Science, Design: A single-blind randomized controlled trial.
University of Hyogo, Akashi City, Hyogo, Japan
Sample: Full-time PHNs working for local governments across Japan.
3
Department of Medical Statistics, School of Measurements: The primary outcome was nurses’ self-perception of competencies
Nursing, Mejiro University, Saitama City, in public health policy. The secondary outcome was self-perception of knowledge,
Saitama, Japan
4
skills, and perspectives regarding local healthcare planning. We analyzed inter-
Department of Human Health Sciences,
Graduate School of Medicine, Kyoto group differences using the intention-to-treat principle and the Mann–Whitney
University, Kyoto City, Kyoto, Japan U-test.
5
Department of Nursing, Faculty of Healthcare
Intervention: The intervention group received six web-based learning modules includ-
Sciences, Chiba Prefectural University of
Health Sciences, Chiba City, Chiba, Japan ing substantial knowledge and skills regarding local healthcare planning based on
6
Faculty of Policy Studies, Doshisha the analysis, design, development, implementation, and evaluation model and adult
University, Kyoto City, Kyoto, Japan
learning theory.
Correspondence Results: Totally, 273 PHNs registered, and 38 were excluded without completing the
Kyoko Yoshioka-Maeda, Department of baseline survey; 235 were randomly allocated to either the intervention (n = 118) or
Community Health Nursing, Division of Health
Sciences and Nursing, Graduate School of control (n = 117) groups. Sixty-four participants in the intervention group completed
Medicine, The University of Tokyo, Japan, the program. Over 70% of the participants lacked opportunities to learn about local
7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033,
Japan. healthcare planning. The intervention group showed significant improvement in self-
Email: [email protected] perception of competencies, knowledge, and skills regarding local healthcare planning,

Funding information
except for items related to evaluation.
JSPS KAKENHI, Grant-in-Aid for Scientific Conclusions: The web-based learning program effectively improved participants’ self-
Research (B), Grant/Award Number:
19H03972
perception of competencies in local healthcare planning.

KEYWORDS
continuing education, health policy, public health nursing competencies

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Public Health Nursing published by Wiley Periodicals LLC.

Public Health Nurs. 2023;40:685–695. wileyonlinelibrary.com/journal/phn 685

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686 YOSHIOKA-MAEDA ET AL .

1 BACKGROUND (Japan Ministry of Health, Labour and Welfare [JMHLW], 2013). They
are expected to identify community health needs in their daily prac-
Developing sustainable healthcare systems and policies to bridge tices and reflect them in local healthcare plans. However, competencies
health inequities is a global trend (Greer et al., 2022). Health poli- regarding local healthcare planning have only recently begun to be
cies focus on resolving health needs and bridging the gap between taught in basic nursing education (JMHLW, 2022). Additionally, there
the social determinants of health and their gradients to reduce vul- is only one validated scale in Japan to assess PHNs’ self-perceived
nerability and inequities in community settings (Lucyk & McLaren, competencies regarding local health policy development (Suzuki &
2017). Approximately 60% of healthcare professionals are nurses Tadaka, 2014). A nationwide survey showed that less than half of
(World Health Organization, 2020); nurses must be involved in pub- PHNs had received practical training (Yoshioka-Maeda et al., 2022).
lic health policy development that fulfills individual, aggregate, and Due to personnel changes in public sectors, local healthcare plan-
community health needs (International Council of Nurses, 2005). It is ning can only be experienced by those in charge. Therefore, most
essential to identify vulnerable individuals and groups to develop local PHNs may lack training and practical experience in local healthcare
health policies. Public health nurses (PHNs) are crucial for identifying planning.
community health needs and targeting vulnerable groups to promote This study aimed to examine the effectiveness of a web-based learn-
evidence-based health policymaking (American Public Health Associ- ing program regarding local healthcare planning among PHNs using
ation [APHA] & Public Health Nursing Section, 2013; Quad Council a randomized controlled trail (RCT) design. Continuing education is
Coalition [QCC], 2018). Developing PHNs’ competencies among in vital to enhance nursing competencies and update knowledge and
health policy formulation is a significant challenge. skills with lifelong learning perspectives and quality of care (Lera et al.,
Health policies should focus on the social norms, cultures, and gra- 2020). Web-based learning modules are suitable for flexible continu-
dients that impact community health disparities (Brown et al., 2019). ing education with reduced time and costs (Rouleau et al., 2019). A
Social determinants of health should also be considered in health poli- literature review showed that most studies focus on improving nurses’
cies to reduce disparities (Marmot, 2017). For emergencies and daily knowledge and skills in individual and family care (Du et al., 2013).
routines, PHNs identify community health needs by providing indi- There are no web-based learning modules for improving skills and
vidual care and reflecting on these needs in developing healthcare knowledge regarding local healthcare planning by PHNs (Yoshioka-
plans (QCC, 2018). PHNs enhance their policy development com- Maeda, Shiomi, Katayama, & Hosoya, 2019; Yoshioka-Maeda, Shiomi,
petencies through daily routines and career development because Katayama, Hosoya, & Kuroda, 2019). A web-based education program
practical experience is necessary for competency development (Saeki is necessary for busy PHNs to improve their skills and knowledge
et al., 2020). However, owing to busyness, PHNs have difficulty assess- regarding local healthcare planning.
ing community health needs using the methods they learned in their
undergraduate education (Shiomi et al., 2022). During the coron-
avirus disease 2019 (COVID-19) pandemic, nurses faced difficulties 1.1 Hypotheses
developing health policies due to rapid changes in community health
needs (Catton, 2021). Moreover, the shortage of PHNs became severe PHNs who receive web-based education may improve their self-
(Nganga-Good et al., 2023). Therefore, training PHNs is essential for perception of knowledge, skills, and perspectives regarding local
improving health equity in the community through developing health healthcare planning. The primary outcome was PHNs’ self-perception
policies. of competencies in local health policy development in Japan (Suzuki &
PHNs can be essential in local healthcare planning (Yoshioka- Tadaka, 2014). The secondary outcome assessed their self-perception
Maeda et al., 2022). There are 47 prefectures in Japan that provide of knowledge, skills, and perspectives regarding local healthcare plan-
technical advice and support for various municipalities. Most PHNs ning (Yoshioka-Maeda et al., 2023).
work as public servants at the local government level. Every few
years, local healthcare plans are developed as community-based pub-
lic health policies to promote community health based on national 2 METHODS
laws. Plans include programs and projects aimed at concrete resolu-
tions for achieving the policy’s goal (Mayama, 2001; Yoshioka-Maeda, 2.1 Design
2020). Additionally, other departments also develop different local
plans. Thus, when PHNs try to develop a new local healthcare plan, A single-blind RCT design was used following the wait-list method. The
they need to consider the relationship between existing policies, pro- protocol was registered in the University Hospital Medical Informa-
grams, and projects to avoid duplication. Local healthcare planning tion Network Clinical Trial Registry [UMIN-CTR] before starting the
is a basic activity of each local government and crucial for bridging study (no. UMIN000048037, Registered date: June 12, 2022). It was
the gap between community health needs and existing services to approved by the International Committee of Medical Journal Editors,
appropriately allocate resources (Yoshioka-Maeda et al., 2021). Based and published previously (Yoshioka-Maeda et al., 2022). All eligible par-
on the national guidelines of public health nursing, PHNs need to ticipants completed a baseline survey. According to the Consolidated
be involved in local healthcare planning as an upstream intervention Standards of Reporting Trials (CONSORT) statement (Schulz et al.,
 15251446, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13229, Wiley Online Library on [18/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
YOSHIOKA-MAEDA ET AL . 687

2010), the second author conducted randomization based on the per- Yoshioka-Maeda, Shiomi, Katayama, & Hosoya, 2019), the analysis,
muted block method using six blocks of four sizes (Matts & Lachin, design, development, implementation, and evaluation model (Gagne
1988). The participants were randomly allocated to the intervention et al., 2005/2007) and template for intervention description and
or control group [1:1]. Other researchers were blinded to interven- replication framework (Hoffmann et al., 2014).
tions after the assignment. All the participants were informed about We used the adult learning theory (Knowles, 1980) to design a
the group to which they were assigned by e-mail. After the intervention web-based learning program, which provided on self-directed learn-
group completed the modules, a post-test assessment was conducted ing of practical knowledge and skills. The education program focused
in both groups. Initially, the intervention group received the educa- on andragogy to help PHNs, who identify different community health
tional program, and then both groups completed the post-test survey. needs through individual care, learn how to reflect those needs in
Subsequently, the control group received the same program as the their local healthcare plans. Based on the results of a previous nation-
intervention group. wide survey, we focused on the development of Health Promotion
Plans, which many PHNs experience difficulties with (Yoshioka-Maeda
et al., 2021), and included the essential knowledge and skills of local
2.2 Sample healthcare planning based on community health needs.
The following module themes were covered in this study: (1) creat-
We conducted a pilot test 35 municipalities of one prefecture in 2021. ing a clear picture of the ideal community; (2) connecting daily routines
Sixteen PHNs registered and 12 were randomly allocated to the inter- and local healthcare planning through the Plan–Do–Check–Action
vention or control group. All participants had more than 25 years cycle; (3) understanding the relationship between existing policies
of experience as PHNs. Due to the COVID-19 pandemic, only two and a new local healthcare planning; (4) understanding the process
participants completed the test. Considering the lack of training oppor- and goal setting of a new plan; (5) understanding how to collabo-
tunities regarding local healthcare planning in Japan, the inclusion rate with the relevant people for developing and implementing a new
criterion was all full-time PHNs who worked for a local government plan; and (6) setting goals and evaluating each project based on the
in Japan, regardless of their years of experience as a PHN. The exclu- national/prefectural government’s target values. The time required to
sion criteria were being a part-time employee and not being able to use receive each module was 10−20 min. Through snow-ball sampling,
the Internet. We also excluded PHNs who worked at municipalities that five PHNs with previous involvement in local healthcare planning con-
cooperated in the pilot study. firmed the modules and content in 2020. All participants agreed with
Based on the pilot test and using G*Power 3.1.9.2., we assumed a the content. Based on their comments, we developed an introduc-
significance level of α = 0.05, β = 0.2, and power = 0.8, and the total tion to the web-based learning modules and a worksheet to help
score of the primary outcome differed by 4 points between the pre- participants understand each module and summarize their local gov-
and post-intervention scales (Faul et al., 2009). A total of 148 partici- ernments’ situations and evaluation indicators for using their practices
pants (74 in each group), were required. As PHNs were occupied with (Yoshioka-Maeda et al., 2022). Based on feedback from participants in
the COVID-19 response in Japan, we assumed a dropout rate of 40%; the 2021, we made the materials available for download.
thus, 210 participants were required for this study. After the baseline survey, the intervention group received web-
Before beginning recruitment, we developed a web site for regis- based learning modules individually via e-mail on August 15, 2022.
tering participants, collecting data, distributing the web-based learning The intervention group, wherever and whenever they liked, watched
materials, and respond to participant questions and comments. Then, each module and filled out a worksheet. Both groups completed the
the research team sent letters to 46 prefectural and 1706 municipal post-test survey until October 14, 2022. The control group received
public health nursing directors in Japan in July 2022. The directors the same program via e-mail from October 15 to December 14,
shared the letters with PHNs. Eligible PHNs accessed the study web 2022.
site. After reading the documents explaining the study, PHNs provided
web-based informed consent and registered their pseudonyms and
e-mail addresses. To ensure that participants could receive all informa- 2.4 Data collection
tion regarding this study, we replied to the e-mail address that PHNs
had registered with on the study web-site. There was no case who The study web-site was used to collect baseline and post-test data. A
could not receive an e-mail from us. reminder e-mail was sent to all participants to prevent dropouts and
increase response rates. To prevent contamination and minimize bias,
we explained that all eligible participants would collaborate with us
2.3 Interventions and maintain the confidentiality of the intervention until the end of the
study. The participants agreed to maintain confidentiality.
The research team, who worked in public health nursing, policy studies, Demographic data on age, gender, years of public health nurs-
and statistics, developed all materials. We reviewed previous stud- ing experience, designation (staff, senior staff, chief assistant section
ies (Lankshear et al., 2010; Mayama, 2001; Polivka & Chaudry, 2015; manager, section manager), education, affiliation, department, the
QCC, 2018; Saeki et al., 2020; Shiomi, 2015; Yoshioka-Maeda, 2020; opportunity to receive training at the undergraduate level and after
 15251446, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13229, Wiley Online Library on [18/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
688 YOSHIOKA-MAEDA ET AL .

graduation, and having experience in local healthcare planning were randomly allocating the remaining 235 to either the intervention
collected as the baseline assessment. (n = 118) or control (n = 117) groups on August 15, 2022. Among
We used a scale assessing primary outcomes regarding PHNs’ the intervention group, 1 participant withdrew voluntarily and 53 did
self-perception of competencies in local health policy development not answer the follow-up survey. Sixty-four participants (54.2%) in
(Suzuki & Tadaka, 2014). We chose this scale because healthcare plan- the intervention group completed the full modules and the follow-up
ning is very similar to local health policy development in Japan. The survey until October 14, 2022. In the control group, we excluded 20
scale has been validated in Japan, and includes 16 items within two participants who did not respond to the follow-up survey; thus, the data
domains: community partnership and community nursing diagnosis of 97 participants (82.9%) were analyzed.
cycle. Responses were rated on a 4-point Likert scale (0 = unable to do, Table 1 shows the sample characteristics at baseline. Most par-
1 = partially unable to do, 2 = partially able to do, and 3 = able to do). In ticipants were women and worked in the Department of Health and
this study, Cronbach’s alpha and the inter-item correlations was 0.95, Welfare. Their mean number of years working as a PHN was 17.3
high internal consistency. (standard deviation = 9.7). More than 70% of the participants did not
The secondary outcome assessed PHNs’ self-perception of knowl- have the opportunity to learn about local healthcare planning in basic
edge, skills, and perspectives regarding local healthcare planning. All nursing education or training seminars in their local governments after
items were originally developed to measure the effectiveness of the graduation because of the recent start of education in this area.
teaching module and correspond with the content of each module
to evaluate whether the participants could understand and acquire it
(Yoshioka-Maeda et al., 2023). Based on the results of the pilot study, 3.2 Primary outcome: PHNs’ self-perception of
we used 28 items, modified for clarity. Responses were rated on a 4- competencies in local health policy development
point Likert scale (1 = never, 2 = not much, 3 = a little, and 4 = a
lot). Table 2 shows the intergroup differences in the increase or decrease
in PHNs’ scores for self-perception of competencies in local health
policy development. Among the community partnership domains, the
2.5 Analytic strategy scores of seven items in the intervention group improved significantly
compared with those in the control group. Additionally, in the inter-
The second researcher deleted participants’ pseudonyms and e-mail vention group, the scores for two items regarding the community
addresses and assigned the research IDs. Then, the third researcher nursing diagnosis cycle improved significantly more than in the control
conducted the statistical analysis and described the baseline demo- group. However, the evaluation phase items did not show an intergroup
graphic data. In accordance with the intention-to-treat principle, those difference.
who dropped out of the trial were considered to have experienced no
change in their knowledge. The Mann–Whitney U-test was used to con-
firm whether there was a statistically significant difference between 3.3 Secondary outcome: PHNs’ self-perception of
pre- and post- intervention scores using SPSS for Windows version knowledge, skills, and perspectives regarding local
25 (IBM Corp, Armonk, NY). P-values < .05 indicated statistically healthcare planning
significant intergroup differences.
Table 2 shows the intergroup differences in the increase or decrease in
knowledge and performance scores concerning local healthcare plan-
2.6 Ethical considerations ning. The intervention group showed significantly improved scores for
20 of the 28 items regarding Module Themes 1−5 compared to the
The Institutional Review Board (IRB) of the primary researcher’s control group. However, items in Module Theme 6, which focused on
institution approved the study protocol on May 30 (ID: 2022024NI) evaluating the outcomes of local healthcare planning, did not show
and July 28 (ID: 2022024NI-(1)), 2022. All participants provided intergroup differences.
web-based informed consent before registration. There were no dis-
crepancies between the trial registration entry and report.
4 DISCUSSION

3 RESULTS To the best of our knowledge, this is the first RCT to evaluate the effec-
tiveness of educational modules in local healthcare planning among
3.1 Sample characteristics PHNs. The strength of this study is that the web-based education
program enhanced PHNs’ self-perception of competencies, knowl-
Figure 1 shows the CONSORT flowchart of this study. Two hun- edge, skills, and perspectives on local healthcare planning during the
dred and seventy-three PHNs registered until August 14, 2022. We COVID-19 pandemic. Despite being essential healthcare resources in
excluded 38 participants who did not complete the baseline survey, local governments, PHNs have limited opportunities for professional
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YOSHIOKA-MAEDA ET AL . 689

TA B L E 1 Characteristics of the participants.

Total Intervention group Control group

(N = 235) (n = 118) (n = 117)
n(%) or M(SD) n(%) or M(SD) n(%) or M(SD)
Sex
Male 7 (3.0) 3 (2.5) 4 (3.4)
Female 228 (97.0) 115 (97.5) 113 (96.6)
Age (years) 42.2 (9.3) 41.9 (9.8) 42.4 (8.8)
Years of public health nursing experience 17.3 (9.7) 16.8 (10.2) 17.8 (9.3)
Designation
Staff 70 (29.8) 38 (32.2) 32 (27.4)
Senior staff 68 (28.9) 31 (26.3) 37 (31.6)
Chief 56 (23.8) 25 (21.2) 31 (26.5)
Assistant section manager 25 (10.6) 13 (11.0) 12 (10.3)
Section manager 16 (6.8) 11 (9.3) 5 (4.3)
Educational background
Vocational training school 66 (28.1) 30 (25.4) 36 (30.8)
Junior college 22 (9.4) 11 (9.3) 11 (9.4)
University 129 (54.9) 67 (56.8) 62 (53.0)
Graduate school 15 (6.4) 9 (7.6) 6 (5.1)
Other 3 (1.3) 1 (0.8) 2 (1.7)
Affiliation
Prefecture 32 (13.6) 15 (12.7) 17 (14.5)
Designated city 39 (16.6) 21 (17.8) 18 (15.4)
City with a public health center 54 (23.0) 32 (27.1) 22 (18.8)
Municipality 110 (46.8) 50 (42.4) 60 (51.3)
Department
Health and Welfare 178 (75.7) 92 (78.0) 86 (73.5)
Planning 17 (7.2) 9 (7.6) 8 (6.8)
Long-term care 3 (1.3) 1 (0.8) 2 (1.7)
Community Comprehensive Care 10 (4.3) 4 (3.4) 6 (5.1)
National Health Insurance 11 (4.7) 2 (1.7) 9 (7.7)
Other 16 (6.8) 10 (8.5) 6 (5.1)
Opportunity to receive local healthcare planning training at undergraduate level
Yes 51 (21.7) 27 (22.9) 24 (20.5)
No 184 (78.3) 91 (77.1) 93 (79.5)
Opportunity to receive local healthcare planning training after graduation
Yes 63 (26.8) 27 (22.9) 36 (30.8)
No 172 (73.2) 91 (77.1) 81 (69.2)
Experience in local healthcare planning
None 108 (46.0) 58 (49.2) 50 (42.7)
Supervisory role 74 (31.5) 34 (28.8) 40 (34.2)
Member of the planning committee 10 (4.3) 6 (5.1) 4 (3.4)
Members of working groups 36 (15.3) 17 (14.4) 19 (16.2)
Other 7 (3.0) 3 (2.5) 4 (3.4)

(Continues)
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690 YOSHIOKA-MAEDA ET AL .

TA B L E 1 (Continued)

Total Intervention group Control group

(N = 235) (n = 118) (n = 117)
n(%) or M(SD) n(%) or M(SD) n(%) or M(SD)
PHN’s managers and colleagues who are motivated to develop a plan
Yes 135 (57.4) 77 (65.3) 58 (49.6)
No 100 (42.6) 41 (34.7) 59 (50.4)
Multidisciplinary managers and colleagues who are motivated to develop a plan
Yes 120 (51.1) 56 (47.5) 64 (54.7)
No 115 (48.9) 62 (52.5) 53 (45.3)

development (Nganga-Good et al., 2023). PHNs are crucial for iden- opment in local governments (Shiomi et al., 2022), for which they would
tifying health needs and targeting vulnerable groups to promote need to acquire the required competencies (JMHLW, 2013; JMHLW,
evidence-based health policy development (APHA & Public Health 2022). During the COVID-19 pandemic, traditional face-to-face edu-
Nursing Section, 2013; QCC, 2018). Community health needs influ- cation was rapidly replaced by web-based nursing education (Leaver
ence the policy development process (Scarlett et al., 2020). Therefore, et al., 2022), which allows people to study at their preferred time and
PHNs are perfectly positioned to improve needs-oriented policy devel- location (Rouleau et al., 2019). Our results suggest that web-based

Enrollment Assessed for eligibility (n = 273)

Excluded (n = 38)
i Did not meet inclusion criteria (n = 0)
i Did not answer the baseline survey (n = 38)

Randomized (n = 235)

Allocation
Allocated to intervention group (n = 118) Allocated to control group (n = 117)
i Received allocated intervention (n = 118) i Received allocated intervention (n = 117)
i Did not receive allocated intervention (n = 0) i Did not receive allocated intervention (n = 0)

Follow-Up
Lost to follow-up (n = 0) Lost to follow-up (give reasons) (n = 20)
Discontinued intervention (n = 1) iDid not answer the follow-up survey (n = 20)
i Withdrew voluntarily (n = 1)
Completed intervention and follow-up (n = 117)

Analysis
Analysed (n = 64) Analysed (n = 97)
i Did not answer the follow-up survey (n = 53)

FIGURE 1 CONSORT flowchart of participant.

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YOSHIOKA-MAEDA ET AL . 691

TA B L E 2 Increase or decrease in outcomes’ scores.

Intervention Control
group group
(n = 118) (n = 117)
M M p
PHNs’ Competencies regarding public health policy
Community partnership 1 Share health issues to be resolved with community residents. 0.119 0.052 .145
2 Share health issues to be resolved with local stakeholders, 0.153 -0.026 .001
organizations, or institutions.
3 Explain the need for program development to community 0.297 0.147 .001
residents.
4 Explain the need for program development to relevant staff, 0.203 0.034 .004
organizations, or institutions in the community.
5 Obtain agreement with local residents, community 0.305 0.086 .001
organizations, and relevant institutions regarding the need
for program development.
6 Coordinate roles in program development with local 0.288 0.103 .003
residents, community organizations, and relevant
institutions.
7 Provide equal opportunities for local residents, community 0.322 0.190 .023
organizations, and relevant institutions to participate in
program development.
8 Report the progress of the programs to local residents, 0.280 0.086 .005
community organizations, and relevant institutions.
Community Nursing Diagnosis Cycle 9 Analyze local health issues using epidemiology. 0.144 0.069 .518
10 Assess health issues from multiple perspectives. 0.076 -0.009 .977
11 Determine priorities of health issues to be addressed by a 0.110 0.017 .551
local government.
12 Consider solutions to health issues with long-term 0.178 0.060 .041
perspectives.
13 Understand programs in related fields including welfare, 0.195 0.052 .018
education, and environment.
14 Clarify evaluation indicators for programs. 0.178 0.069 .053
15 Clarify the rationale for the need to implement programs. 0.186 0.086 .353
16 Evaluate programs based on the perspective of 0.178 0.103 .198
cost-effectiveness.
PHNs’ self-perception of knowledge, skills and perspectives regarding local healthcare planning
Module theme 1 1 Can organize the residents’ voices that are heard through 0.314 0.181 .011
daily practices into demands and needs.
Creating a clear picture of the ideal 2 Understands the need to identify what the true community 0.203 0.103 .050
community health needs are.
3 Understands that reducing too much ineffectuality can lead 0.229 0.112 .000
to inadequate community outreach.
4 Understands that numerical goals are only one of the passing 0.280 0.121 .005
points.
Module theme 2 5 Understands how to utilize the reflection of daily practices in 0.254 0.164 .008
local healthcare planning.
Connecting daily routines and local 6 Use an opportunity for local healthcare planning with the 0.212 0.103 .001
healthcare planning through the evaluation of daily practices and progressing the
Plan–Do–Check–Action cycle Plan-Do-Check-Action cycle.
(Continues)
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692 YOSHIOKA-MAEDA ET AL .

TA B L E 2 (Continued)

Intervention Control
group group
(n = 118) (n = 117)
M M p
7 Understand how to evaluate daily practice. 0.144 0.009 .009
8 Can understand how to identify improvement measures 0.178 0.069 .015
through evaluation and transpose them to local healthcare
planning.
Module theme 3 9 Understand the difference between policies, programs, and 0.517 0.319 .000
projects and how to use them.
Understanding the relationship 10 Can recognize policies, programs, and projects relevant to the 0.305 0.198 .012
between existing policies and a work.
new local healthcare planning
11 Understand the vertical relationship between plans 0.297 0.112 .013
(upper-level and lower-level plans).
12 Can list relevant upper-level or lower-level plans that are 0.093 0.009 .060
related to the future local healthcare plan.
13 Understands the interconnectedness of various plans within, 0.153 0.026 .003
related to, or in other fields of the local government.
14 Can list the specific plans within their municipality, related, 0.144 0.060 .181
and other fields that are relevant to the local healthcare
plan they are involved in.
Module theme 4 15 Understand the overall schedule for developing a plan. 0.347 0.172 .000
Understanding the process and goal 16 Understand when and what tasks needs to be completed for 0.381 0.190 .000
setting of a new plan local healthcare planning.
17 Understand the rationale for considering discontinuation of 0.390 0.250 .002
programs and projects.
18 Identify health issues that need to be addressed based on 0.144 0.147 .106
evaluating of the previous plan.
19 Understand that outcome measures are frequently used in 0.136 0.121 .147
target indicators.
Module theme 5 20 Understand how to set target indicators. 0.381 0.181 .000
Understanding how to collaborate 21 Understand the meetings that need to be established in the 0.288 0.121 .001
with the relevant people for planning process.
developing and implementing a
22 Understand the preparations and procedures required to set 0.280 0.198 .049
new plan
up the meeting.
23 Can select relevant staff and community residents for 0.288 0.121 .025
participation to utilize the plan in daily routines.
24 Understand the necessary methods for sharing objectives, 0.347 0.155 .005
coordination, and consensus building with internal and
external stakeholders and community residents.
25 Understand the importance of sharing objectives and building 0.136 0.095 .010
cooperative systems within the organization.
Module theme 6 26 Can clarify local health issues using health checkup data, 0.076 0.026 .302
Kokuho (National Health Insurance) Data Base System
data.
Setting goals and evaluating each 27 Set numerical indicators for solving priority health issues. 0.203 0.155 .111
project based on the national/
prefectural government’s target 28 Understand the contents of the national and the prefectural 0.076 0.069 .213
values health promotion plans.
Note: Mann-Whitney U-test.
 15251446, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13229, Wiley Online Library on [18/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
YOSHIOKA-MAEDA ET AL . 693

learning modules are optimal for improving self-perception of compe- tent is not immediately useful to PHNs who are not in charge of local
tencies in local healthcare planning in a versatile manner beyond the healthcare planning. We included all PHNs who wanted to partici-
time, place, and infection control limitations of COVID-19. pate, regardless of their experience in local healthcare planning. To
The results showed that more than 70% of the participants did not reduce dropout rates, only PHNs with no experience in local healthcare
have adequate opportunities to receive undergraduate and postgradu- planning should be invited to participate.
ate education in this field. In Japan, despite the national government
promoting local healthcare planning by PHNs (JMHLW, 2013), these
competencies have only recently begun to be taught in basic nursing 4.2 Implications for research
education (JMHLW, 2022). Additionally, although each local govern-
ment provides practical training seminars to ensure the quality of care Local healthcare planning by PHNs is an upstream strategy that is a
for the community, only approximately half of the PHNs had such good opportunity for both the development of needs-oriented poli-
opportunities (Yoshioka-Maeda et al., 2022; Yoshioka-Maeda et al., cies and enhancement of health equity (Cropley et al., 2022; Greer
2023). The results indicate that PHNs generally lack opportunities et al., 2022). Health policy development is essential competency of
for practical training seminars in local healthcare planning. Promot- PHNs (APHA & Public Health Nursing Section, 2013; QCC, 2018).
ing community health necessitates strengthening PHNs’ capacity for Since local healthcare planning is a kind of community-based local
policy leadership (Nganga-Good et al., 2023). public health policy development, PHNs would need to develop needs-
We found that the web-based learning modules improved most oriented health policies. In the future, an international collaborative
of the primary and secondary outcomes regarding self-perception study will be helpful to improve PHNs’ competencies in this field.
of competencies in local healthcare planning, except those related
to evaluation including the community nursing diagnosis cycle and
Module Theme 6. PHNs should manage progress and evaluate local 4.3 Implications for practice
healthcare plans (JMHWL, 2013). According to the QCC’s, 2018 Com-
munity/Public Health Nursing Competencies, Domain 2 regarding Nurses are responsible for developing and promoting health policy
policy development/ program planning skills showed that evaluation (Ellenbecker et al., 2017). PHNs are perfectly positioned to assess
and quality improvement are essential skills among PHNs (QCC, 2018). community health needs (Shiomi et al., 2022) and need to close the
Process and outcome evaluations help in the development of evidence- gap between practice and policy development (QCC, 2018). Through
based policy and health services (Haldane et al., 2019). However, developing health policies, PHNs could enhance the health of popula-
many PHNs have faced difficulties with conducting community nursing tions in the community (APHA, & Public Health Nursing Section, 2013).
assessment in their daily practices (Shiomi et. al., 2022). Addition- The use of educational modules as demonstrated by this study would
ally, personnel changes in public sectors and local healthcare planning contribute to PHN competency in this field. Collaborating with local
were conducted every few years. Most PHNs may have difficulties universities would help improve their competencies through practical
imaging the evaluation phase. Although the web-based learning mod- training. Additionally, evaluation should be a fundamental skill of PHNs
ule included instructions on evaluating community health data, the (APHA & Public Health Nursing Section, 2013). PHNs need to improve
educational contents would be complex for the participants. Further their evaluation competencies, including analyzing community health
refinement of the evaluation content is required to improve PHNs’ data and visualizing the outcomes.
knowledge and skills regarding the evaluation phase.

5 CONCLUSION
4.1 Limitations
An RCT was conducted to enhance PHNs’ self-perception of competen-
This study has some limitations. First, the high dropout rate and the cies in local healthcare planning using a web-based education program.
limited number of participants impacted the effect size and entailed Our findings provide new evidence that web-based programs improve
selection bias, respectively. Further, this study was conducted based PHNs’ self-perception of competencies, knowledge, skills, and per-
on the assumption that the participants had a strong desire to acquire spectives regarding local healthcare planning. Web-based educational
competencies in local healthcare planning. Therefore, the general- modules are useful when restrictions are in place that keep people
izability of these findings is limited. Second, 53 participants in the from in-person learning. Thorough acquiring skills in local health-
intervention group did not answer the post-test survey. This number care planning, PHNs can contribute to promoting health equity in
was more than double that in the control group. Although we sent a communities.
reminder e-mail to all participants to reduce the dropout rate, PHNs’
primary responsibility was to help patients during the COVID-19 pan- AUTHOR CONTRIBUTION
demic. The participants received web-based learning modules without All authors met the criteria of the International Committee for Med-
answering the post-test survey because of their busyness and lack ical Journal Editors through direct contributions to the design and
of time. Therefore, the study web-site must be refined accordingly. conduct of this study. All authors had significantly revised the draft and
Third, participants could have dropped out because the program con- confirmed the final version of the manuscript.
 15251446, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13229, Wiley Online Library on [18/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
694 YOSHIOKA-MAEDA ET AL .

ACKNOWLEDGMENTS Brown, A. F., Ma, G. X., Miranda, J., Eng, E., Castille, D., Brockie, T., Jones,
We would like to thank all public health nurses who supported and par- P., Airhihenbuwa, C. O., Farhat, T., Zhu, L., & Trinh-Shevrin, C. (2019).
Structural interventions to reduce and eliminate health disparities.
ticipated in this study. We will report part of the results at the 82nd
American Journal of Public Health, 109(S1), S72–S78. https://doi.org/10.
Annual Meeting of the Japanese Society of Public Health. This work 2105/AJPH.2018.304844
was supported by JSPS KAKENHI Grant Number 19H03972 (to KYM). Catton, H. (2021). COVID-19: The future of nursing will determine the fate
The funding agency is not directly involved with the research. of our health services. International Nursing Review, 68(1), 9–11. https://
doi.org/10.1111/inr.12673
Cropley, S., Hughes, M., & Belcik, K. (2022). Engaging leadership compe-
CONFLICT OF INTEREST STATEMENT tencies through population health policy advocacy: A review of the
The authors declare no conflicts of interest. evidence. Policy, Politics & Nursing Practices, 23(4), 259–271. https://doi.
org/10.1177/15271544221112893
Du, S., Liu, Z., Liu, S., Yin, H., Xu, G., Zhang, H., & Wang, A. (2013). Web-based
DATA AVAILABILITY STATEMENT
distance learning for nurse education: A systematic review. International
Research data are not publicly shared because of privacy restrictions. Nursing Review, 60(2), 167–77. https://doi.org/10.1111/inr.12015
Ellenbecker, C. H., Fawcett, J., Jones, E. J., Mahoney, D., Rowlands, B., &
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ETHICS APPROVAL STATEMENT
icy. Policy, Politics & Nursing Practices, 18(1), 44–56. https://doi.org/10.
The Institutional Review Board (IRB) of the primary researcher 1177/1527154417709254
approved the study protocol on May 30 (ID: 2022024NI) and July 28 Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power
(ID: 2022024NI-(1)), 2022. The second approval was obtained because analyses using G*Power 3.1: Tests for correlation and regression anal-
of the separation of the roles of the co-researcher in data fixing and yses. Behavior Research Methods, 41(4), 1149–1160. https://doi.org/10.
3758/BRM.41.4.1149
data analysis. The IRB of the fourth researcher approved this study
Gagne, R. M., Wager, W. W., Golas, K. C., & Keller, J. M. (2007). Principles
on June 24 (C1574) and August 3 (C1574-(1)), 2022. Additionally, the of instructional design. (Suzuki, K., & Iwasaki, S., Trans.). Kitaouji Shobou
IRB of the remaining researchers also comprehensively approved the (Original work published 2005).
study on June 10 (ID: none and 22016CR), June 15 (ID: none), and June Greer, S. L., Falkenbach, M., Siciliani, L., McKee, M., Wismar, M., & Figueras,
J. (2022). From health in all policies to health for all policies. The
23 (ID: none), 2022. There were no discrepancies between the trial
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