Managerial skills required for new community public health graduates during the COVID-19 pandemic: Employers’ perspective

Abstract Employers claim managerial skills are more important for community public health students than specialist subject knowledge. However, to date, there is no valid and reliable instrument to measure these skills. Furthermore, employers’ viewpoints are often not considered in developing such a measure. This study aimed to develop an instrument by considering employers’ perspectives in health agencies to define the required managerial skills new graduates should possess. A cross-sectional study was conducted during the COVID-19 pandemic. A preliminary list of skills was developed based on the Delphi technique. The final list was then distributed to 410 employers who provided feedback. Exploratory and confirmatory factor analysis was employed to analyze the responses. The employers identified 19 items that indicate four types of managerial skills students need to possess: (a) vision-grounded skill, (b) collaboration skill, (c) systems thinking skill, and (d) health promotion and disease prevention skill. Each skill has a Cronbach’s alpha coefficient ranging from 0.87 to 0.94. The ability to collaborate is the most crucial skill. The limited but valid and reliable tool is relevant in the Thai context because a few instruments are already measuring “competency” or “leadership” skills of community public health professionals. Educators and employers should prepare new practitioners with the four managerial skills identified in the study to perform their jobs effectively.


PUBLIC INTEREST STATEMENT
Training and/or education should focus on four component skills: vision-grounded skills, collaboration skills, systems thinking skills, and promoting health and preventing disease skills.Collaboration skills are the most valued by employers during COVID-19. Employers and university lecturers may need to pay more attention to such skills because future severe pandemics may emerge.Most employers require graduates to have the ability to coordinate with others and work in a team, have good interpersonal skills, listen to opinions, and be flexible at work to be effective in their job performance.Before graduation, our managerial skill tool can be used to assess the managerial skills of students in order to improve the curriculum.

Introduction
Understanding employer expectations allows universities to help students improve their skills to enter the job market (Alford et al., 2020;Bawadi et al., 2019;Dinning, 2017). Managerial skills are defined as a set of characteristics that help individuals achieve better results and be successful (Popescu et al., 2020). Public health professionals need managerial skills to help inform, educate, and empower individual communities on issues related to their health safety and well-being (Broucke, 2020;Fanelli et al., 2022;Johnson & Davey, 2021).
The ability to mobilize community partnerships promoting health and well-being requires such skills. Previous research indicates that employers value managerial skills, such as collaboration and teamwork, more than specialist subject knowledge (Scaffidi, 2019). This is not to underestimate the importance of subject knowledge but to highlight the added value of effective personal qualities and core skills.
Many employers are currently confronted with changing economic conditions and global challenges. Hence, they need to recruit people who can manage change, thrive on it, and be flexible and adaptable to learning quickly (Scaffidi, 2019). For example, preventing the transmission of the novel coronavirus (COVID-19) requires organizations and individuals within the community to work together. In this case, Thai community public health professionals need to plan and screen patients with the assistance of village health volunteers, police officers, the military, and transportation personnel to manage the pandemic situation (Thailand Ministry of Public Health, 2020).
Amid emerging infectious diseases, public health workers must open their minds to new ideas and approaches to address the situation in a timely manner and work collaboratively with a diverse and interdisciplinary team (Broucke, 2020). Graduating students should be prepared to work as part of an interdisciplinary team that will go above and beyond the call of duty. Employers need to hire people with these characteristics to ensure that quality health services are delivered.
However, despite the importance of these skills in their profession, there are claims that future healthcare professionals lack the necessary managerial skills. Research in Thailand suggests that community public health workers should have community-based management skills, such as engaging communities in co-thinking, co-working, problem-solving and mutual benefit-making, as well as teamwork (Jitaram, 2020;Rasiri & Songthap, 2018). People also expect the most from community health workers to work together as a team with others (Ansa et al., 2020). This is consistent with the results of the training needs survey, which found that community health workers need to train the most in interpersonal skills and teamwork (Grant et al., 2018;Mhlongo et al., 2020). A study demonstrated that healthcare professionals' managerial skills are inadequate, and training at the undergraduate level is needed to develop these skills (Leal et al., 2018). Hence, managerial skills are essential for students in community public health programs when they enter a job market because such skills will enable them to work with all stakeholders to care for people's health.
A tool is needed for community public health students and future health professionals because it will enable them to assess their managerial skills and allow universities to further develop their curriculum in line with the needs of employers. The tools used should be management-specific to promote the health and well-being of the people in the community.
More importantly, in developing the instrument, employers' perspectives must be considered because their expectations can shape the motivation of students and the implementation of a rigorous strategy that facilitates the acquisition of skills and attributes to meet employers' expectations (Alford et al., 2020;Damoah et al., 2021). If the employers' input is ignored, there will be a crucial disconnect between what employers and university management believe to be essential skills for graduates. Thai employers place the greatest emphasis on health management skills in the community (Charoenchang et al., 2016). Hence, the focus should be on assessing the managerial skills of new graduates.
Previous research has primarily surveyed on the desirable characteristics of community public health graduates, such as health education and health promotion, consumer protection, research and biostatistics, and professional ethics, quantitative and qualitative research skills (Manawiroj, 2019;Supaporn et al., 2016). The desirable characteristics include community management, interpersonal relationships, and collaboration, which reveal some managerial abilities.
However, in assessing the graduates' desirable characteristics, previous researchers primarily used Cronbach's alpha to measure the instrument's internal consistency; no advanced psychometric property tests based on factor analysis and model fitting were performed. As a result, the validity and reliability of the instrument are suspect. The advantages of factor analysis range from improved research data to more accurate statistical research (Hair et al., 2014). Hence, the present research aimed to improve the validity and reliability of the existing managerial skills questionnaire for community public health graduates using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).
The literature indicates that instruments applicable to other health professionals, such as doctors, nurses, and pharmacists, are available (Furmenti et al., 2021;Liou et al., 2022;Peivand et al., 2019). However, because the tools are job-specific, they are not applicable to graduates. For example, physicians diagnose and plan medical treatments, while nurses take responsibility for hands-on care (Boyd et al., 2018). Pharmacists optimize medicine use, and community public health professions promote health and prevent disease (Chagas et al., 2022;Wongnuch et al., 2022). Hence, to be able to validly assess the managerial skills of graduates, the tool should be jobspecific (Cunningham & Mohr, 2019).
Given the gaps in the existing body of knowledge, this study aims to describe the development of a valid and reliable psychometric measurement tool to assess community public health students' managerial skills and investigate employers' expectations.

Role of Thai community public health professions
Most Thai community public health professionals work in health centres as public health technical officers (Charoenchang et al., 2016;Rutchanagul & Sangnimitchaikul, 2022). The health centre, a primary care unit that offers basic health services, is the first point of service in both the health care setting and the community. Its main mission is to promote public health, and the health centre only provides outpatient services. Thailand has 9,806 health centres (Tuangratananon et al., 2021), with the majority of such jobs concentrated in health centres rather than other facilities such as community hospitals or local government organizations.
One of the key roles of community public health professionals is health promotion and disease prevention (Wongnuch et al., 2022). In light of Thailand's rapidly ageing society, one of the main challenges is ensuring the elderly have a good quality of life in Thai communities in urban and rural settings (Anantanasuwong, 2021;Sirisuwan et al., 2022). Active ageing and health literacy are becoming increasingly essential.
In COVID-19, for example, 33% of elderly adults adopted preventative behaviours (Vicerra, 2021). Public health technical officers must hasten the search for older people who have not been vaccinated and educate, motivate, and urge additional immunization (Hfocus, 2022March4). Collaboration skills and promoting health and disease prevention skills are paramount. Health officers must collaborate with elderly families, community leaders, and village health volunteers to encourage the elderly in the community to prevent infection (Afzal et al., 2021;Kaweenuttayanon et al., 2021;WHO Thailand, 2020).
The Thai government enacted the Community Public Health Professions Act in 2013, Volume 130, Chapter 18, first Thai alphabet, to ensure that community public health professionals perform efficiently in their careers (Council of Community-Public Health, 2015). The Act defines their roles in relation to public health actions for individuals and families, community and environmental health as follows.
(a) Support learning and provide advice and counselling on health promotion, disease prevention disease, disease control, primary therapeutic approaches, and rehabilitation for individuals, families, and communities.
(b) Utilize scientific principles in occupational health and environmental health actions to control and prevent disease-causing factors and reduce the risk of illness in individuals, families, and communities.
(c) Carry out a health assessment and fundamental therapy, patient care, immunization, and family planning.
(d) Conduct illness assessment and assist the patient for a referral.
In addition, people licensed to practise community public health must be members of the Community Public Health Council, pass a professional exam, and possess a bachelor's degree in public health (Council of Community-Public Health, 2015). As a result, graduates of other professions, for example, nursing, will be unable to take the exam required to earn a Community Public Health Council license unless those nurses also have a degree in Community Public Health.
Before graduation, community public health students participate in a Professional Skills in Community Public Health course, a type of pre-service training in which they practice at a health centre (School of Public Health, 2021). The course focuses on (a) health promotion and community health, (b) prevention and control of disease and public health research, (c) health assessment and fundamental therapy, (d) public health administration and law, and (e) occupational and environmental health.
The employers provide the course of in-service training for public health technical officers. For example, the Department of Local Administration course in Thailand covers a wide range of topics for employees to learn during the job, including fundamental subjects, King's sciences subjects, position-specific subjects, and experience enhancement subjects (Department of Local Administration, 2021). Some position-specific issues are public engagement, fund management, procurement processes, and public health supervision.
In brief, the practice of community public health professions focuses on disease prevention and control, health assessment and fundamental therapy, patient care, rehabilitation, and occupational and environmental health (Jitaram et al., 2021). Hence, management skills are needed in community public health workers to ensure that effective healthcare services to the community are met.

The importance of managerial skills
Community health management is a critical role of community public health professionals. Its goal is to manage the health of individuals in the community (Baiya & Nilkong, 2020). It is regarded as the foundation of society, not only for health maintenance, preventing disease, health promotion, diagnosis, and medical treatment.
More importantly, it is for community health management to increase community health selfreliance. Actions must be taken alongside efforts to improve people's lifestyles so that they are healthy and capable of caring for their own health according to the community's self-determined approach, as determined and assessed by the community. For this purpose, health personnel are in charge of promoting and supporting mechanisms that improve work or health in the context of operations and coordinating for optimal and long-term benefits (Baiya & Nilkong, 2020).
Community health care is complex and requires various public health strategies to organize health service activities (Enria et al., 2021). Employers in district health offices, community hospitals, health centres, and local administrative organizations anticipate that community public health graduates will be capable of managing community health to the maximum extent (Supaporn et al., 2016).
However, studies on healthcare professionals revealed that even those who are employed lack expertise in health management (Wauters & Tiparat, 2019). In this case, new graduates must be capable of collaborating with strong network partners to understand and address common problems. If they fail to understand the importance of such a network, coordination and cooperation in healthcare operations will be difficult (Castañer & Oliveira, 2020).

Managerial skills of new healthcare graduates: global overview
Managerial skills can be defined as: • a set of characteristics that assist individuals in achieving better results and success; • characteristics required to carry out the managerial processes required for the organization to achieve efficient results; • basic attributes for managerial effectiveness; • managerial attitudes that allow individuals to impose their style, strategies, techniques, and tools on the organization (Popescu et al., 2020).
As shown by Katz's managerial skill theory (1974), the efficient management of an organization is based on three critical skills required of administrators: technical, human, and conceptual skills. Technical skill represents understanding and proficiency in a specific type of activity, notably one involving methods, processes, procedures, or techniques. Working with people is the most crucial aspect of human skills. This skill can be seen in how individuals perceive their superiors, equals, subordinates, and people outside the organization.
Finally, conceptual skills refer to the ability to perceive the entire organization. These abilities allow not only for the recognition of how an organization's various functions are interdependent but also for the visualization of the organization's relationship with the industry, the community to which it belongs, and the overall political, social, and economic forces of the nation.
According to Becker's human capital theory (1962), managerial skills are classified as general skills that can be transferred across industries and firm-specific skills that are valuable only within a specific organization. Many universities have attempted to develop students' managerial skills to deliver private and public services. Human capital is a set of personal characteristics, such as knowledge, skills, experience, training, abilities, talent, intelligence, and judgment.
The human capital theory's key argument is that education and training are investments that increase people's productivity. Based on this theory, Custódio et al. (2019) discovered that general management skills can promote innovation. Ma'dan et al. (2021) researched the role of human capital competences and discovered that management skills are valued in the labour market.
As Sarkar et al. (2021) outlined, non-specific or generic skills can be hired. Graduates need generic skills to get a job, keep it, and advance in their careers. Generic skills, also known as transferable skills, core skills, soft skills, and key competencies, are the key skills and capabilities that can be transferred to a variety of tasks and contexts outside of the educational setting, such as communication, collaboration, problem-solving, critical thinking, and initiative. Given the global push to increase graduate employability, higher education has been emphasizing generic skills over the last two decades.
According to Succi and Canovi (2020), generic skills are more important than job-specific skills. Graduates working in health services management highlighted essential interpersonal and communication skills, self-management skills, and critical thinking skills.
Once graduates begin their careers in public health as new practitioners, they should meet employer expectations. A study by Heshmati et al. (2020) revealed that community public health workers require good interpersonal communication skills. Recently, public health professionals expressed their opinions on specific managerial skills for healthcare organizations (Bhandari et al., 2020). The primary abilities are assessment and analysis, policy and program management, financial management and budgeting, partnerships and collaboration, communication, and leadership.

New healthcare graduates' managerial skills in the Thai context
A review of past studies conducted in many countries, including Thailand, suggests a dearth of studies on managerial skills in fresh community public health graduates. Most research in Thailand focuses on the professional competence of discipline-specific skills rather than soft skills or generic skills (Intisan et al., 2021;Supaporn et al., 2016).
In their study, Supaporn et al. (2016) indicated that the characteristics of community public health graduates for which employers in district health facilities and local administrative organizations had high expectations were professional ethics, community health management, and health education and promotion. The ability to manage community health was one of the characteristics that employers sought. This is because community public health practitioners are regarded as one of the mechanisms in the community health system and are involved in managing the community or society to live in an environment that promotes health and self-reliance.
Manawiroj (2019) demonstrated that healthcare employers in the sub-district expect community public health graduates to be the most capable of applying their education-based knowledge to solve holistic problems for individuals, families, and communities. Talented individuals are expected to be competent at their jobs and have positive interpersonal relationships.
Furthermore, Charoenchang et al. (2016) conducted a study of community public health professional competency from the perspectives of policymakers, academics, community organizations, primary care workers, village health volunteers, and people. They reported that four skills are required for community public health practitioners working in primary care: (1) providing integrated health care services to individuals, families, and communities, (2) managing health information, (3) collaboration and teamwork, and (4) researching a routine job to improve community health. As a result, personal relationships and teamwork abilities are required to care for the health of the community's residents.

Generation items of an initial list of relevant managerial skills
Our study aimed to develop an instrument that could capture what employers look for in new community public health graduates in terms of managerial skills in the context of Thai district health services. In developing such an instrument, we took the following steps.
Based on a study on the roles and responsibilities of community health workers (Mhlongo et al., 2020), the criteria for selecting an article should respond to the research question: What are the managerial skills of community public health students? Identifying relevant studies includes determining population, concept, context and peer reviewing the literature. So, we searched the relevant literature by combining the keyword terms such as (1) "managerial competencies", "managerial skills", "managerial competences", "management competencies", and "health", and (2) "skill scale", "competency scale", "competence scale", "skill assessment", "competency assessment", "competence assessment", and "primary care" with filters in English and full text.
We then searched publications from 1980 to 2019 due to the increasing involvement of community health workers in healthcare organization management in the 1981s (Bennett, 1981). We searched relevant publications in such databases as PubMed and ProQuest because they contain much public health literature. Our search resulted in 804 articles: 551 articles identified in PubMed and 253 articles in ProQuest. We deleted duplicate articles from the search performed on two different databases. Of these, 583 full-text articles were retained.
We read the abstracts of the remaining papers to select the most relevant articles by using the following four selection criteria: (1) The article should be about the role of community health professionals.
(2) The article must include participants from the district or local or primary care.
(3) The article is about identifying managerial skills or assessing managerial skills.
(4) The articles are published in peer-reviewed journals because such journals are considered the most reliable source of scientific information.
The current study adopted the managerial skills items studied in the primary care unit by Dikic et al. The authors used a basic managerial competency matrix that includes six competencies with 18 items: communication, teamwork, planning and priority-setting, performance evaluation, problemsolving, and leading. Cronbach's alpha values ranged from 0.62 to 0.88 in each dimension. Kitreerawutiwong et al. (2015) developed the competency scale for primary care managers in Thailand. Public health officers, nurses, public health officers, dental hygienists, and pharmacy assistants were among those who responded. With 48 items, exploratory factor analysis identified nine dimensions. The finalized instrument had the following skills: leadership, communication, partnership, system thinking and strategic decision making, organizational development and professionalism, emotional intelligence, proactive approach, financial planning, and information management. The Cronbach's alpha for each dimension ranged from 0.70 to 0.88. Chuttipattana and Mohd-Shamsudin (2011) identified the critical managerial competencies of Thailand's primary care managers. Those who responded included public health administrative officers, public health technical officers, nurses, and community health officers. The factor analysis yielded six factors with 24 items, including visionary leadership; assessment, planning, and evaluation; promotion of health and prevention of disease; information management; partnership and collaboration; and communication. The Cronbach's alpha values in each dimension ranged from 0.79 to 0.89.
In Thailand, new community public health practitioners typically have to perform four tasks: (1) operations (such as research, analysis, investigation, collection of preliminary statistical and academic data, and assistance in the creation of a database), (2) planning (for example, planning responsible work, carrying out joint planning of the agency's or project's work so that the operation achieves the goals), (3) coordination (such as coordinating collaboration within and outside the team or agency to achieve the specified cooperation and accomplishments), and (4) services for people (such as training, education, and health promotion; Office of the Civil Service Commission, 2011).
Consistently, we considered leadership, information management, analysis, planning, evaluation, collaboration, communication, systems thinking, health promotion and disease prevention, and financial management in the initial list of managerial skills relevant to entry-level community public health practitioners in the Thai context.
Based on the literature, we developed an initial list of 100 items for managerial skills for community public health practitioners. We grouped them into several categories based on the literature: leadership, information management, analysis, planning, and evaluation, collaboration, communication, systems thinking, health promotion and disease prevention, and financial management.

Delphi technique
Next, the researchers recruited five experts to verify the items using the Delphi technique. The questionnaire was only available in Thai from the Delphi technique to the Survey. Three lecturers in an educational institution with expertise in competency were identified. All of them studied the competency of employees and students. Two of them hold a doctorate, while one has a master's degree. They have had managerial and administrative roles for more than five years. Two of the three lecturers served as public health managers in the Ministry of Public Health and the health centre before working for an educational institution.
In addition, two experts, practitioners in community public health, have a minimum of ten years of management experience. One is a public health director of the municipality with a master's degree. Another was a primary care manager at a community hospital with a doctoral degree. One of their responsibilities is to recruit public health professionals to work with the organization.
The present study employed the same approach, i.e., the Delphi technique, used by Bhandari et al.
(2020) to identify the core competencies of practising public health professionals and Hu et al. (2019) to develop a scale of caring behaviour for healthcare providers in China. This technique was used to achieve group consensus (Bassi et al., 2020). The key advantage of this technique is that it replaces group diversity with a single representative viewpoint (Shinners et al., 2021) and is frequently used when there is little evidence or the knowledge base is limited. Furthermore, this technique has been used in healthcare to develop professional skills (Sirevåg et al., 2021).
Between March and May 2020, two rounds of the Delphi method were conducted with the same participants in each round. In the first round, questions about communication skills, for example, were formed with questions about leadership and collaboration. The experts provided feedback on the appropriateness and clarity of the 100 items on a paper-based questionnaire (Shinners et al., 2021). The managerial skills generated were analyzed for similarities, redundancies, and ambiguities (Sirevåg et al., 2021).
In the second round, the experts were asked to respond to a general question, "How important is the skill of each item?" (Dikic et al., 2019) and rate the managerial skills on a Likert-type scale of 1 to 5, 1 being the least important and 5 being the most important on 100 items. They were also asked to justify their position. In the second round, no statements were revised. Consensus was defined as an expression of an agreement by the mean of each question was not less than 4.5 (Nasa et al., 2021). After the two rounds of the Delphi process, 62 statements from six categories were accepted as final. Except for financial management, available categories included leadership, information management, analysis, planning and evaluation, collaboration, systems thinking, and health promotion and disease prevention.

Pretest and pilot test
Next, 62 items were sent to five academics in community public health management for content validity evaluation. Content validity was examined using the Item Objective Congruence (IOC) index (Turner & Carlson, 2003). The items had acceptable content validity with IOC coefficients between 0.6 and 1.0 for all items. Three items were removed because the coefficients were less than 0.6. Finally, 59 items were incorporated into the final questionnaire for a pilot test.
In this test, the researchers posted the questionnaire to 30 employers chosen from a district in a province not included in the main study. The purpose of the survey was to determine whether the questions were clearly written and the response options made sense (Fraser et al., 2018).
According to Wang et al. (2023), a pilot study with 30 representative participants from the population of interest is a reasonable minimum recommendation for a preliminary survey or scale development. This is accepted as a reasonable minimum sample size for bootstrapped confidence intervals due to its simplicity and ease of calculation. The internal consistency coefficient was found to be 0.9, indicating that the questionnaire was reliable.
The final questionnaire consisted of two parts. Part one included six questions about the participants' characteristics. Part two included 59 items from six categories about the employer's expectations, measured on a five-point Likert-type scale (1 = very low, 2 = low, 3 = medium, 4 = high, 5 = very high).

Survey
Finally, the validated questionnaire was targeted to a population of 1,036 employers from district health agencies in Thailand's seven southern provinces. The employers were from various organizations in community public health. At the minimum, they hold positions equivalent to a senior supervisor, such as a health professional practitioner, and above, such as a director of a primary care unit and a local manager.
They are involved in recruiting prospective employees who have graduated from health study programs. They also work most closely with community public health practitioners; hence, they are the best sources to assess the latter's capabilities and know-how. The study did not include participants who are not senior supervisors, directors, or managers because they fall outside the scope of the study. The study focuses on the public sector, not the private sector.
Using Krejcie and Morgan's table (Krejcie & Morgan, 1970), the researchers arrived at the required sample size of 285 at a confidence level of 95%. Cluster sampling was used to recruit the participants. By calculating the average size of a cluster (i.e., province), we needed 1.93 clusters. We then selected two provinces using simple random sampling without replacement. The provinces selected were Nakhon Si Thammarat and Surat Thani. In these two provinces, we identified 594 employers who received the questionnaire by mail. A total of 410 questionnaires were returned, representing a response rate of 69.02 percent. The questionnaire was mailed to all the participants from July to September 2020.

Ethical considerations
The researchers followed the relevant ethical guidelines and regulations of the Declaration of Helsinki in carrying out the study. The employers were requested to sign a permission form attached to the questionnaire if they agreed to participate in the study. The researchers gathered the data in a personal locker that is safe and inaccessible to third parties. Individually identifiable data of research participants were not public; we published aggregate data.

Analysis of data
We performed the exploratory factor analysis (EFA) to identify the dimensions of managerial skills and reduce the items into smaller groups using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). Confirmatory factor analysis (CFA) was used to determine the fit of the factor solution by using AMOS 4.01 (SmallWaters Corp., Chicago, IL, USA). Before the analyses were performed, outliers were checked using the univariate method. Observations with standardized variable values exceeding 4 for each variable were deleted (Hair et al., 2014). Consequently, seven cases were removed. The EFA was conducted with 403 observations.

Participants and descriptive data
Many were women (54.1 per cent), aged 51 and over (43.4 per cent), had a bachelor's degree (75.6 per cent), and were designated as directors of primary care units (65.9 per cent). Seventyseven percent of them worked at a sub-district primary care unit and had an organizational tenure of more than ten years (55.9 per cent; Table 1).

Exploratory factor analysis (EFA)
Each summated scale consists of items highly loaded on a single factor, reflecting its unidimensionality. Validity measures, including convergent, discriminant, and nomological validity, were examined to assess whether the set of measures accurately represented the concept of interest. For factor interpretation, a threshold value of 0.50 or higher on a specific factor and a loading of no higher than 0.35 on other factors were set (Guedes et al., 2018). Variables with communalities greater than 0.50 were retained in the analysis (Hair et al., 2014). The scale purification process reduced the number of managerial skill items from 59 to 19 (Table 2).
Of the 19 items, the factor analysis extracted four factors: vision-grounded skills (Factor 1), collaboration skills (Factor 2), systems thinking skills (Factor 3), and health promotion and disease prevention skills (Factor 4). The labelling of skills under leadership was changed to vision-grounded skills because its meaning focuses on understanding the mission and acknowledging organizational goals rather than directing others to the organization's goals. The meaning of leadership is frequently demonstrated by leading the process of defining, setting its framework, facilitating others' understanding, articulating about it, integrating it and community vision into a single direction, and clarifying health programs (Chuttipattana & Mohd-Shamsudin, 2011).
Each dimension/skill represented a Cronbach's alpha coefficient of between 0.87 and 0.94 (Table 3), indicating acceptable internal consistency (Hair et al., 2014). The subscales measuring the same aspect clustered onto the same factor (a test of convergent validity) and the scales measuring different topics that fell on different factors (a test of discriminant validity) are depicted in Table 3.

Confirmatory factor analysis (CFA)
CFA was conducted to assess the adequacy of the fit of the model (each factor structure) to the observed data to validate all variables generated by the EFA from the employers' ratings. The model included the four constructs/skills generated. With a sample size of more than 250 cases (Hair et al., 2014), the statistical values are listed in Table 4.
After EFA, the outcomes of the initial estimation of the four constructs were satisfactory. The chi-square value of 411.16, with 146 degrees of freedom, was significant at a p-value < 0.001, indicating a very good fit between the model and the data (Table 4). A chi-square: degree of freedom ratio of 2.816:1 was appropriate. Other fit indices also indicated a good fit (CFI = 0.953, RMSEA = 0.067, and SRMR = 0.046). No indicators were removed from the analyses.

Discussion
The purpose of this study was to develop and validate an instrument that measures employers' expectations of the managerial skills of new graduates in community public health. Based on the analysis, four managerial skills were identified: (1) vision-grounded skills, (2) collaboration skills, (3) systems thinking skills, and (4) promoting health and preventing disease skills. Vision-grounded skill is the ability to support an organization's mission. New graduates should understand the mission and vision of an organization and work responsibly toward accomplishing them. Healthcare professionals who understand the corporate mission form an emotional bond with the organization, resulting in positive work behaviour and organizational performance because they are concerned about the customers and services (Pan et al., 2018;Santos, 2020).
Collaboration skills refer to the ability to coordinate with others and work in a team. Working in teams requires graduates to have good interpersonal skills, listen to opinions, and be flexible at work. In a study among healthcare professionals, collaboration refers to a cooperative arrangement in which two or more parties work together to complete a task or achieve a common goal (Ansa et al., 2020). Employers place the greatest value on this skill, which could be attributed to the nature of community healthcare work that cannot be done alone. This will be a multidisciplinary team made up of representatives from various community organizations (Charoenchang et al., 2016). Systems thinking skills refer to the ability to solve health problems and conduct research using theoretical concepts. Graduates need to identify, synthesize, and consolidate work-related issues and work toward solving health problems. They are also required to understand that their work is interlinked with others to solve problems efficiently and effectively.
In addition, graduates must have the ability to engage in turbulent and complex environments to perform well. In this regard, new practitioners must be able to identify research problems based on public health and empirical health in the area and implement research to solve the problem to keep up with changes (Grimm et al., 2022).
Promoting health and disease prevention skills involves encouraging others, such as colleagues and members of the community, to take part in self-care and educate them about disease prevention. The Community Public Health Professions Act requires that such work must be carried out by those with the expertise (Jitaram et al., 2021). This skill is crucial for promoting community health and reducing unnecessary burdens on healthcare systems.
Previous studies found that because collaboration, systems thinking, and promoting health and disease prevention skills reflect the current needs of the workforce, students should possess them to Systems thinking research has revealed that a systems thinker must understand the big picture, observe how elements within a system change over time, and identify and categorize the root causes to resolve health issues (Hassan et al., 2020). Moreover, expertise in behavioural health change is one of the core competencies of health educators and promoters; their advice could help governments achieve the required behavioural change in the community (Broucke, 2020).
Other research has found that leadership is vital in the public health profession (Bhandari et al., 2020). In this study, we define leadership as a vision-grounded skill, a component of leadership. Past studies have identified leadership skills because their subjects were in mid-level supervisory positions. However, our subjects were fresh graduates whom employers expect to be committed to an organization's mission.
The strength of the present study was the use of the Delphi technique and both EFA and CFA to evaluate construct validity. The Delphi technique ensured that each expert contributed significantly to the study. Using the EFA followed by the CFA to test employers' data, the validation of the employer's expectation instrument on the managerial skills of new graduates was confirmed since EFA allows researchers to organize or conceptualize a set of measurements obtained within the context of a research program (Meyer et al., 2016).
The CFA procedure enables researchers to hypothesize a particular model or factor structure they believe underlines the study's variable. Hence, within the limits of its generalizability, the use of this measuring tool is recommended to meet employers' expectations. The findings may be generalized to people working in community health at the district level.

Implications of the study
One of the key contributions is validating an instrument that offers four managerial skills informed by employers' perspectives from various organizations. The results indicate that the model has the best fit for the data. Within the boundaries of its generalizability, this instrument can be used to understand employers' expectations of new graduates better. According to human capital theory, education and training are investments that increase people's productivity. We propose that training or education should focus on four component skills: vision-grounded skills, collaboration skills, systems thinking skills, and promoting health and preventing disease skills.
Although past studies have found the four managerial skills in healthcare professions, healthcare employers in the present study highlight that collaboration is the most critical skill during the COVID-19 Community public health professionals are in close contact with the people of the village and are responsible for promoting health in order for individuals to be healthy. A newcomer should support an organization's mission, collaborate with others, work as part of a team, solve health problems, and conduct research using theoretical concepts, including educating others about disease prevention. Therefore, healthcare managers and educators should not overlook the skills needed.

Further research
Since this study did not examine the expectation lacuna between community public health students' perceptions and employers' expectations of skills, future research may look into this. This is a significant limitation of this study because it focuses on employers' perspectives. There were no interviews or group discussions with employers to strengthen the findings of the study. Hence, we recommend conducting a follow-up study to determine which of the four managerial skills is the most important and ask employers about the validity of the findings and their reflections.
Future research may study employers' expectations in provincial agencies and the private sector and investigate undergraduate students' perceptions of the skills employers seek in new hires. It should include interviews with employers and group discussions to supplement survey research. Further research should be conducted in other countries to confirm the validity of this conclusion. It would also be useful to research whether the findings apply to other healthcare programs.
In addition, the program curricula need to be designed and/or revised to enhance new graduates' managerial skills to perform well in future jobs. Employers can reduce operating costs by incorporating internships. Although health promotion and disease prevention are critical aspects for community public health professionals, the findings of this study show that collaboration skills are most in demand by employers. It is possible to alert attention to a change in priorities. Future researchers may focus on a teaching and learning model that enhances collaborative skills among community public health students so that graduates can deal with other pandemic diseases besides COVID-19.

Conclusion
This study demonstrated that the scale of managerial skills is a valid instrument for community public health programs in Thailand. The four-factor structure with 19 items displayed the best absolute fit indices. The EFA test results were acceptable. Each factor's Cronbach's alpha coefficient was between 0.87 and 0.94. The CFA results of the original assessment of four constructs gave a satisfactory outcome.
During the COVID-19 pandemic, employers reflect on the need for management skills, with collaborative skills being the most in trend. University educators and those in charge of newcomer training should prepare new community public health practitioners with the four managerial skills identified in the study.
granted by the Walailak University Research Ethics Committee (approval number: WUEC-19-183-01). We confirmed that all methods used in this study were carried out according to the relevant guidelines and regulations.

Disclosure statement
No potential conflict of interest was reported by the author(s).

correction
This article has been republished with minor changes. These changes do not impact the academic content of the article.