Public health workforce enumeration: beware the "quick fix"

Salary Disparities in Public Health Occupations: Analysis of Federal Data, 2021‒2022

Objectives. To assess salary differences between workers within key public health occupations in local or state government and workers in the same occupations in the private sector. Methods. We used the US Department of Labor's Occupational Employment and Wage Survey (OEWS). Referencing previous studies matching Standard Occupational Classification (SOC) codes with health department occupations, we selected 44 SOC codes. We contrasted median salaries in OEWS for workers in each occupation within state or local government with workers in the same occupations outside government. Results. Thirty of 44 occupations paid at least 5% less in government than the private sector, with 10 occupations, primarily in management, computer, and scientific or research occupations paying between 20% and 46.9% less in government. Inspection and compliance roles, technicians, and certain clinicians had disparities of 10% to 19%. Six occupations, primarily in social work or counseling, paid 24% to 38.7% more in government. Conclusions. To develop a sustainable public health workforce, health departments must consider adjusting their salaries if possible, market their strong benefits or public service mission, or use creative recruitment incentives such as student loan repayment programs for hard-to-fill roles. (Am J Public Health. 2024;114(3):329-339. https://doi.org/10.2105/AJPH.2023.307512).

Standard Occupational Classification Codes: Gaps in Federal Data on the Public Health Workforce

Objectives. To determine whether US Department of Labor standard occupational classification (SOC) codes can be used for public health workforce research. Methods. We reviewed past attempts at SOC matching for public health occupations and then used the National Institute for Occupational Safety and Health Industry and Occupation Computerized Coding System (NIOCCS) to match the actual job titles for 26 516 respondents to the 2021 Public Health Workforce Interests and Needs Survey (PH WINS) with SOC codes, grouped by respondents' choice of job category in PH WINS. We assessed the accuracy of the NIOCCS matches and excluded matches under a cutpoint using the Youden Index. We assessed the percentage of SOC matches with insufficient information and diversity of SOC matches per PH WINS category using the Herfindahl-Hirschman Index. Results. Several key public health occupations do not have a SOC code, including disease intervention specialist, public health nurse, policy analyst, program manager, grants or contracts specialist, and peer counselor. Conclusions. Without valid SOC matches and detailed data on local and state government health departments, the US Department of Labor's data cannot be used for public health workforce enumeration. (Am J Public Health. 2024;114(1):48-56. https://doi.org/10.2105/AJPH.2023.307463).

Enhancing Public Health Practice Through a Regional Student Field Placement Program

Experiential learning links knowledge to real practice through seasoned mentor support, professional reflection, and hands-on experience in authentic work environments. While academic public health programs seek to train the future workforce, the current workforce has a critical need for training as well. The Region IV Public Health Training Center’s Pathways to Practice Scholar program gives public health students the opportunity to apply knowledge to competency-based experiences while fulfilling the current workforce’s short- and long-term human resource needs. Placements are offered in all eight states of the region to broaden opportunities for both agencies and student scholars. On completion of the program, scholars are required to submit an executive summary, reflection statement, photos of the experience, and a draft abstract suitable for submission to a professional conference. Since 2015, 36 scholars have been placed in positions across Region IV, 11 in states other than those of their home universities. Students were placed at state, local, and tribal health departments; area health education centers (AHECs); and other agencies (e.g., primary care settings), and the most common work plan domains selected by scholars were analytic/assessment, policy development/program planning, and leadership/systems thinking skills. Scholars’ perceived confidence increased across all domains with the highest increases in financial planning/management and cultural competency. Program implementation and evaluation findings are described, including types of projects, differences in confidence in performing competency domains, and confidence and interest in working with underserved populations. Evaluation findings indicate that the Region IV Public Health Training Center scholars increased their confidence in performing practice competencies while providing support for public health agencies serving underserved populations.

Health workforce metrics pre- and post-2015: a stimulus to public policy and planning

BACKGROUND

Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015.

METHODS

Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies.

RESULTS

There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed.

CONCLUSIONS

There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning.

Application of a Taxonomy to Characterize the Public Health Workforce

OBJECTIVE

A public health workforce taxonomy was published in 2014 to provide a standardized mechanism for describing public health worker characteristics. The Public Health Workforce Interests and Needs Survey (PH WINS) used 7 of the taxonomy's 12 axes as a basis for its survey response choices, 3 of which are the focus of this analysis. The purpose of this study was to determine the relative utility, reliability, and accuracy of the public health workforce taxonomy in categorizing local and state public health workers using a survey tool. This specifically included the goal of reducing the number of responses classified as "other" occupation, certification, or program area by recoding responses into taxonomy categories and determining potential missing categories for recommendation to the advisory committee that developed the taxonomy.

DESIGN

Survey questions associated with the occupation, certification, and program area taxonomy axes yielded qualitative data from respondents who selected "other." The "other" responses were coded by 2 separate research teams at the University of Michigan Center of Excellence in Public Health Workforce Studies and NORC at the University of Chicago.

MAIN OUTCOME MEASURES

Researchers assigned taxonomy categories to all analyzable qualitative responses and assessed the percentage of PH WINS responses that could be successfully mapped to taxonomy categories.

RESULTS

Between respondent self-selection and research team recoding, the public health workforce taxonomy successfully categorized 95% of occupation responses, 75% of credential responses, and 83% of program area responses. Occupational categories that may be considered for inclusion in the taxonomy in the future include disease intervention specialists and occupations associated with regulation, certification, and licensing.

CONCLUSIONS

The public health workforce taxonomy performed remarkably well in categorizing worker characteristics in its first use in a national survey. The analysis provides some recommendations for future taxonomy refinement.

Characterization of the federal workforce at the Centers for Disease Control and Prevention

CONTEXT

Studies characterizing the public health workforce are needed for providing the evidence on which to base planning and policy decision making both for workforce staffing and for addressing uncertainties regarding organizing, financing, and delivering effective public health strategies. The Centers for Disease Control and Prevention (CDC) is leading the enumeration of the US public health workforce with an initial focus on CDC as the leading federal public health agency.

OBJECTIVE

To characterize CDC's workforce, assess retirement eligibility and potential staff losses, and contribute these data as the federal component of national enumeration efforts.

METHODS

Two sources containing data related to CDC employees were analyzed. CDC's workforce was characterized by using data elements recommended for public health workforce enumeration and categorized the occupations of CDC staff into 15 standard occupational classifications by using position titles. Retirement eligibility and potential staffing losses were analyzed by using 1-, 3-, and 5-year increments and compared these data across occupational classifications to determine the future impact of potential loss of workforce.

RESULTS

As of the first quarter of calendar year 2012, a total 11 223 persons were working at CDC; 10 316 were civil servants, and 907 were Commissioned Corps officers. Women accounted for 61%. Public health managers, laboratory workers, and administrative-clerical staff comprised the top 3 most common occupational classifications among CDC staff. Sixteen percent of the workforce was eligible to retire by December 2012, and more than 30% will be eligible to retire by December 2017.

CONCLUSIONS

This study represents the first characterization of CDC's workforce and provides an evidence base upon which to develop policies for ensuring an ongoing ability to fulfill the CDC mission of maintaining and strengthening the public's health. Establishing a system for continually monitoring the public health workforce will support future efforts in understanding workforce shortages, capacity, and effectiveness; projecting trends; and initiating policies.

How to characterize the public health workforce based on essential public health operations? environmental public health workers in the Netherlands as an example

Background

Public health workforce planning and policy development require adequate data on the public health workforce and the services provided. If existing data sources do not contain the necessary information, or apply to part of the workforce only, primary data collection is required. The aim of this study was to develop a strategy to enumerate and characterize the public health workforce and the provision of essential public health operations (EPHOs), and apply this to the environmental public health workforce in the Netherlands as an example.

Methods

We specified WHO’s EPHOs for environmental public health and developed an online questionnaire to assess individual involvement in these. Recruitment was a two-layered process. Through organisations with potential involvement in environmental public health, we invited environmental public health workers (n = 472) to participate in a national survey. Existing benchmark data and a group of national environmental public health experts provided opportunities for partial validity checks.

Results

The questionnaire was well accepted and available benchmark data on physicians supported the results of this study regarding the medical part of the workforce. Experts on environmental public health recognized the present results on the provision of EPHOs as a reasonable reflection of the actual situation in practice.

All EPHOs were provided by an experienced, highly educated and multidisciplinary workforce. 27 % of the total full-time equivalents (FTEs) was spent on EPHO ‘assuring governance for health’. Only 4 % was spent on ‘health protection’. The total FTEs were estimated as 0.66 /100,000 inhabitants.

Conclusions

Characterisation of the public health workforce is feasible by identification of relevant organisations and individual workers on the basis of EPHOs, and obtaining information from those individuals by questionnaire. Critical factors include the operationalization of the EPHOS into the field of study, the selection and recruitment of eligible organisations and the response rate within organisations.. When existing professional registries are incomplete or do not exist, this strategy may provide a start to enumerate the quantity and quality of the public health within or across countries.

Trends and characteristics of the state and local public health workforce, 2010-2013

OBJECTIVES

We assessed state and local public health workforce characteristics by occupational category from 2010 to 2013. We also examined health department characteristics to determine whether workforce size and composition varied across these domains.

METHODS

We analyzed Association of State and Territorial Health Officials (2010, 2012) and National Association of County and City Health Officials (2010, 2013) profile study data, including 47 state health departments and 2005 and 1953 local health departments (LHDs) in 2010 and 2013, respectively. We determined number of workers and percentage of change by occupation, population size, geographic region, and governance structure.

RESULTS

The LHD workforce remained stable between 2010 and 2013. In states, the workforce decreased by 4%, with notable decreases in public information (-33%) and public health informatics (-29%); state health departments in small (-9%), New England (-13%), and centralized (-7%) states reported the largest decrease in number of workers.

CONCLUSIONS

Study findings provide evidence of a shifting public health workforce profile, primarily at the state level. Future research should seek to explain changing workforce patterns and determine whether they are planned or forced responses to changing budgets and service priorities.

Enumeration of the governmental public health workforce, 2014

BACKGROUND

Regular assessment of the size and composition of the U.S. public health workforce has been a challenge for decades. Previous enumeration efforts estimated 450,000 public health workers in governmental and voluntary agencies in 2000, and 326,602 governmental public health workers in 2012, although differences in enumeration methodology and the definitions of public health worker between the two make comparisons problematic.

PURPOSE

To estimate the size of the governmental public health workforce in 14 occupational classifications recommended for categorizing public health workers.

METHODS

Six data sources were used to develop enumeration estimates: five for state and local public health workers and one for the federal public health workforce. Statistical adjustments were made to address missing data, overcounting, and duplicate counting of workers across surveys. Data were collected for 2010-2013; analyses were conducted in 2014.

RESULTS

The multiple data sources yielded an estimate of 290,988 (range=231,464-341,053) public health workers in governmental agencies, 50%, 30%, and 20% of whom provide services in local, state, and federal public health settings, respectively. Administrative or clerical personnel (19%) represent the largest group of workers, followed by public health nurses (16%); environmental health workers (8%); public health managers (6%); and laboratory workers (5%).

CONCLUSIONS

Using multiple data sources for public health workforce enumeration potentially improves accuracy of estimates but also adds methodologic complexity. Improvement of data sources and development of a standardized study methodology is needed for continuous monitoring of public health workforce size and composition.

Public health workforce taxonomy

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012-2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection.

Assessment of workforce capacity for Local Health Departments in Nebraska: a perspective from public health programmatic areas

OBJECTIVE

This study assessed the workforce capacity of Nebraska Local Health Departments (LHDs) from the perspective of public health programmatic areas. DESIGN AND OUTCOMES MEASURES: We conducted a mail survey of 21 LHD directors in Nebraska and collected the information on LHD workforce capacity, training, and competency by public health programmatic areas (eg, environmental health, mental health). An FTE shortage index score for each public health programmatic area was calculated to estimate an LHD's current shortage in that area. Spearman correlation analysis was conducted to examine the relationships between LHD capacity, manpower shortage, and staff training and competency.

RESULTS

Our results indicated that a significant proportion of the 18 responding LHDs in Nebraska did not have staff to cover the areas of mental health (66.7%), sexually transmitted diseases (44.4%), occupational safety and injury (38.9%), oral health (27.8%), and health disparities (22.2%). The results also suggest that Nebraska's LHDs experienced the greatest workforce shortages in environmental health (mean shortage index = 0.45), followed by chronic diseases (0.44), health disparities (0.41), and sexually transmitted diseases (0.41).

CONCLUSIONS

The identified shortage areas should be a high priority for federal and state policy makers to address through developing appropriate strategies and providing adequate funding for LHD workforce development in Nebraska. Using the public health programmatic area approach to collect workforce data may help fill some gaps in the current efforts of LHD workforce enumeration. Future research is needed to examine the validity and reliability of the workforce measures based on public health programmatic areas.

Enumeration and composition of the public health workforce: challenges and strategies

The field of public health needs a comprehensive classification data system that provides a better assessment of the size and composition of its workforce. Such a data system is necessary for understanding the capacity, trend projections, and policy development critical to the future workforce. Previous enumeration and composition studies on the public health workforce have been helpful, but the methodology used needs further improvements in standardization, specificity, data storage, and data availability. Resolving this issue should follow a consensus-based course of action that includes public and private stakeholders at the national, state, and local level. This prime issue should be addressed now, particularly in the current environment of comprehensive health care reform.

Assessment of epidemiology capacity in state health departments, 2004-2009

OBJECTIVES

To assess the number of epidemiologists and epidemiology capacity nationally, the Council of State and Territorial Epidemiologists surveyed state health departments in 2004, 2006, and 2009. This article summarizes findings of the 2009 assessment and analyzes five-year (2004-2009) trends in the epidemiology workforce.

METHODS

Online surveys collected information from all 50 states and the District of Columbia about the number of epidemiologists employed, their training and education, program and technologic capacity, organizational structure, and funding sources. State epidemiologists were the key informants; 1,544 epidemiologists provided individual-level information.

RESULTS

The number of epidemiologists in state health departments decreased approximately 12% from 2004 to 2009. Two-thirds or more states reported less than substantial (< 50% of optimum) surveillance and epidemiology capacity in five of nine program areas. Capacity has diminished since 2006 for three of four epidemiology-related Essential Services of Public Health (ESPHs). Fewer than half of all states reported using surveillance technologies such as Web-based provider reporting systems. State health departments need 68% more epidemiologists to reach optimal capacity in all program areas; smaller states (< 5 million population) have higher epidemiologist-to-population ratios than more populous states.

CONCLUSIONS

Epidemiology capacity in state health departments is suboptimal and has decreased, as assessed by states' ability to carry out the ESPHs, by their ability to use newer surveillance technologies, and by the number of epidemiologists employed. Federal emergency preparedness funding, which supported more than 20% of state-based epidemiologists in 2006, has decreased. The 2009 Epidemiology Capacity Assessment demonstrates the negative impact of this decrease on states' epidemiology capacity.

Perspectives on public health workforce research

The Centers for Disease Control and Prevention Office of Workforce and Career Development is committed to developing a competent, sustainable, and diverse public health workforce through evidence-based training, career and leadership development, and strategic workforce planning to improve population health outcomes. This article reviews the previous efforts in identifying priorities of public health workforce research, which are summarized as eight major research themes. We outline a strategic framework for public health workforce research that includes six functional areas (ie, definition and standards, data, methodology, evaluation, policy, and dissemination and translation). To conceptualize and prioritize development of an actionable public health research agenda, we constructed a matrix of key challenges in workforce analysis by public health workforce categories. Extensive reviews were conducted to identify valuable methods, models, and approaches to public health workforce research. We explore new tools and approaches for addressing priority areas for public health workforce and career development research and assess how tools from multiple disciplines of social sciences can guide the development of a research framework for advancing public health workforce research and policy.

Toward standardized, comparable public health systems data: a taxonomic description of essential public health work

OBJECTIVE

To identify taxonomy of task, knowledge, and resources for documenting the work performed in local health departments (LHDs).

DATA SOURCES

Secondary data were collected from documents describing public health (PH) practice produced by organizations representing the PH community.

STUDY DESIGN

A multistep consensus-based method was used that included literature review, data extraction, expert opinion, focus group review, and pilot testing.

DATA EXTRACTION METHODS

Terms and concepts were manually extracted from documents, consolidated, and evaluated for scope and sufficiency by researchers. An expert panel determined suitability of terms and a hierarchy for classifying them. This work was validated by practitioners and results pilot tested in two LHDs.

PRINCIPAL FINDINGS

The finalized taxonomy was applied to compare a national sample of 11 LHDs. Data were obtained from 1,064 of 1,267 (84 percent) of employees. Frequencies of tasks, knowledge, and resources constitute a profile of PH work. About 70 percent of the correlations between LHD pairs on tasks and knowledge were high (>0.7), suggesting between-department commonalities. On resources only 16 percent of correlations between LHD pairs were high, suggesting a source of performance variability.

CONCLUSIONS

A taxonomy of PH work serves as a tool for comparative research and a framework for further development.