Assessment of Epidemiology Capacity in State Health Departments, 2001–2006

Under-Funded and Under-Pressure: State Epidemiologists During the COVID-19 Response

OBJECTIVES

We conducted interviews with state epidemiologists involved in the state-level COVID-19 response to understand the challenges and opportunities that state epidemiologists and state health departments faced during COVID-19 and consider the implications for future pandemic responses.

METHODS

As part of a broader study on policymaking during COVID-19, we analyzed 12 qualitative interviews with state-epidemiologists from 11 US states regarding the challenges and opportunities they experienced during the COVID-19 response.

RESULTS

Interviewees described the unprecedented demands COVID-19 placed on them, including increased workloads as well as political and public scrutiny. Decades of under-funding and constraints posed particular challenges for meeting these demands and compromised state responses. Emergency funding contributed to ameliorating some challenges. However, state health departments were unable to absorb the funds quickly, which created added pressure for employees. The emergency funding also did not resolve longstanding resource deficits.

CONCLUSIONS

State health departments were not equipped to meet the demands of a comprehensive COVID-19 response, and increased funding failed to address shortfalls. Effective future pandemic responses will require sustained investment and adequate support to manage on-going and surge capacity needs. Increased public interest and skepticism complicated the COVID-19 response, and additional measures are needed to address these factors.

Epidemiología de campo en tiempos de COVID-19: retos para los servicios de salud pública. Informe SESPAS 2021

Durante la crisis por la COVID-19, las unidades periféricas de epidemiología se han visto obligadas a gestionar un volumen de casos, contactos y brotes para el que no estaban dimensionadas ni dotadas. En situaciones ordinarias, el estudio y el control eficiente de los brotes y de las alertas requieren recursos humanos y materiales, análisis de la situación para identificar causas y emitir recomendaciones, coordinación con otras estructuras del sistema sanitario, así como la devolución de los resultados y las actuaciones en un informe y una propuesta de actuaciones. El estudio de brotes sobre el terreno ha evolucionado, alcanzando un grado de sistematización que ha permitido implementar de forma generalizada medidas rápidas y eficaces, para la interrupción de las cadenas de transmisión y la gestión de las situaciones de riesgo. Para conseguirlo, se ha tenido que realizar un ejercicio rápido y extraordinario de integración informática, de movilización de personal y de creación de estructuras ad hoc. La solidaridad y la cooperación entre profesionales de distintas Administraciones ha sido el pilar que ha sostenido el sistema de vigilancia. A pesar de ello, se han detectado obstáculos fruto de la falta de coordinación, las desigualdades sociales en salud y, posteriormente, la fatiga pandémica, que han disminuido la adherencia y la efectividad de las medidas. A su vez, se ha puesto de manifiesto la necesidad de redimensionar estas unidades, dotarlas de profesionales con formación y equiparar las condiciones de trabajo y de remuneración con los servicios de salud.

A review of the applied epidemiology workforce in the United States: past, present, and future

Applied epidemiologists are key professionals within the public health workforce, fulfilling core public health science functions. The public health system in the United States has been rapidly transforming over the last decade and epidemiologists will need to develop new skill sets to be successful in the future of public health. A review of the literature was undertaken to gain a comprehensive understanding of the past and present of the applied epidemiology workforce to inform future workforce initiatives aimed at improving applied epidemiology practice. The literature search identified 48 articles related to applied epidemiologists working in the United States at the federal, state, and local levels. These articles described efforts to build, enumerate, and assess the competency of the applied epidemiology workforce in addition to putting forward opinions about it. Overall, the articles demonstrated significant prior work enumerating the applied epidemiology workforce, some prior work identifying epidemiology training needs, and few prior studies assessing competency. The functions, skill sets, and training needs of epidemiologists have changed over time and the literature provides a number of recommendations for future training. Continued assessment of the workforce literature is recommended to monitor training needs and competency for use in implementing effective workforce development activities.

One Field Epidemiologist per 200,000 Population: Lessons Learned from Implementing a Global Public Health Workforce Target

The World Health Organization monitoring and evaluation framework for the International Health Regulations (IHR, 2005) describes the targets for the Joint External Evaluation (JEE) indicators. For workforce development, the JEE defines the optimal target for attaining and complying with the IHR (2005) as 1 trained field epidemiologist (or equivalent) per 200,000 population. We explain the derivation and use of the current field epidemiology workforce development target and identify the limitations and lessons learned in applying it to various countries' public health systems. This article also proposes a way forward for improvements and implementation of this workforce development target.

Epidemiology Workforce Capacity in 27 Large Urban Health Departments in the United States, 2017

OBJECTIVES

The Council of State and Territorial Epidemiologists (CSTE) has periodically assessed the epidemiological capacity of states since 2001, but the data do not reflect the total US epidemiology capacity. CSTE partnered with the Big Cities Health Coalition (BCHC) in 2017 to assess epidemiology capacity in large urban health departments. We described the epidemiology workforce capacity of large urban health departments in the United States and determined gaps in capacity among BCHC health departments.

METHODS

BCHC, in partnership with CSTE, modified the 2017 State Epidemiology Capacity Assessment for its 30 member departments. Topics in the assessment included epidemiology leadership, staffing, funding, capacity to perform 4 epidemiology-related Essential Public Health Services, salary ranges, hiring requirements, use of competencies, training needs, and job vacancies.

RESULTS

The 27 (90%) BCHC-member health departments that completed the assessment employed 1091 full-time equivalent epidemiologists. All or nearly all health departments provided epidemiology services for programs in infectious disease (n = 27), maternal and child health (n = 27), preparedness (n = 27), chronic diseases (n = 25), vital statistics (n = 25), and environmental health (n = 23). On average, funding for epidemiology activities came from local (47%), state (24%), and federal (27%) sources. Health departments reported needing a 40% increase from the current number of epidemiologists to achieve ideal epidemiology capacity. Twenty-five health departments reported substantial-to-full capacity to monitor health problems, 21 to diagnose health problems, 11 to conduct evaluations, and 9 to perform applied research.

CONCLUSIONS

Strategies to meet 21st century challenges and increase substantial-to-full epidemiological capacity include seeking funds from nongovernmental sources, partnering with schools and programs of public health, and identifying creative solutions to hiring and retaining epidemiologists.

Examining state health agency epidemiologists and their training needs

PURPOSE

Despite increases in formal education, changing trends affecting epidemiologic practice prompted concerns over whether epidemiologists had sufficient training.

METHODS

This study sought to explain factors that predicted low self-reported proficiency levels among daily important work tasks of state health agencies' epidemiologists. The number of knowledge gaps, instances where epidemiologists identified a work-related task both as 'very' important in their daily work and felt they were "unable to perform" or performed at a "beginner" level, was studied, and predictor variables were assessed. A total of 681 epidemiologists responded to the 2014 Public Health Workforce Interests and Needs Survey, a national survey of state health agency workers; epidemiologists represented 7% of all respondents.

RESULTS

Epidemiologists at state health agencies worked mostly in communicable disease (31%) or general surveillance (26%). Epidemiologists reported eight key daily work-related activities with an average of three training gaps. Factors that decreased the likelihood of epidemiologists' low proficiency in performing key activities were the presence of internal trainings (adjusted odds ratio = 0.69, 95% confidence interval, 0.49-0.99) and length of time working in public health (adjusted odds ratio = 0.95, 95% confidence interval, 0.93-0.98).

CONCLUSION

Although formal education of epidemiologists is on the rise, state health agencies' epidemiologists feel unprepared to tackle one-third of their important daily tasks.

Predictors of capacity in public health, environmental, and agricultural laboratories

OBJECTIVES

Ensuring adequate capacity to address population health concerns has challenged public health for decades. Organizational and workforce characteristics are theorized to contribute to organizational capacity. This article considers 2 possible quantitative measures of organizational capacity using public health, environmental, and agricultural laboratories (PHEALs) as the unit of interest and tests their associations with workforce and human resources variables.

DESIGN

The National Laboratory Capacity Assessment was developed by the University of Michigan Center of Excellence in Public Health Workforce Studies and the Association of Public Health Laboratories. Online data collection took place from July to September 2011. All statistical analyses were performed in 2013.

SETTING

US PHEALs were invited to participate in the study. All study participants were Association of Public Health Laboratories members.

PARTICIPANTS

The Association of Public Health Laboratories distributed the National Laboratory Capacity Assessment survey to 105 PHEAL directors in all 50 states, the District of Columbia, and Puerto Rico, including 50 state public health laboratories, 41 local public health laboratories, 8 environmental laboratories, and 6 agricultural laboratories.

MAIN OUTCOME MEASURES

Logistic regression analyses were performed to assess relationships between outcome measures of overall capacity and averaged program capacity and variables representing characteristics of PHEALs and their workforce, including number of workers, proportion of scientists, education, experience, training, and equipment quality.

RESULTS

The survey achieved a 76% response rate. Both capacity models showed that PHEALs offering an array of training opportunities are 4 times more likely to report higher capacity scores. One model showed a positive association between workforce size and capacity. Worker education and equipment quality were negatively associated with capacity in both models.

CONCLUSIONS

The findings of this study provide empirical evidence that some workforce factors may influence organizational capacity of PHEALs. Techniques used to measure capacity and workforce factors must be improved to produce consistent findings across public health organizational data sets.

The epidemiology and surveillance workforce among local health departments in California: mutual aid and surge capacity for routine and emergency infectious disease situations

OBJECTIVE

Public health surveillance and epidemiologic investigations are critical public health functions for identifying threats to the health of a community. We conducted a survey of local health departments (LHDs) in California to describe the workforce that supports public health surveillance and epidemiologic functions during routine and emergency infectious disease situations.

METHODS

The target population consisted of the 61 LHDs in California. The online survey instrument was designed to collect information about the workforce involved in key epidemiologic functions. We also examined how the public health workforce increases its epidemiologic capacity during infectious disease emergencies.

RESULTS

Of 61 LHDs in California, 31 (51%) completed the survey. A wide range of job classifications contribute to epidemiologic functions routinely, and LHDs rely on both internal and external sources of epidemiologic surge capacity during infectious disease emergencies. This study found that while 17 (55%) LHDs reported having a mutual aid agreement with at least one other organization for emergency response, only nine (29%) LHDs have a mutual aid agreement specifically for epidemiology and surveillance functions.

CONCLUSIONS

LHDs rely on a diverse workforce to conduct epidemiology and public health surveillance functions, emphasizing the need to identify and describe the types of staff positions that could benefit from public health surveillance and epidemiology training. While some organizations collaborate with external partners to support these functions during an emergency, many LHDs do not rely on mutual aid agreements for epidemiology and surveillance activities.

Building leadership skills and promoting workforce development: evaluation data collected from public health professionals in the field of maternal and child health

Professional development, including training and leadership skill building, is important for maternal and child health (MCH) epidemiologists. Current workforce development and training opportunities vary, but lack an emphasis on linking leadership competencies with MCH epidemiology. This paper describes efforts at the annual MCH Epidemiology Conference (the "Conference") to promote leadership activities and workforce development, and recommendations to enhance professional development. An evaluation of attendee opinions on Conference workforce development activities was conducted during the 2009 and 2010 Conferences (70 and 66 % response rates, respectively). Frequencies and percentages were calculated overall and by attendee profession. Qualitative responses to questions regarding workforce and professional development were classified by theme in 2009, and a categorical question was developed for the 2010 evaluation. A combined 38 % of Conference attendees in 2009 and 2010 were MCH epidemiologists and 62 % were other MCH professionals. Attendees recommended more support and access to training, mentoring, and resources including job opportunities. Continuing education (41 %), special knowledge and skills-building training (51 %), and development of online resources for training (57 %) were highly recommended by attendees. Career (47 %) and leadership (49 %) mentoring by senior-level professionals in the field were also highly recommended. Promotion of leadership can be achieved by integrating the concept of leadership into the Conference itself; by publishing and disseminating MCH epidemiologic research in scientific, program, and policy settings; and by communicating the importance of epidemiologic findings to stakeholders and other non-scientific audiences.

Disease reporting among Georgia physicians and laboratories

Opportunities for improved disease reporting are identified by describing physicians' reporting knowledge and practices as well as reporting knowledge and specimen referral patterns among clinical laboratories in the state of Georgia. In 2005, a sample of physicians(n = 177) and all Georgia clinical laboratories (n = 139) were surveyed about reporting knowledge and practices. Knowledge was greater among physicians who received their medical degree before 1980 (P = .04), accessed e-mail (P< .01), used the Internet to obtain public health information (P < .01), and reported frequently (P= .06). Increased knowledge was not associated with training in reporting (P = .14). Physicians were often unaware of reporting procedures and mechanisms and often did not report because they believed others would report (52%). Laboratory representatives (56%) more often received training on disease reporting than physicians (32%). All laboratories sent some specimens for diagnostic testing at reference laboratories and 35% sent the specimens outside of Georgia. Physicians'characteristics may affect reporting knowledge independent of training on disease reporting, and increased knowledge is associated with increased reporting. Investigation of physician characteristics that contribute to improved reporting, such as an active engagement with public health, could help to guide changes to reporting-related training and technology. Reporting by other health care providers and physicians' perceptions that others will report both indicate that studies of all reporting stakeholders and clear delineation of reporting responsibilities are needed. Extensive specimen referral by laboratories suggests the need for coordination of reporting regulations and responsibilities beyond local boundaries.

Assessing the roles of brokerage: an evaluation of a hospital-based Public Health epidemiologist program in North Carolina

CONTEXT

The North Carolina Division of Public Health established an innovative program in 2003 that placed public health epidemiologists (PHEs) in hospitals around the state to improve communication between hospitals and local public health departments (LHDs) and bolster public health surveillance and response.

OBJECTIVE

To use social network analysis to assess how the hospital-based PHE program in North Carolina facilitates the exchange of public health surveillance information.

DESIGN

Using a Gould-Fernandez brokerage analysis, this study examines communication among organizational actors and their dependence on third parties to broker information and knowledge.

PARTICIPANTS

Survey and interview data were collected to identify the interorganizational network among 220 organizational actors and their public health surveillance-related activities, including 11 PHEs, 100 county-level offices of North Carolina's 85 LHDs, and 109 hospitals.

MAIN OUTCOME MEASURES

Social network analysis is used to calculate the frequency with which an actor serves as an intermediary in each of the 5 brokerage roles as well as total brokerage equal to the sum of the number of times an actor occupies each role.

RESULTS

Results identify a frequent tendency for PHEs to serve as an intermediary between LHDs and hospitals. Interactions between these entities are frequently facilitated by PHEs, with a high measure of degree centrality by LHDs and a low frequency of brokerage among hospitals.

CONCLUSIONS

Results validate PHEs' mission to enhance communication between LHDs and hospitals around communicable disease surveillance, reporting, and management.

Public health workforce research in review: a 25-year retrospective

CONTEXT

The Robert Wood Johnson Foundation commissioned a systematic review of public health workforce literature in fall 2010. This paper reviews public health workforce articles published from 1985 to 2010 that support development of a public health workforce research agenda, and address four public health workforce research themes: (1) diversity; (2) recruitment, retention, separation, and retirement; (3) education, training, and credentialing; and (4) pay, promotion, performance, and job satisfaction.

EVIDENCE ACQUISITION

PubMed, ERIC, and Web of Science databases were used to search for articles; Google search engine was used to identify gray literature. The study used the following inclusion criteria: (1) articles written in English published in the U.S.; (2) the main theme(s) of the article relate to at least one of the four public health workforce research themes; and (3) the document focuses on the domestic public health workforce.

EVIDENCE SYNTHESIS

The literature suggests that the U.S. public health workforce is facing several urgent priorities that should be addressed, including: (1) developing an ethnically/racially diverse membership to meet the needs of an increasingly diverse nation; (2) recruiting and retaining highly trained, well-prepared employees, and succession planning to replace retirees; (3) building public health workforce infrastructure while also confronting a major shortage in the public health workforce, through increased education, training, and credentialing; and (4) ensuring competitive salaries, opportunities for career advancement, standards for workplace performance, and fostering organizational cultures which generate high levels of job satisfaction for effective delivery of services.

CONCLUSIONS

Additional research is needed in all four thematic areas reviewed to develop well-informed, evidence-based strategies for effectively addressing critical issues facing the public health workforce.

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

Building an effective workforce: a systematic review of public health workforce literature

CONTEXT

The Robert Wood Johnson Foundation commissioned a systematic review of public health workforce literature in fall 2010. This paper reviews public health workforce articles published from 1985 to 2010 that support development of a public health workforce research agenda and address four public health workforce research themes: size and composition, effectiveness and health impact, demand, and policy.

EVIDENCE ACQUISITION

PubMed, ERIC, and Web of Science databases were used to search for articles; Google search engine was used to identify gray literature. The study used the following inclusion criteria: (1) the document was published in the U.S.; (2) the main theme(s) of the article address public health workforce research or relate to at least one of the four workforce research themes; and (3) the article focuses on the domestic workforce.

EVIDENCE SYNTHESIS

A total of 126 public health workforce articles and gray literature documents were analyzed in this review, including 34 related to effectiveness and health impact, 32 summary articles, 30 articles on size and composition, 20 articles about demand, and 10 policy articles. The primary sources for identifying articles were PubMed (66%); Google (28%); and Web of Science (6%).

CONCLUSIONS

The majority of public health workforce articles are descriptive in nature; few empirical studies about the public health workforce have been published in the peer-reviewed literature. Future research should consider use of organizational theories to develop workforce capacity models for public health and development of quantifiable output measures on which to base models that incorporate workforce demand.

Challenges to recruitment and retention of the state health department epidemiology workforce

BACKGROUND

With nearly one quarter of the combined governmental public health workforce eligible for retirement within the next few years, recruitment and retention of workers is a growing concern. Epidemiology has been identified as a potential workforce shortage area in state health departments.

PURPOSE

Understanding strategies for recruiting and retaining epidemiologists may help health departments stabilize their epidemiology workforce. The Council of State and Territorial Epidemiologists conducted a survey, the Epidemiology Capacity Assessment (ECA), of state health departments to identify recruitment and retention factors.

METHODS

The ECA was distributed to 50 states, the District of Columbia (DC), and four U.S. territories in 2009. The 50 states and DC are included in this analysis. The State Epidemiologist completed the organizational-level assessment; health department epidemiologists completed an individual-level assessment. Data were analyzed in 2010.

RESULTS

All states responded to the ECA, as did 1544 epidemiologists. Seventeen percent of epidemiologists reported intent to retire or change careers in the next 5 years. Ninety percent of states and DC identified state and local government websites, schools of public health, and professional organizations as the most useful recruitment tools. Top recruitment barriers included salary scale, hiring freezes, and ability to offer competitive pay; lack of promotion opportunities and merit raise restrictions were main retention barriers.

CONCLUSIONS

Although the proportion of state health department epidemiologists intending to retire or change careers during the next 5 years is lower than the estimate for the total state public health workforce, important recruitment and retention barriers for the employees exist.

Structure and functions of state public health agencies in 2007

We sought to document the structure and functions of state public health agencies throughout the United States in 2007 and compare findings with those from a similar 2001 assessment. In 2007 a survey of the structure and functions of state public health agencies was sent to and completed by senior deputies in all 50 states and the District of Columbia (a 100% response rate). The results of the survey showed that all emerging practice areas in 2001 had expanded by 2007. Also, state health departments generally had greater levels of responsibility in 2007 than they did in 2001, emphasizing the need for continued support of governmental public health systems and research on the operations of those systems.

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.

Review of the UNC Team Epi-Aid graduate student epidemiology response program six years after implementation

Service learning is one way that academia can contribute to assuring the public's health. The University of North Carolina's Team Epi-Aid service-learning program started in 2003. Since then, 145 graduate student volunteers have contributed 4,275 hours working with the state and local health departments during 57 activities, including outbreak investigations, community health assessments, and emergency preparedness and response. Survey data from student participants and public health partners indicates that the program is successful in meeting its goal of creating effective partnerships among the university, the North Carolina Center for Public Health Preparedness, and state and local health departments; supplying needed surge capacity to health departments; and providing students with applied public health experience and training. In this article, we discuss the programmatic lessons learned around administration, maintaining student interest, program sustainability, and challenges since program implementation.