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

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).

Enumeration of the Public Health Workforce in New York State: Workforce Changes in the Wake of COVID-19

The governmental public health workforce in the United States has faced staffing shortages for over a decade that have been exacerbated by the COVID-19 pandemic. To assess this critical issue, the Region 2 Public Health Training Center collaborated with the New York State Association of County Health Officials to enumerate the city and county public health workforce in New York State. The organizations used an online survey to: (1) count employees and full-time equivalent (FTEs) staff in local health departments in 2021; (2) assess workforce trends since the COVID-19 pandemic; and, (3) identify challenges local health departments encounter in recruiting and retaining qualified public health workers. To assess trends, findings were compared with secondary data from 2019. Despite playing a central role in COVID-19 mitigation, local health departments experienced no overall increase in staffing in 2021 compared to 2019, with many health departments experiencing large increases in vacant positions. Recruitment challenges include noncompetitive salaries, difficulties finding qualified candidates, and lengthy hiring processes. This study complements accumulating evidence indicating that long-term investment in local public health infrastructure is needed to bolster the workforce and ensure that communities are protected from current and future health threats.

A Qualitative Study of the COVID-19 Response Experiences of Public Health Workers in the United States

The mental health impacts of the COVID-19 pandemic on frontline, patient-facing healthcare staff have been described in several studies, but the effects of the COVID-19 response on the US public health workforce have not been well characterized. In early 2021, we conducted interviews with a subset of public health practitioners in the United States who participated in a cross-sectional survey and indicated their willingness to participate in a follow-up interview. An interview guide was developed to collect information about professional roles since the start of the pandemic, aspects of the individual COVID-19 response that impacted mental health, and aspects of the organizational/institutional COVID-19 response that impacted mental health, as well as the strengths and weaknesses of, opportunities for, and threats to public health professionals and organizations going forward. Interviews were transcribed and inductively coded to identify themes. Of the 48 people invited to participate, 24 completed an interview between January 28 and February 23, 2021. Five key themes were identified through inductive coding of interview transcripts: (1) teamwork and workplace camaraderie, (2) potential for growth in the field of public health, (3) considerations for adaptive work environments (eg, remote work, work out of jurisdiction, transition to telework), (4) politicization of response, and (5) constrained hiring capacity and burnout. After more than a year of public health emergency response to the COVID-19 pandemic, it is critically important to understand the detrimental and supportive factors of good mental health among the public health workforce.

The New Public Health Workforce: Employment Outcomes of Public Health Graduate Students

CONTEXT

Much has been written about the public health workforce, but very little research has been published-and none in a peer-reviewed journal or other report since 1992-regarding the employment outcomes and employment sectors of graduate students pursuing public health as an area of study.

OBJECTIVES

Our objectives were to review the literature and analyze data regarding the employment outcomes of public health graduate students and to examine how public health schools and programs might respond to changes in the sectors hiring their graduates.

DESIGN

We reviewed the literature regarding the employment of public health graduates; analyzed 5 years of graduate outcomes from Columbia University's Mailman School of Public Health using logistic regression; and we examined data collected by the Association of Schools & Programs of Public Health.

PARTICIPANTS

The study included data from surveys of 2904 graduates of Columbia University's Mailman School of Public Health, across 5 graduating cohort years, for whom there were employment sector data available for 1932.

RESULTS

Much of the research on the public health workforce has defined it as governmental public health. Across each of 5 graduating classes from Columbia University's Mailman School of Public Health, the odds of for-profit sector employment increased by 23% (2012-2016), while hiring by government agencies declined or remained flat. Publicly available employment data from the Web sites of schools of public health and from surveys by the Association of Schools & Programs of Public Health show that hiring of new graduates by for-profit corporations now either closely matches or exceeds governmental hiring at many schools of public health.

CONCLUSIONS

Public health graduates are increasingly working outside of government, and additional analyses are required to determine whether core competencies of public health curricula reflect the needs of the employers that are hiring public health graduates today. Schools and programs of public health should invest in their career services offices and gather input from employers that are currently hiring their graduates, especially as the sectors hiring them may be changing.

A Novel Approach for Workforce Surveillance at the US Department of Health and Human Services

BACKGROUND

Expert groups have recommended ongoing monitoring of the public health workforce to determine its ability to execute designated objectives. Resource- and time-intensive surveys have been a primary data source to monitor the workforce. We evaluated an administrative data source containing US Department of Health and Human Services (HHS) aggregate federal civil service workforce-related data to determine its potential as a workforce surveillance system for this component of the workforce.

METHODS

We accessed FedScope, a publicly available online database containing federal administrative civilian HHS personnel data. Using established guidelines for evaluating surveillance systems and identified workforce characteristics, we evaluated FedScope attributes for workforce surveillance purposes.

RESULTS

We determined FedScope to be a simple, highly accepted, flexible, stable, and timely system to support analyses of federal civil service workforce-related data. Data can be easily accessed, analyzed, and monitored for changes across years and draw conclusions about the workforce. FedScope data can be used to calculate demographics (eg, sex, race or ethnicity, age group, and education level), employment characteristics (ie, supervisory status, work schedule, and appointment type), retirement projections, and characterize the federal workforce into standard occupational categories.

CONCLUSIONS

This study indicates that an administrative data source containing HHS personnel data can function as a workforce surveillance system valuable to researchers, public health leaders, and decision makers interested in the federal civil service public health workforce. Using administrative data for workforce development is a model that can be applicable to federal and nonfederal public health agencies and ultimately support improvements in public health.

Strengthening the public health workforce: An estimation of the long-term requirements for public health specialists in Serbia

At the beginning of the 21st century, planning the public health workforce requirements came into the focus of policy makers. The need for improved provision of essential public health services, driven by a challenging non-communicable disease and causes of death and disability within Serbia, calls for a much needed estimation of the requirements of the public health professionals. Mid and long-term public health specialists' supply and demand estimations out to 2025were developed based on national staffing standards and regional distribution of the workforce in public health institutes of Serbia. By 2025, the supply of specialists, taking into account attrition rate of -1% reaches the staffing standard. However, a slight increase in attrition rates has the impact of revealing supply shortage risks. Demand side projections show that public health institutes require an annual input of 10 specialists or 2.1% annual growth rate in order for the four public health fields to achieve a headcount of 487 by 2025 as well as counteract workforce attrition rates. Shortage and poor distribution of public health specialists underline the urgent need for workforce recruitment and retention in public health institutes in order to ensure the coordination, management, surveillance and provision of essential public health services over the next decade.

Reconciling Supply and Demand for State and Local Public Health Staff in an Era of Retiring Baby Boomers

INTRODUCTION

The purpose of this study is to reconcile public health workforce supply and demand data to understand whether the expected influx of public health graduates can meet turnover events.

METHODS

Four large public health workforce data sources were analyzed to establish measures of workforce demand, voluntary separations, and workforce employees likely to retire at state and local health departments. Data were collected in 2014-2016 and analyzed in 2016 and 2017. Potential workforce supply (i.e., candidates with formal public health training) was assessed by analyzing data on public health graduates. Supply and demand data were reconciled to identify potential gaps in the public health workforce.

RESULTS

At the state and local level, ≅197,000 staff are employed in health departments. This is down more than 50,000 from 2008. In total, ≥65,000 staff will leave their organizations during fiscal years 2016-2020, with ≤100,000 staff leaving if all planned retirements occur by 2020. During 2000-2015, more than 223,000 people received a formal public health degree at some level. More than 25,000 students will receive a public health degree at some level in each year through 2020.

CONCLUSIONS

Demands for public health staff could possibly be met by the influx of graduates from schools and programs of public health. However, substantial implications exist for transferal of institutional knowledge and ability to recruit and retain the best staff to sufficiently meet demand.

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.

The Affordable Care Act's implications for a public health workforce agenda: taxonomy, enumeration, and the Standard Occupational Classification system

The Affordable Care Act brings a renewed emphasis on the importance of public health services and those whose occupations are defined by performing the essential public health functions. The Affordable Care Act Prevention and Public Health Fund is a signal to the field that its work is important and critical to the health of the nation. Recent reports by the Institute of Medicine describe the changing dimensions of public health work in primary care integration and the need for enhanced financing of public health as investment. Gaining knowledge about the public health workforce, that is, how many workers there are and what they are doing, is of growing interest and concern for the field. Although enumeration of the public health workforce has been attempted several times by the federal government beginning as early as 1982, it was not until the year 2000 that a major effort was undertaken to obtain more complete information. Limitations that hampered Enumeration 2000 have persisted however. With implementation of the Affordable Care Act and other new ventures, key federal agencies are developing strategies to pursue a systemic and systematic enumeration and consistent taxonomy process. Included in these efforts is use of the Bureau of Labor Statistics, Standard Occupational Classification system. A clear and accurate understanding of the public health workforce and its characteristics is a major challenge. A well-constructed, systematic enumeration process can add to our understanding of the nature and functions of that workforce. In addition, discussion of enumeration must include the need for a consensus within the field that leads to a consistent taxonomy for the public health occupations. This article will provide a stage-setting brief of historical actions regarding enumeration, and it will examine selected enumeration activities taking place currently. It will discuss positive and negative implications facing public health and the potential for enhancing the existing Standard Occupational Classification system to aid enumeration studies.

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.

Profile of the public health workforce: registered TRAIN learners in the United States

OBJECTIVES

We analyzed data from the TrainingFinder Real-time Affiliate Integrated Network (TRAIN), the most widely used public health workforce training system in the United States, to describe the public health workforce and characteristics of individual public health workers.

METHODS

We extracted self-reported demographic data of 405,095 learners registered in the TRAIN online system in 2012.

RESULTS

Mirroring the results of other public health workforce studies, TRAIN learners are disproportionately women, college educated, and White compared with the populations they serve. TRAIN learners live in every state and half of all zip codes, with a concentration in states whose public health departments are TRAIN affiliates. TRAIN learners' median age is 46 years, and one third of TRAIN learners will reach retirement age in the next 10 years.

CONCLUSIONS

TRAIN data provide a limited but useful profile of public health workers and highlight the utility and limitations of using TRAIN for future research.

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.

In-depth interviews with state public health practitioners on the United States National Physical Activity Plan

BACKGROUND

The United States National Physical Activity Plan (NPAP; 2010), the country's first national plan for physical activity, provides strategies to increase population-level physical activity to complement the 2008 physical activity guidelines. This study examined state public health practitioner awareness, dissemination, use, challenges, and recommendations for the NPAP.

METHODS

In 2011-2012, we interviewed 27 state practitioners from 25 states. Interviews were recorded and transcribed verbatim. Transcripts were coded using a standard protocol, verified and reconciled by an independent coder, and input into qualitative software to facilitate development of common themes.

RESULTS

NPAP awareness was high among state practitioners; dissemination to local constituents varied. Development of state-level strategies and goals was the most frequently reported use of the NPAP. Some respondents noted the usefulness of the NPAP for coalitions and local practitioners. Challenges to the plan included implementation cost, complexity, and consistency with other policies. The most frequent recommendation made was to directly link examples of implementation activities to the plan.

CONCLUSIONS

These results provide early evidence of NPAP dissemination and use, along with challenges encountered and suggestions for future iterations. Public health is one of eight sectors in the NPAP. Further efforts are needed to understand uptake and use by other sectors, as well as to monitor long-term relevance, progress, and collaboration across sectors.