An effective public health system relies heavily on the workforce capacity of national, state, and local health departments. At the local level, local health department (LHD) staff carry out a wide array of responsibilities to promote and preserve the health of their communities.1 The increasing complexity of disease patterns, interventions, partnerships, and technologies requires a broad skill set among public health professionals. The existing and expanded responsibilities in public health practice have provided both challenges and opportunities for LHDs to redefine and reevaluate the competencies of their staff.2
A report released in 2010 by the Department of Health and Human Services Office of the Assistant Secretary of Health3 identified public health workforce and education as 1 of the 6 public health areas that urgently need improvement in quality. In addition to discipline-specific expertise, public health practitioners require broad, crosscutting skills and competencies to carry out much-needed services and to improve the health status of the US population.4
The Council on Linkages Between Academia and Public Health Practice developed the Core Competencies for Public Health Professionals, which are a set of skills for the practice of public health defined by the 10 essential public health services.5 The core competencies include 8 domains: analytical/assessment, policy development/program planning, communication, cultural competency, community dimensions of practice, basic public health science, financial planning and management, and leadership and systems thinking. The content and definition of the skills vary by tiers, which represent stages of career development (frontline/entry-level staff, program management/supervisory-level staff, and senior management/executive-level staff). Previous literature has provided evidence on the core competencies as a tool for evaluating competencies of the public health workforce.6
With the growing recognition of the importance of core competency development, public health agencies, including LHDs, have set workforce development as a priority. Some evidence has suggested that core competencies should be incorporated in workforce development programs and serve as a framework for assessing the effectiveness of these programs.7,8 Therefore, it is important to gain a comprehensive understanding of the development and training needs of the public health workforce, especially the areas that are perceived as high priorities. In a recent study intended to assess workforce development needs and priorities across all disciplines within public health, the investigators identified systems thinking, communicating persuasively, change management, information and analytics, problem solving, and working with diverse populations as priority crosscutting areas.4 However, these findings are based on interviews with representatives from public health membership organizations and federal agencies, rather than state or local public health practitioners, so these results may not directly reflect the perceptions of public health agency staff.
The number of staff and occupations employed by LHDs varies by the population of the jurisdiction served by the LHD. According to the data from the 2013 National Association of County & City Health Officials (NACCHO) National Profile of Local Health Departments (Profile study), the median number of LHD staff varies by almost 2 orders of magnitude between those serving the smallest and largest jurisdictions.9 In addition, LHDs serving small jurisdictions tend to have many fewer specialized occupations (eg, epidemiologists, informatics specialists, public information specialists) than large LHDs. These variations may affect employees' perception of skills required for their work.
Leaders are essential for success in public workforce development.10 Good leadership creates a supportive work climate, inspires and motivates employees, and facilitates the implementation of programs and activities.11 LHD top executives, who are the highest-ranking employees with administrative and managerial authority at LHDs, lead efforts to identify health needs, set priorities, and cope with changes in community characteristics and public health practices. During this process, they need to ensure that staff have a consistent understanding of organizational goals and strategies and are well-equipped with the skills needed to contribute to their LHD's mission.12 In addition, leaders are in the position to help employees develop their personal career goals and to identify training needs and preferences. Literature has suggested that perceived supervisor and management support in employees' career development is related to higher job satisfaction and retention.13,14
Although public health workforce development has gained increasing attention and interest, there are sparse data on how LHD employees perceive core workforce skills. This study aims to examine how top executives and staff from LHDs perceive the importance of various types of workforce skills and to assess the differences in the perception of the importance of these workforce skills between these 2 groups and among LHDs serving different-sized jurisdictions.
Data for this study were drawn from the 2014 Public Health Workforce Interests and Needs Survey (PH WINS) and the 2015 Forces of Change (FoC) survey. PH WINS was conducted by Association of State and Territorial Health Officers, with an aim to assess workforce knowledge, skills, and attitudes. Detailed information about the PH WINS methodology is available elsewhere.15 The survey targeted state and local public health practitioners. Three sampling frames were used: (1) employees of state health agencies; (2) employees of LHD members of the Big City Health Coalition; and (3) employees from LHDs in a 7-state local pilot (Arkansas, Georgia, Mississippi, South Carolina, Vermont, Washington, and Wisconsin). All participants in the second and third sampling frames were classified as local employees; if participants in the first sampling frame reported working in a local office of state agencies, they were also classified as local employees. All the local employees identified in the 3 types of sampling frames were included in this study.
A total of 12 435 PH WINS participants were local employees. To focus on LHD staff, only nonexecutive participants were included in the study. As the public health workforce skills are primarily applicable to employees engaged in public health–related roles, employees whose role was classified as administrative (eg, human resources personnel, clerical personnel) were excluded. In addition, those reported as interns or temps were removed from the data. A final sample of 8932 LHD staff was included in the analysis.
The 2015 FoC survey was conducted by NACCHO and was administered to top executives from a statistically representative sample of 948 LHDs in the United States. LHDs were stratified by 2 variables: size of the population served and state. A total of 690 LHDs completed the survey (response rate of 73%).
Perceived importance of workforce skills
In PH WINS, participants were asked to rate 18 workforce skills in terms of importance to their current position on a 4-point scale, with 1 = not important and 4 = very important. In the FoC survey, top executives were asked to rate the importance of 10 workforce skills for the mangers and professional public health staff in their LHDs on a 7-point scale, with 1 = not at all important and 7 = extremely important. These 10 questions were almost identical to the 10 questions on workforce skills in PH WINS, with a few minor adjustments in wording. Only the workforce skills measured by these 10 questions were examined in the study to allow a meaningful cross-survey comparison. These measures assessed the different domains of core competencies, with at least 1 measure related to each domain. The measures in both PH WINS and the FoC survey were reviewed by expert panels to ensure the skills are of high priority and reflect the domains in the core competency sets.4
LHD staff characteristics
Several staff demographic variables from PH WINS were included in the sample description, including age (40 years and younger, 41-50 years, 51-60 years, 61 years and older), gender, race/ethnicity (non-Hispanic white, non-Hispanic black or African American, Hispanic or Latino, non-Hispanic Asian, and non-Hispanic other), educational attainment (associate's degree, bachelor's degree, master's degree, doctoral degree, no college degree indicated) years in public health practice (0-5, 6-10, 11-15, 16-20, 21 and above), and supervisory status (without supervisory role, with supervisory role).
To make the matched comparison of responses from these 2 sets of participants, we converted the 4-point scale in PH WINS to a 7-point scale. We employed a formula on an SPSS-supporting document on using linear transformation to convert different Likert scales to a common scale.16 We used rescaling instead of z-score transformation because the transformed mean of the latter is zero, which would not allow meaningful significance tests to compare means. Descriptive statistics were conducted to examine demographic features of the PH WINS sample. Analysis of variance and Tukey HSD post hoc tests for unequal sample sizes were conducted to examine differences in the mean rating of each skill among top executives, supervisory staff, and nonsupervisory staff.
Further examination was conducted to assess how the perceived importance of these skills varied by the size of jurisdiction population. Those with missing information on their LHD names could not be linked to jurisdiction population data and thus were removed from these analyses. The t tests for unequal sample size and unequal variance were used to compare the mean reported rating by LHD staff versus top executives by 3 jurisdiction population categories: small (<50 000), medium (50 000-499 999), and large (500 000+). All P values are 2-tailed, with values less than .05 considered statistically significant.
Table 1 presents the sampled LHD staff demographic characteristics from PH WINS. Of those included in the analysis, nearly 80% of respondents were females and more than 45% were older than 50 years. The majority of respondents were non-Hispanic white (64%), followed by non-Hispanic black/African American (14%) and Hispanic (9%). Nearly a quarter of respondents had 5 or fewer years of experience in public health practice, and approximately another quarter had more than 20 years of experience in this field. In addition, about 60% of the respondents reported not having a supervisory role.
Table 2 presents the mean ratings of importance of workforce skills by top executives, supervisory staff, and nonsupervisory staff. Overall, top executives rated most workforce skills as more important than LHD staff, with or without a supervisory role, except for 4 items—communicating ideas and information (M = 6.20), addressing the needs of diverse population (M = 5.98), managing change in response to dynamic, evolving circumstances (M = 6.04), and applying quality improvement (QI) concepts in their work (M = 5.92). Top executives gave much higher scores to ensuring that programs are managed within budget constraints (M = 6.22) and influencing policy development (M = 5.69) than the other 2 groups. Supervisory employees gave significantly higher average ratings for all 10 skills than did their nonsupervisory counterparts.
For LHD leaders, ensuring that programs are managed within budget constraints (M = 6.22) and communicating ideas and information (M = 6.20) were the 2 highest rated skills for their staff. Comparatively, influencing policy development (M = 5.69) was rated the lowest. For both supervisory and nonsupervisory staff, communicating ideas and information effectively to different audiences (M = 6.18) had the highest average rating among all skills. In addition, applying QI concepts in their work was the third highest rated skill for both supervisors and staff, but rated second lowest by top executives.
Table 3 shows the comparison of the mean ratings by top executives and LHD staff within different LHD jurisdiction population categories (small, medium, and large). The sample size of PH WINS reduced to 4870 individuals for these analyses. Data on LHD jurisdiction population were available for all 690 respondents to the FoC survey.
For several items, the difference in ratings by staff and leaders varied by jurisdiction size. For small LHDs, staff rated addressing the needs of diverse population (M = 6.36) higher than top executives (M = 5.73), whereas large LHDs showed an opposite pattern (top executive: M = 6.57; staff: M = 6.19). Top executives in medium or large LHDs put more emphasis on the interpretation of public health data (medium LHDs: M = 6.21; large LHDs: M = 6.42) than staff (medium LHDs: M = 5.56; large LHDs: M = 5.59), whereas there was no difference in this skill's rating between the 2 groups in small LHDs. In medium and large LHDs, their leaders rated collaborating with diverse communities (medium LHDs: M = 6.32; large LHDs: M = 6.40) higher in importance than staff (medium LHDs: M = 5.65; large LHDs: M = 5.67). In contrast, in small LHDs, staff provided a slightly higher rating for this skill (top executive: M = 5.70; staff: M = 5.90).
Top executives in medium and large LHDs gave higher ratings to all skills than their counterparts in small LHDs. In contrast, staff in small LHDs often rated skills as more important when compared with staff in larger LHDs. In particular, staff in small LHDs gave a higher rating to ensuring that programs are managed within budget constraints than those in medium and large LHDs.
Our findings suggest that, overall, LHD workers at all levels believe that skills embodied in the core competencies are important for their jobs. Overwhelmingly, high percentages of participants (≥80%) of both PH WINS and the FoC surveys selected the positive end of the scale for each skill. The perceived importance of these skills differed somewhat across the supervisory level (nonsupervisory staff vs supervisory staff vs top executives) and among LHDs serving different jurisdiction sizes.
Staff with supervisory roles rated all these skills as more important for their position than nonsupervisory staff. As the 2014 Core Competencies for Public Health Professionals5 declares, although the same core competency domains apply to both frontline staff (tier 1) and program managers/supervisors (tier 2), the competencies progress from lower to higher levels of skill complexity across the tiers. The higher level of importance that supervisory staff give to the skills may reflect a more complex and diverse skill set required for their positions.5
Influencing policy development received the lowest mean rating among all skills from both LHD top executives and staff. The relatively lower rating may be associated with the limited policy-oriented work at some LHDs.17 Although nearly all LHDs have some involvement in policy-making activities, the staff involved at some LHDs may be limited to the top executive or members in the leadership team.9 As more LHDs adopt a “Health in All Policies” approach to public health practice, skills in the policy arena will become more important for employees at all levels.
Managing a program within budget constraints received the highest mean rating by top executives. Most LHDs experienced cuts in budgets, staff, and programs during the Great Recession and the years immediately following.18 LHD leaders had to employ various strategies to mitigate the impact of funding cuts.19,20 It is not surprising that LHD leaders expect their staff to provide services and programs on budget. However, such an expectation is not reflected in the responses from staff; both supervisory and nonsupervisory staff rated this skill as second-to-least important to their current positions. At a time when LHDs are asked to do more with less, leaders need to clearly communicate the importance of financial management to staff at all levels and consider ways to strengthen staff skills in this area. Moreover, it may be important for top executives to help their staff, particularly frontline staff, to understand how they can contribute to ensuring that the agency's resources are used most effectively and efficiently.
Our findings indicate different opinions between top executives and staff about the relative importance of QI and cultural competency. Both supervisors and staff ranked QI and cultural competency somewhat higher than top executives. These are 2 competencies that are highly relevant for frontline public health workers, and top executives should give priority to them in training plans. As the 2013 Profile study shows, increasing numbers of LHDs implemented formal QI programs but most LHDs (60%) did not offer QI training to their staff.9 Given the critical role of QI and cultural competency in improving the performance and functioning of the LHD,21,22 leaders may need to make these competencies higher priorities for training.
Staff in small LHDs gave higher mean ratings to most core skills in the survey than staff in larger LHDs. Small LHDs typically employ a narrow range of occupations, and the top executive is frequently the only employee in a management position.9 Frontline staff in those LHDs may need to perform multiple-occupation functions and thus need to have a more comprehensive skill set. Our results also show that employees in small LHDs gave particularly high ratings for several skills, such as financial planning and management. The typically small budgets of these LHDs may require all employees to be more cognizant of program budgets and to be actively engaged in looking for ways to save resources and improve efficiency. As a result, staff from small LHDs may give higher priority to financial management skills than staff from larger LHDs.
This study has a few limitations. First, the rating scales of the measure on workforce skills in PH WINS and the FoC survey were not identical. Although the conversion of scores made the cross-survey comparison possible, it is unknown whether results would remain the same if scales with same point interval were used in both surveys. It should be noted that this limitation may only potentially affect the comparison between top executives and staff but not the comparison between supervisory and nonsupervisory staff and between ratings within each subgroup. To assess whether the conversion from a smaller scale to a larger scale would result in biased results, we also tried the alternative, converting 7-point scale in the FoC survey to 4-point scale and got approximately identical results in cross-group comparisons. Second, the FoC survey used a nationally representative sample whereas PH WINS used several different sampling frames that included LHD staff but were not intended to be nationally representative. The PH WINS participants included in the analysis were from 38 states, 25 of which had at least 100 survey participants. One possible concern is whether the results are confounded by differences in sampling. To assess the potential for bias, we compared mean scores in the FoC survey for the subset of respondents in states with a substantial number of employees (at least 100) included in the PH-WINS data to the mean scores for all FoC survey respondents. The mean scores for the subset were quite similar to the mean scores for all respondents (differences <0.2 points), so we believe that bias due to differences in sampling is modest.
This study represents an initial endeavor to understand the perceived importance of core competencies by LHD staff, from the perspectives of top executives, other supervisors, and frontline staff. Although there are some variations in rated importance of skills among groups with different supervisory levels and across LHDs serving different population sizes, all of these competencies were judged relevant and important to LHD staff. Data from the 2013 Profile study (unpublished) indicate that only a small proportion of LHDs nationwide (26%) were using the Core Competencies for Public Health Professionals for writing position descriptions, assessing training needs, or developing training plans. In addition, most LHDs (especially those serving small jurisdictions) do not have formal workforce development plans. Our findings highlight the importance of incorporating these core competencies into training for LHD staff. The Public Health Accreditation Board has included a competency-based training plan as one of requirements for accreditation, which may encourage more LHDs (even those not applying for accreditation) to formalize their workforce development plans.23 More investigation is needed to assess whether and how gaps in staff competencies are addressed in the workforce development strategies.
LHD leaders and staff agree on the relative importance of some competencies. Both leaders and staff give high ratings to the importance of communication skills, which emphasizes the importance of that competency for public health staff at all levels. Both leaders and staff give relatively low ratings to policy development skills, suggesting that the anticipated shift from individual-level public health interventions to environmental- and policy-level interventions is happening slowly, and that equipping LHD staff for these kinds of roles will require significant investments in training.
Leaders of small LHDs rated all staff competencies lower on average than leaders of larger LHDs, whereas their employees rated them higher than employees at medium or large LHDs. Staff in small LHDs may require a wider range of competencies because of the many roles that may be filled by a single staff member, but small LHDs are less likely than larger LHDs to have formal workforce development plans (unpublished NACCHO data). These findings highlight the workforce development challenges experienced by small LHDs, which represent the majority of all LHDs in the United States.
It is essential to strengthen the communication between public health leaders and staff regarding the importance of workforce skills. While leaders should clearly convey their expectations and priorities, they should also actively seek and incorporate staff input into workforce development plans and programs.24 The public health workforce is very diverse in terms of education, experience, and job duties, so there will always be differences in training needs and preferences. But all LHD staff, from top executives to frontline workers, agree that the skills embodied in the Core Competencies for Public Health Professionals are important for the 21st-century LHD workforce.
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core competencies; local health departments; workforce; executive perceptions; staff perceptions