Respondents were given a list of national trends, which included concise definitions, and asked to report how much they had heard about the trend, how important they thought it was, how much they thought it would impact their day-to-day work, and how much more or less emphasis they thought should be put on the trend in the future. Respondents were counted as having heard of a trend if they indicated they had heard about it “not much,” “a little,” or “a lot” (as opposed to “nothing at all”). The national trends results are displayed in Table 5. Respondents were most likely to have heard about “implementation of the Affordable Care Act” (92%; 95% CI, 91-93). While 85% (95% CI, 84-86) of staff who had heard of the Patient Protection and Affordable Care Act (ACA) considered it to be important to public health, this was among the least important of the trends listed. Implementation of the ACA was rated lower than most other trends in terms of impact on day-to-day work and needing more emphasis in the future. “Fostering a culture of quality improvement” was the next most common trend for workers to have heard of (83%; 95% CI, 83-84), and it was most almost universally rated as important (96%; 95% CI 95-96). Quality improvement was considered the trend to be most likely to impact day-to-day work and was second only to “leveraging electronic health information” in terms of trends needing more emphasis in the future.
“Evidence-based public health practice” and “public health and primary care integration” were recognized by approximately three-fourths of respondents and were among the most highly rated trends in terms of importance. Roughly half of respondents reported that more emphasis should be placed on these 2 trends in the future.
PH WINS is the first nationally representative survey of central office employees in SHAs. This survey provides a unique opportunity to learn about what workers from the front lines to the leadership teams know, think, and believe about their own training needs, the environment in which they work, and the national trends that are, to some extent, driving health system transformation. A number of the insights gained from this survey are immediately actionable for leaders wishing to develop a more robust workforce prepared to protect and promote population health in a transformed health system.
As expected, the survey showed that women are strongly disproportionally represented among public health workers. The proportion of African Americans among public health workers mirrors that of the general public. Hispanic/Latino workers, on the contrary, make up 7% of the workforce compared with 17% of the population.46 Young adults are also represented in the workforce in markedly smaller proportion to the population, with only 8% of the workforce 30 years or younger and almost half (47%) older than 50 years. These findings are consistent with demographic characteristics previously reported by the Association of State and Territorial Health Officials.47 Addressing the health needs of Hispanics and Latinos will be a continuing priority of SHAs as their population size continues to grow, making the recruitment of Hispanic/Latino workers a priority. And to ensure a sustainable workforce, recruitment of young adults will also be a priority.
While the workforce is largely college-educated (75% hold at least a bachelor's degree, and another 10% hold an associate's degree), only 17% have any formal training in public health. Given recent growth in the undergraduate public health major and the potential to bring these recruits in at lower price points than master's educated staff, agencies might consider targeting graduates of bachelor's in public health programs when recruiting young adults and ensure that those without public health degrees participate in basic public health science training.
The finding that 79% of workers are “very satisfied” or “somewhat satisfied” with their jobs was surprising. Given the multiple rounds of cumulative budget cuts SHAs have experienced, along with the constant change induced by health reform, technological advances, and emerging health issues, it would have been reasonable to predict that morale at SHAs would be below average. The Federal Employee Viewpoint Survey found that 64% of all federal workers and 67% of federal HHS staff are “very satisfied” or “somewhat satisfied” with their jobs. Among federal workers, 55% are somewhat or very satisfied with their organization (61% in HHS) compared with 65% among SHA central office employees.48,49 A survey of workers from a variety of fields in both the public and private sectors found that 81% of employees were “very satisfied” or “somewhat satisfied” with their jobs.50 Two other articles in this supplement explore worker satisfaction in more depth.51,52
For some time, those with an interest in monitoring the public health workforce have warned that many workers will be leaving their jobs. The proportion of workers eligible for retirement has been alarmingly high for years. Possibly because of the recession of 2007-2009, however, many who were eligible did not retire, and some who retired were subsequently rehired. But those who delayed retirement during the recession are several years older now and more likely to retire. This is the first study of the governmental public health workforce to use nationally representative data on intentions to retire, augmenting retirement eligibility data. When combined with the 13% of workers intending to leave governmental public health in the next year for reasons other than retirement, the 25% leaving to retire before 2020 contribute to a bleak forecast: at least 38% of current workers may have left public health by 2020. SHAs will be under pressure to hire new employees, train them, and retain them. Much of the institutional memory, managerial experience, and leadership experience represented by the more senior segment of the workforce will soon be gone. Despite high overall job satisfaction, leaders of SHAs need to identify subgroups with higher rates of intention to leave, determine what aspects of the job or organization are driving lower satisfaction in those subgroups, and target interventions toward improving those specific aspects. This targeted approach could help prevent some of the turnover workers are contemplating, even in the context of fairly high overall job satisfaction.
While most SHA employees have some access to training (92% are allowed to use working hours for training, 80% have on-site training available, and 77% report that the agency pays travel or registration fees for training), there is more that can be done, even without substantial new funding for workforce development. Only 45% of workers report that their training needs are assessed, and only 59% report that the agency provides recognition of achievement. Another opportunity for improvement is in providing the training workers need to use technology and information systems needed to perform their jobs; only half of workers report having adequate training to use their technology.
SHA workers clearly communicated that they need to increase their skills, especially in the areas of policy analysis and development as well as business and financial management, echoing the National Academy of Medicine's 1998 and 2002 reports.3,4,35 Systems thinking and working with diverse populations have also been highlighted as a potential need by other studies in recent years.53 Likewise, workers seem eager to learn what they need to know to find “evidence on public health efforts that work” and apply “evidence-based approaches to solve public health issues.” This study also found receptivity to the idea of training on “collaborating with diverse communities to identify and solve health problems” and “addressing the needs of diverse populations in a culturally sensitive way.” All of these findings reinforce previous calls for crosscutting training that transcends the traditional, categorically funded silos of public health practice.37,54
Interestingly, workers rated the items related to persuasive communications as very important, but something they felt they already performed fairly well. Kaufman et al54 found that public health leaders from across the entire breadth of public health practice believe that public health workers do not have well-developed skills in communicating persuasively. This may be an example of an individual worker's assessment of his or her own skills differing from that of a colleague or supervisor.
In addition to showing an interest in training in policy development, management, systems thinking, and other topics, the workforce also indicated receptivity to stronger emphasis on quality improvement, leveraging health information, and public health/health care integration. The fact that awareness of these trends was high, combined with a pervasive belief that these trends are important, means that the workforce is mentally ready to do what is needed to advance these initiatives. Public health leaders can seize this opportunity to ensure that the workforce knows what to do continuously improve quality, make the most of electronic health information, and collaborate effectively with the health care sector. On the contrary, only 52% had heard of Health in All Policies. Particularly given the strong interest in policy, public health leaders should make sure the whole public health workforce hears about the use of a Health in All Policies approach to improving both health and health equity.
The generalizability of these findings is limited by the fact that 13 of the 50 states did not agree to participate. We used a large sample, a regional approach, and statistical weights to minimize the impact of nonparticipating states (and individuals), but this remains a limitation. We also acknowledge that many workers were concerned about the confidentiality of their responses and recognize that some may have tempered their responses (particularly in the workplace environment questions) for fear that their employers would read the concerns they expressed. Others with low levels of job or organizational satisfaction may have declined to participate because of confidentiality concerns or lack of interest. We limited this potential bias by keeping the survey anonymous and assuring all respondents that raw data would not be shared with their employers. An important consideration is that these data are a cross section of SHA central office employees during fall 2014. The results should not necessarily be generalized to local or regional health department staff. See articles by Shah and Madamala55 and Ye et al56 in this supplement for analyses of data from staff working in local and regional health departments. Finally, we used workers' self-assessments to measure their training needs, which likely yield different information from what an objective test of their skills or observation of their performance might yield. The workers' self-assessments, however, provide important insight into the workers' receptivity to training.
PH WINS fills a critical gap in the literature by asking public health workers for their own perspectives on national initiatives. Public health leaders at the national level have been working tirelessly to ensure that quality improvement becomes infused in the culture of health departments or that public health departments can harness the power of electronic health data in a meaningful way, but no one else has asked the nation's public health workers what they think of these important developments. Public health leaders have been building a vision of a transformed health system but have not asked frontline workers how such transformation will impact them. PH WINS gives public health leaders a unique opportunity to better understand the workforce they rely on to follow their lead.
These findings support a number of concrete recommendations. First, governmental public health must make a high priority of succession planning. Preserving institutional knowledge, preparing mid-level managers to lead, and retaining high-performing individuals must be key objectives of the workforce and succession planning. SHAs also need to devise a strategy to recruit young and mid-career professionals into the field, with a particular emphasis on Hispanic/Latino staff given their underrepresentation in the workforce and the needs of the population they serve. The demographic composition of the workforce will need to be continually monitored as the demographics of the population evolve in order to ensure that the workforce is well suited to serve the diverse population of the United States.
Second, the results recommend investments in training for the existing public health workforce in policy analysis and development, business and financial management, systems thinking and social determinants of health, evidence-based public health practice, and collaborating with and engaging diverse communities. These topics are covered in the Core Competencies, which should be used to develop the curricula and evaluate the training.
Third, the workforce has heard about quality improvement, harnessing the influx of electronic health information from electronic health records and elsewhere, and integrating public health with health care, and believe these are important initiatives. Almost half of the workforce has yet to hear about using a Health in All Policies57,58 approach to improving health and health equity. More education and training on this topic will be important.
The PH WINS data set contains a large amount of rich data on understudied topics in public health services and systems research. With repeated rounds of the survey in the future, particularly with more robust local health department participation, these data could serve to answer many of the previously unaddressed questions in public health workforce research.
1. University of Kentucky Center for Public Health Systems and Services Research. Public Health Systems and Services Research Workforce report: recent and future trends in public health workforce research, 2009. http://www.nlm.nih.gov/nichsr/phssr/phssr_workforce.html
. Published 2010. Accessed June 16, 2015.
4. Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. The future of the public's health in the 21st century. http://www.ncbi.nlm.nih.gov/books/NBK221239
. Published 2002. Accessed March 6, 2015.
6. Lichtveld MY, Cioffi JP, Baker EL, et al. Partnership for front-line success: a call for a national action agenda on workforce development. J Public Health Manag Pract. 2001;7(4):1–7. http://www.ncbi.nlm.nih.gov/pubmed/11434035
. Accessed February 16, 2015.
8. Lichtveld MY, Cioffi JP. Public health workforce development: progress, challenges, and opportunities. J Public Health Manag Pract. 2003;9(6):443–450. http://www.ncbi.nlm.nih.gov/pubmed/14606182
. Accessed February 16, 2015.
10. Tilson HH. Turning the focus to workforce surveillance: a workforce data set we can count on. Am J Prev Med. 2014;47(5)(suppl 3):S278–S279.
11. Rashman L, Withers E, Hartley J. Organizational learning and knowledge in public service organizations: a systematic review of the literature. Int J Manag Rev. 2009;11(4):463–494. http://doi.wiley.com/10.1111/j.1468-2370.2009.00257.x
. Accessed October 29, 2014.
13. Coronado F, Polite M, Glynn MK, Massoudi MS, Sohani MM, Koo D. Characterization of the federal workforce at the Centers for Disease Control and Prevention. J Public Health Manag Pract. 2014;20(4):432–441. http://www.ncbi.nlm.nih.gov/pubmed/23963253
. Accessed June 16, 2015.
15. Jacobs RL, Hawley JD. In: Maclean R, Wilson D, eds. The Emergence of “Workforce Development”: Definition, Conceptual Boundaries and Implications. Dordrecht, the Netherlands: Springer Netherlands; 2009: chap VIII.16, pp1383–1393. http://www.springerlink.com/index/10.1007/978-1-4020-5281-1
. Accessed May 1, 2015.
19. Naquin SS, Holton EF. Redefining state government leadership and management development: a process for competency-based development. Public Pers Manage. 2003;32(1):23–46. http://ppm.sagepub.com/content/32/1/23.abstract
. Accessed May 15, 2015.
23. Locke EA, Latham GP. A Theory of Goal Setting & Task Performance. Ann Arbor, MI: Prentice Hall Inc; 1990.
27. Heywood L, Gonczi A, Hager P. A Guide to Development of Competency Standards for Professions. Canberra, Australia: Australian Government Publishing Service; 1992. http://www.voced.edu.au/content/ngv33638
. Accessed May 15, 2015.
31. Arthur W, Bennett W, Edens PS, Bell ST. Effectiveness of training in organizations: a meta-analysis of design and evaluation features. J Appl Psychol. 2003;88(2):234–245. http://www.ncbi.nlm.nih.gov/pubmed/12731707
. Accessed May 15, 2015.
33. Wheelan SA. Group Processes: A Developmental Perspective. Columbus, OH: Allyn & Bacon; 1994.
34. Honoré PA. Aligning public health workforce competencies with population health improvement goals. Am J Prev Med. 2014;47(5)(suppl 3):S344–S345. http://www.ncbi.nlm.nih.gov/pubmed/25439255
. Accessed February 4, 2015.
36. Council on Linkages Between Academia and Public Health Practice. Core Competencies for Public Health Professionals. phf.org/corecompetencies
. Published 2014. Accessed March 25, 2015.
41. Barry MM, Allegrante JP, Lamarre M-C, Auld ME, Taub A. The Galway Consensus Conference: international collaboration on the development of core competencies for health promotion and health education. Glob Health Promot. 2009;16(2):5–11. http://www.ncbi.nlm.nih.gov/pubmed/19477858
. Accessed June 16, 2015.
42. Markenson D, DiMaggio C, Redlener I. Preparing health professions students for terrorism, disaster, and public health emergencies: core competencies. Acad Med. 2005;80(6):517–526. http://www.ncbi.nlm.nih.gov/pubmed/15917353
. Accessed June 16, 2015.
43. Campbell SL, Fowles ER, Weber BJ. Organizational structure and job satisfaction in public health nursing. Public Health Nurs. 2004;21(6):564–571. http://www.ncbi.nlm.nih.gov/pubmed/15566562
. Accessed March 1, 2015.
44. Leider J, Bharthapudi K, Pineau V, Liu L, Harper E. The methods behind PH WINS. J Public Health Manag Pract. 2015;21(6 Supp):S28–S35.
45. Popper M, Lipshitz R. Organizational learning mechanisms: a structural and cultural approach to organizational learning. J Appl Behav Sci. 1998;34(2):161–179.
47. Association of State and Territorial Health Officials. ASTHO Profile of State Public Health. Vol Three3. Arlington, VA: Association of State and Territorial Health Officials; 2014. www.astho.org/profile
. Accessed March 25, 2015.
51. Harper E, Castrucci B, Bharthapudi K. Understanding the correlates of employee job satisfaction in public health. J Public Health Manag Pract. 2015;21(6 Supp):S46–S55.
52. Liss-Levinson R, Bharthapudi K, Sellers K, Leider J. Loving and leaving public health: predictors of intentions to quit among state health agency workers. J Public Health Manag Pract. 2015;21(6 Supp):S91–S101.
53. Place JL, Edgar M, Sever M. Assessing the needs for public health workforce development. Paper presented at: PHTC Annual Meeting; 2012; Washington, DC.
55. Shah G, Madamala K. Knowing where public health is going: levels and determinants of workforce awareness of national public health trends. J Public Health Manag Pract. 2015;21(6 Supp):S1102–S110.
56. Ye J, Leep C, Robin N, Newman S. Perception of workforce skills needed among public health professionals in local health departments: staff vs. top executives. J Public Health Manag Pract. 2015;21(6 Supp):S151–S158.
APPENDIX: Job Classification Categories
These items were collapsed from a list of job classifications respondents were asked to select as best representing their position. This includes Administration & Business Support—Accountant/Fiscal, Clerical Personnel (Administrative Assistant, Secretary), Custodian, Grant and Contracts Specialist, Health Officer, Human Resources Personnel, Information Technology Specialist, Other Facilities/Operations worker, Public Health Agency Director, Public Information Specialist; Clinical and Lab & Behavioral Health Professional, Community Health Worker, Home Health Worker, Laboratory Aide/Assistant, Laboratory Developmental Scientist, Laboratory Scientist (Manager, Supervisor), Laboratory Scientist/Medical Technologist, Laboratory Technician, Licensed Practical/Vocational Nurse, Medical Examiner, Nutritionist, Other Oral Health Professional, Other Physician, Other Registered Nurse—Clinical Services, Other Veterinarian, Physician Assistant, Public Health Dentist, Public Health/Preventative Medicine Physician, Registered Nurse—Community Health Nurse, Registered Nurse—Unspecified; Public Health Science & Animal Control Worker, Behavioral Health Professional, Department/Bureau Director, Deputy Director, Engineer, Environmentalist, Epidemiologist, Health Educator, Other Management and Leadership, Other Professional and Scientific, Program Director, Public Health Manager/Program Manager, Public Health Veterinarian, Public Health Informatics Specialist, Sanitarian/Inspector, Technician, Statistician, Student—Professional and Scientific; Social Services and All Other & Social Services Counselor, Social Worker, Other. Cited Here...
public health workforce; Public Health Workforce Interests and Needs Survey (PH WINS); state health agencies; workforce development