Nearly a decade after the Health Information Technology for Economic and Clinical Health Act of 2009, electronic health record adoption continues to increase in the health care sector, with 80.5% of hospitals deploying at least a basic electronic health record.1 2 3 4 workforce to develop the necessary tools, work processes, and data interfaces.
While the need for academic and workforce training in public health informatics (PHI) has been discussed for more than 2 decades,5 , 6 7 8–11
In practice, PHI specialists apply informatics principles to develop work processes and technologies that improve the quality and availability of information used to improve the public's health.12 Workforce Interests and Needs Survey (PH WINS), Dixon and colleagues13 workforce . While the proportion of staff identifying as PHI specialists is small, the informatics needs agency-wide are large, and other public health staff try to fill the gap. As a result, informatics skills have been added to essential competencies across public health disciplines,14 , 15 16
As public health departments, schools of public health, apprenticeships, and fellowships incorporate informatics competencies into their curricula, it is important to monitor the skills and needs of the workforce and to identify informatics skills gaps. Recognizing the importance of understanding and addressing workforce development, in 2014, the Association of State and Territorial Health Officials (ASTHO) and the de Beaumont Foundation collaborated to field PH WINS, the first nationally representative sample of SHA public health workers in the United States. With the second fielding of PH WINS, we can continue to track characteristics and informatics needs among PHI workers and the broader public health workforce . In this article, we present an updated analysis of the PH WINS, with a focus on comparisons between those who self-reported that they serve a PHI role and other self-reported public health roles. This will clarify the current role of PHI workers within the health department structure and the informatics-related training needs of the broader public health workforce , informing public health agencies, schools of public health, Centers for Disease Control and Prevention (CDC) apprenticeships, and postdoctoral fellows.
Methods
To characterize and compare PHI specialists with other public health workforce segments and to identify their informatics training needs, we performed a cross-sectional study using the nationally representative PH WINS 2017. The Indiana University Institutional Review Board deemed the secondary analysis of de-identified data as nonhuman subjects research.
Survey instrument
PH WINS was designed to influence workforce development; identify trends in attitudes, morale, and climate; and understand the needs and skills gaps across the workforce .17 18
In 2017, PH WINS added a nationally representative probability sample of mid- and large-sized LHDs. The LHDs included in the 2017 PH WINS included 26 of the 30 public health departments that make up the Big City Health Coalition (BCHC), which serve the top 30 most populous urban areas in the United States. In some analyses, we divide the LHD group into BCHC member agencies and other health departments (OHD). Other health departments are defined as those employing a minimum of 25 staff and serving populations of 25 000 or more.
Classification of job roles and program area
Details on the PH WINS data set construction can be found in the article by Leider et al.18 public health informatics specialist” (PHI); “information technology specialist or information system manager” (IT/IS); “public health science” (PHS); and “clinical and laboratory” (CL). For our analysis, the PHI and IT/IS roles consisted of a single response option from the survey. The PHS group included 24 noninformatics job roles, such as environmental health worker, public health manager or program manager, epidemiologist, and health educator. The Clinical and Laboratory (CL) group included 17 noninformatics job roles, such as registered nurse, nutritionist, laboratory scientist, and community health worker.
In addition to their role, the respondents were asked to “specify your primary program area” from a list of 33 public health programs, including the option of working in multiple programs. We grouped this self-reported program area into 3 categories: (1) informatics; (2) multiple programs including informatics; and (3) noninformatics. Examples of noninformatics program areas include administrative support, clinical services, communicable disease, community health assessment, epidemiology surveillance, maternal and child health, public health laboratory, and program evaluation.
Classification of informatics training needs
The PH WINS training needs assessment captured respondents' perceived skills and needs using 21 questions across 8 “strategic skill” domains.18 19
Respondents were asked to rate selected public health competencies with respect to the importance to their day-to-day work (ie, not important, somewhat unimportant, somewhat important, and very important) and their current skill level (eg, not applicable, unable to perform, beginner, proficient, expert). To identify the highest priorities for future workforce training, we present skill gaps. A skill gap was defined as discordance between self-reported importance (ie, need) and skill level, for example, those reporting the competency as “somewhat important” or “very important” and “unable to perform” or “beginner.”
Response weighting and data analysis
Responses were weighted to account for the complex sampling frame and to match the national distributions of SHA and LHD employees. All analyses accounted for the full weighting structure to ensure correct estimates of standard errors.
We calculated descriptive statistics for demographics and selected job satisfaction, workplace environment, and training questions. For the SHA-CO sample, we compared PHI specialists with persons in IT/IS, PHS, and CL job roles because these roles are often technical and information intensive, because PHI specialists often work with staff in these other roles, and these are the staff who tend to address informatics needs in the absence of PHI specialists. The Rao-Scott χ2 test, a design-adjusted version of the Pearson χ2 test, was used to test for differences in the distribution of positive responses (agree or strongly agree) versus neutral or negative (disagree or strongly disagree) between job roles related to job satisfaction and work environment. We compared responses between PH WINS 2014 and 2017 by examining the proportion of positive responses as well as distributions of responses on a 5-point scale (from strongly disagree to strongly agree). Differences in skill gaps between job roles were also tested using the Rao-Scott χ2 test. In the event of a zero cell, the hypothesis test was not performed. All analyses were performed with SAS 9.4 (SAS Institute, Inc, Carey, NC) using the PROC SURVEYMEANS and PROC SURVEYFREQ procedures.
Results
Participants
The percentages of public health employees indicating PHI, IT/IS, PHS, and CL are displayed in Table 1 . Of all public health employees surveyed, the PHI specialist workforce accounted for 1.1% of SHA-CO respondents, 0.5% of BCHC respondents, and 0.2% of OHD respondents.
TABLE 1 -
Self-Reported Job Roles Among State Health Agencies, Big City Health Departments, and Other Mid- to Large-Sized Local Health Departments
Job Rolea
Health Department Setting
State Health Agency —Centralized Office (n = 17 136)Big City Health Department (n = 7489)
Other Health Department (n = 19 070)
n
Weighted % (95% CI)b
n
Weighted % (95% CI)b
n
Weighted % (95% CI)b
Public health informatics specialist187
1.1 (0.9-1.2)
35
0.5 (0.2-0.7)
57
0.2 (0.1-0.3)
Information technology specialist or information system manager
615
3.4 (3.1-3.7)
97
1.3 (0.5-2.2)
241
0.9 (0.6-1.1)
Public health science
6419
36.6 (35.7-37.5)
2456
32.8 (29.0-36.5)
4741
28.7 (23.7-33.8)
Clinical and laboratory
2658
15.6 (15.0-16.2
1780
23.58 (21.1-26.0)
5687
28.2 (26.0-30.3)
Abbreviation: CI, confidence interval.
a Self-reported job role.
b Weighted percentages do not sum to 100% because of omission of other job roles (eg, administrative, social sciences). Job role not reported among 460 (2.7%) state health agency -centralized office, 445 (3.7%) Big City Health Department, and 681 (3.6%) other local health department respondents.
Detailed demographic and work-related information for SHA-CO employees, stratified by self-reported public health role, is presented in Table 2 . Within SHA-COs, PHI staff most closely resembled PHS staff, often being female, having a bachelor's or master's degree, having widely distributed ages, and working in more decentralized SHA-COs. Differences include PHI specialists having less experience in public health, lower salaries, and fewer leadership roles. One-third of SHA-CO PHI specialists worked primarily in informatics or in programs that included informatics. Similar to SHA-COs, PHI specialists at LHDs were dispersed throughout noninformatics agency programs; only 26.1% of BCHC and 21.5% of OHD respondents reported working primarily in informatics programs.
TABLE 2 -
Weighted Proportions, Standard Errors, and Raw Counts for Demographic, Education, Salary, Geographic Location, and Health Department Governance Characteristics for Selected
State Health Agency and Centralized Office Worker Job Roles
Public Health Informatics (n = 187)a Information Technology (n = 615)a
Public Health Science (n = 6 419)a
Clinical and Laboratory (n = 2 658)a
nb
Weighted % (SE %)
nb
Weighted % (SE %)
nb
Weighted % (SE %)
nb
Weighted % (SE %)
Sex
Female
119
63.7 (4.9)
212
34.7 (2.3)
4223
66.7 (0.6)
2095
78.8 (1.3)
Male
65
36.2 (4.9)
390
64.6 (2.2)
2128
32.9 (0.6)
537
20.5 (1.3)
Non-binary
1
0.1 (0.1)
4
0.6 (0.3)
26
0.4 (0.1)
16
0.6 (0.1)
Race/Ethnicity
American Indian or Alaska Native
0
0 (0)
3
0.4 (0.3)
29
0.4 (0.1)
7
0.3 (0.1)
Asian
15
7.8 (2.0)
71
13.5 (2.0)
326
5.8 (0.3)
205
8.6 (0.8)
Black or African American
18
9.8 (1.8)
48
8.8 (1.6)
573
11.7 (0.5)
220
10.0 (0.6)
Hispanic or Latino
23
11.5 (2.7)
35
5.4 (0.8)
475
7.4 (0.3)
217
7.7 (0.5)
Native Hawaiian or Pacific Islander
0
0 (0)
2
0.4 (0.3)
21
0.4 (0.6)
14
0.6 (0.2)
White
120
67.2 (3.9)
404
65.5 (1.7)
4574
69.4 (0.5)
1817
66.8 (1.0)
Two or more races
6
3.6 (1.6)
37
6.0 (0.8)
308
5.0 (0.2)
140
6.1 (0.7)
Age, y
≤30
22
11.7 (2.5)
25
4.7 (1.3)
658
10.6 (0.4)
217
7.8 (0.6)
31-40
41
24.5 (5.1)
104
19.1 (1.9)
1489
24.3 (1.1)
489
18.7 (1.1)
41-50
40
22.1 (3.3)
155
25.2 (2.3)
1559
24.6 (0.7)
615
23.7 (1.1)
51-60
50
27.6 (4.1)
214
35.5 (2.0)
1735
27.3 (0.7)
811
31.4 (1.0)
>60
28
14.1 (2.9)
97
15.5 (1.6)
829
13.2 (0.4)
478
18.4 (1.3)
Tenure in public health, y
0-5
60
33.9 (5.2)
216
39.3 (2.6)
1517
24.3 (0.9)
824
30.8 (1.1)
6-10
39
21.1 (3.3)
99
16.2 (1.4)
1179
18.9 (0.6)
482
19.0 (0.9)
11-15
32
16.2 (2.9)
106
17.0 (1.8)
992
15.5 (0.5)
367
14.1 (1.4)
16-20
26
15.8 (2.9)
72
11.1 (1.3)
925
14.6 (0.4)
289
11.6 (1.3)
≥21
27
13.0 (2.7)
93
16.4 (1.6)
1685
26.8 (0.6)
645
24.5 (0.8)
Supervisory status
Nonsupervisor
144
74.7 (4.9)
445
71.7 (1.8)
3660
55.1 (0.8)
2068
77.4 (1.0)
Supervisor
31
17.2 (3.7)
96
15.1 (1.2)
1309
20.8 (0.5)
413
15.0 (0.8)
Manager
12
8.1 (2.3)
65
11.1 (1.1)
1183
19.5 (0.8)
150
6.0 (0.5)
Executive
0
0 (0)
8
2.1 (1.1)
263
4.5 (0.5)
22
1.5 (0.5)
Highest educational attainment
Doctoral
17
9.0 (2.2)
10
1.7 (0.6)
633
10.4 (0.3)
269
10.9 (0.7)
Masters
55
31.8 (4.3)
128
21.7 (2.1)
3006
48.7 (0.7)
626
25.0 (0.7)
Bachelors
65
34.1 (4.1)
291
48.1 (1.8)
2110
31.2 (0.8)
1267
46.4 (1.2)
Associates
18
9.3 (2.4)
108
17.5 (1.4)
318
4.8 (0.3)
404
14.3 (0.8)
No bachelor or higher
31
15.9 (2.0)
73
11.0 (1.3)
337
4.8 (0.3)
89
3.4 (0.4)
Annual salary
≤$35 000
27
14.7 (3.4)
9
1.5 (0.6)
188
2.8 (0.2)
182
7.8 (0.8)
$35 000.01-$45 000
33
18.1 (4.1)
44
9.4 (1.7)
660
10.4 (0.4)
259
10.0 (0.7)
$45 000.01-$55 000
35
18.4 (2.7)
89
16.7 (1.8)
1190
19.3 (0.5)
488
19.6 (1.3)
$55 000.01-$65 000
25
17.4 (4.1)
83
13.9 (1.2)
1197
19.3 (0.5)
395
15.6 (0.8)
$65 000.01-$75 000
25
14.6 (3.3)
96
17.0 (1.4)
942
16.1 (0.5)
348
15.9 (1.4)
$75 000.01-$85 000
12
8.3 (1.9)
96
15.3 (1.4)
623
11.7 (0.5)
295
13.3 (1.0)
$85 000.01-$95 000
5
3.5 (1.7)
62
11.2 (1.4)
487
8.5 (0.3)
149
6.4 (0.6)
>$95 000
9
5.1 (2.1)
75
15.1 (1.8)
645
11.8 (0.5)
240
11.2 (1.3)
Region
New England and Atlantic (HHS 1 & 2)
30
15.2 (1.8)
54
6.7 (1.6)
1064
15.1 (0.3)
424
14.6 (0.7)
Mid-Atlantic and Great Lakes (HHS 3 & 5)
40
18.6 (2.9)
138
19.2 (1.3)
1525
20.5 (0.5)
609
19.8 (0.5)
South (HHS 4 & 6)
60
33.5 (3.9)
211
38.1 (1.9)
1827
34.0 (0.7)
798
33.1 (1.0)
Mountain/Midwest (HHS 7 & 8)
26
15.1 (2.9)
27
4.4 (1.1)
838
11.7 (0.3)
288
10.1 (0.6)
West (HHS 9 & 10)
31
17.6 (2.8)
185
31.7 (1.8)
1167
18.7 (0.5)
546
22.4 (0.6)
Health department governance
Centralized/largely centralized
34
16.6 (2.6)
157
18.9 (1.2)
1256
16.4 (0.5)
409
13.1 (0.4)
Shared/largely shared
7
7.4 (3.4)
61
14.8 (1.2)
537
15.7 (0.7)
219
13.1 (1.1)
Decentralized/largely decentralized
133
68.4 (3.9)
337
54.2 (1.9)
4095
59.6 (0.7)
1840
66.1 (1.0)
Mixed
13
7.6 (1.6)
60
12.1 (1.3)
533
8.3 (0.3)
197
7.7 (0.4)
Program area
Primary informatics
57
31.4 (4.6)
136
23.2 (2.3)
84
1.5 (0.2)
4
0.2 (0.1)
Multiple, including informatics
4
2.8 (1.5)
17
3.1 (1.0)
42
0.7 (0.2)
5
0.2 (0.1)
Other, noninformatics
116
65.6 (4.4)
395
73.7 (2.8)
5959
97.9 (0.2)
2364
99.6 (0.1)
Abbreviations: HHS, Health & Human Services; SE, standard error.
a A total of 6493 other administrative staff, 269 social sciences and “other,” and 418 without a reported job role omitted from table.
b Number of completed surveys.
Program area of the state and local public health informatics workforce
Given that up to one-third of PHI specialists worked in an informatics program, we investigated noninformatics program areas in detail. The SHA-CO PHI specialists worked in 23 different noninformatics program areas, most commonly epidemiology and surveillance (18%), vital records (8%), communicable disease (7%), health promotion and wellness (4%), and clinical immunization services (3%). Within BCHC, PHI specialists worked in 13 noninformatics programs, most commonly communicable disease (18%), vital records (12%), maternal and child health (5%), and community health assessment and planning (3%). The OHD PHI specialists worked in 14 program areas, most commonly administrative support (16%), immunization services (9%), community health assessment and planning (8%), epidemiology and surveillance (8%), and vital records (8%).
Satisfaction and workplace environment
In the Figure , we summarize the 2017 SHA-CO responses regarding job satisfaction, training needs, and workplace environment by job role. We also include the relative changes in responses from PH WINS 2014. Overall, the workforce responded positively when asked whether they were satisfied with their job, with satisfaction among IT/IS being somewhat lower than among the other roles. Similarly, the workforce was largely satisfied with job security. On average, PHI specialists were slightly more satisfied with their organizations (71%) than the other roles (69%-66%) (P = .01). While satisfaction with pay was relatively low among all roles, it was significantly lower among the PHI subgroup (38%) than the IT/IS (54%), PHS (52%), and CL (44%) segments of the workforce (P < .001).
FIGURE: Job Satisfaction, Workplace Environment Characteristics, and Training Needs Among Selected State Health Agency Employee Job Rolesa Sparkline minimum = 0%, maximum = 61%.b Change bar minimum = −24%, maximum = 15%.
Respondents were further asked how much they agree with statements about their workplace environment and training. In general, the workforce indicated that they felt the work they do is important and relevant to their agency's goals and priorities. Across roles, greater than 90% and 86% agreed or strongly agreed with statements about the importance and relevance of their jobs, respectively. Regarding whether their training needs were assessed, PHI specialists reported a greater agreement (53%) than IT/IS (46%) and PHS (49%) but not CL (57%) roles (P < .001). Similarly, CL roles were more likely to report sufficient training for technology (54%) than PHI (50%), PHS (50%), and IT/IS (45%; P = .01). Finally, all 4 roles agreed at close to 70% that they had the ability to apply their expertise.
Overall, compared with the 2014 PH WINS, positive responses among PHI specialists for satisfaction with pay dropped by 27.4%, job satisfaction declined by 8.5%, and satisfaction in their ability to apply their expertise dropped by 5.8%. Current PHI respondents' satisfaction with their job and workplace environment moved toward more neutral and negative responses, while the IT/IS, PHS, and CL subgroups shifted toward more positive responses (Figure ). It is important to note that in 2014, the proportion of positive responses was greater for PHI specialists than IT, PHS, and CL for all 9 questions, ranging from a difference of 0.2% to 26.0%. In 2017, only 2 of the same 9 questions were unanimously more positive among PHI than other roles, with differences ranging from 0.05% to 2.6%. The largest changes between 2014 and 2017 among PHI specialists pertained to satisfaction with pay, organization, ability to apply expertise, and importance of work.
Data and informatics needs and skills
Table 3 details the discordant skill gaps for the PHI, IT/IS, PHS, and CL roles by setting (SHA-CO, BCHC, or OHD). In general, low need-high skill gaps were reported among less than 10% of employees regardless of role and agency type, apart from the OHD CL group regarding skills for identifying appropriate data sources and information. In most cases, PHI specialists reported lower or similar low need-high skill gaps than other roles.
TABLE 3 -
Data and Informatics Self-Reported Skills Gaps by Job Role for State Health Agencies, Big City Health Departments, and Other Mid- to Large-Sized Local Health Departments
Identify Appropriate Sources of Data and Information to Assess the Health of a Community
Collect Valid Data for Use in Decision Making
Participate in Quality Improvement Processes for Agency Programs and Services
Identify Evidence-Based Approaches to Address Public Health Issues
Low Need, High Skill
High Need, Low Skill
Low Need, High Skill
High Need, Low Skill
Low Need, High Skill
High Need, Low Skill
Low Need, High Skill
High Need, Low Skill
n
w% (SE)
n
w% (SE)
n
w% (SE)
n
w% (SE)
n
w% (SE)
n
w% (SE)
n
w% (SE)
n
w% (SE)
SHA-CO
PHI
2
1.4 (1.1)
12
8.3 (2.6)
0
0 (0)
6
3.8 (2.2)
5
4.3 (2.0)
44
26.1 (3.4)
3
2.0 (1.2)
23
14.7 (2.8)
IT/IS
23
7.0 (1.7)
48
18.6 (4.0)
14
2.9 (0.7)
29
6.7 (1.5)
15
4.2 (1.2)
106
32.4 (3.5)
25
8.5 (1.6)
67
24.5 (3.1)
PHS
168
2.9 (0.3)
851
16.1 (0.8)
85
1.3 (0.2)
577
9.3 (0.5)
188
3.7 (0.5)
1530
29.4 (0.7)
147
2.7 (0.2)
761
13.3 (0.7)
CL
48
2.5 (0.4)
433
22.9 (1.0)
43
1.6 (0.3)
298
13.3 (0.5)
54
2.8 (0.5)
625
32.7 (1.3)
56
2.9 (0.5)
363
18.5 (0.7)
P a
.002
<.001
NR
<.001
.39
.12
<.001
<.001
BCHD
PHI
0
0 (0)
4
17.8 (12.8)
0
0 (0)
1
4.3 (4.3)
3
6.8 (3.7)
4
12.2 (6.0)
1
2.9 (4.7)
3
8.6 (5.4)
IT/IS
3
5.6 (3.1)
12
22.1 (7.7)
2
2.4 (1.5)
8
10.0 (2.8)
1
1.2 (1.0)
22
45.2 (8.7)
1
1.1 (0.9)
17
31.1 (10.5)
PHS
64
2.8 (0.3)
343
16.9 (1.0)
47
2.1 (0.4)
270
12.2 (0.4)
48
2.3 (0.3)
612
32.1 (2.0)
51
2.3 (0.3)
288
13.6 (0.8)
CL
38
2.7 (0.5)
320
22.5 (1.5)
25
2.0 (0.4)
247
17.0 (1.4)
20
1.6 (0.5)
491
39.3 (1.9)
20
1.4 (0.3)
293
20.9 (1.7)
P a
NR
.03
NR
<.001
.10
.001
.23
<.001
OHD
PHI
0
0 (0)
5
8.1 (4.2)
1
3.5 (3.3)
5
6.7 (3.5)
1
1.0 (1.0)
12
25.9 (7.2)
0
0 (0)
10
15.1 (5.9)
IT/IS
6
5.1 (2.6)
22
18.3 (5.1)
4
5.4 (4.8)
16
5.2 (4.8)
4
2.5 (1.4)
42
32.8 (5.9)
9
7.1 (3.1)
25
27.4 (6.5)
PHS
115
2.5 (0.7)
800
18.7 (3.9)
58
1.0 (0.3)
553
12.0 (2.4)
85
2.1 (0.4)
1168
33.0 (1.3)
86
1.8 (0.3)
699
20.2 (2.4)
CL
69
18.7 (5.1)
1176
26.7 (2.3)
70
1.4 (0.3)
830
17.8 (1.3)
51
1.3 (0.2)
1658
41.6 (1.4)
47
1.0 (0.2)
1003
21.9 (1.2)
P a
NR
<.001
.06
<.001
.0698
<.001
NR
.62
Abbreviations: BCHD, Big City Health Department; CL, clinical and laboratory; IT/IS, information technology specialist or information systems manager; NR, not reported (due to zero cell); OHD, other mid- to large-sized local health department; PHI, public health informatics specialist; PHS, public health science; SE, standard error; SHA-CO, State Health Agency —Centralized Office; w%, weighted percentage. p = .07.
a Rao-Scott χ2 test for the distribution of skills gap.
While low need-high skill gaps represent underutilized informatics and data skills, high need-low skill gaps represent a shortage of key skills in the workforce . Across all settings, PHI specialists were less likely to report high need-low skill gaps than the other roles. Within SHA-COs, PHI specialists were less likely than the other roles to have a high need-low skill gap with respect to identifying appropriate sources of data (P < .001) and collecting data for decision making (P < .001). The PHI specialists and PHS roles reported a similar skill gap for identifying evidence-based approaches (15% and 13%, respectively), which were lower skill gaps than IT (24%) and CL (18%) roles (P < .001).
Discussion
Building on our prior analysis of the PH WINS,13 workforce within LHDs. Our aim was to clarify the current role of PHI workers within health departments and the training needs of the broader public health workforce .
Overall assessment of the public health informatics workforce
The PHI specialists remain a small segment of the overall public health workforce . We found that 1.1% and 3.4% of SHA-CO respondents self-reported their role as PHI or IT/IS, respectively. These findings are similar to the inaugural PH WINS findings where the PHI and IT segments were estimated as 1.3% and 4.1%.13 workforce and 0.2% and 0.9% of the OHD workforce self-reported PHI and IT/IS roles, respectively. These estimates are similar to results from studies by the National Association of County & City Health Officials (NACCHO)20 11 workforce .
The survey further characterizes PHI as diffuse within health departments. The prior version of the PH WINS did not include informatics as a program area choice, so this analysis is the first to examine where PHI specialists sit within health department structures. While some health departments now have an informatics program, PHI specialists most commonly work in noninformatics program areas. This was especially true in LHDs where more than 75% of PHI respondents worked exclusively in noninformatics areas. Where informatics programs do exist, they are often supported by IT/IS and PHS workers. These patterns suggest that many public health agencies may address informatics needs through discrete projects, rather than through a coordinated, agency-wide program.21
Public health informatics specialists' attitudes toward job and salaryWhile PHI specialists reported positive attitudes overall toward their job and agency, attitudes toward salary were less positive than other roles within SHA-COs. More importantly, we observed that attitudes of PHI specialists shifted downward since the prior fielding of PH WINS. The PHI specialists in the most recent fielding of the survey are less satisfied with their job, organization, and salary. Given that reported salaries are lower than IT/IS, PHS, and CL roles, it is not surprising that satisfaction with salary is low. Perhaps related to salary, PHI specialists in SHA-COs were less likely than IT/IS, PHS, and CL staff to be in leadership positions. This may be related to having less public health experience, although their distribution of years in public health was similar to staff in the IT/IS role. Negative views of pay among PHI specialists were not observed in 2014, so the change is cause for concern. In combination with decreasing satisfaction with job and organization, a follow-up study is warranted to examine PHI specialists' attitudes, the reasons why they are less satisfied than other public health workers, and whether these attitudes affect likelihood of leaving their agency for other public health or non–public health positions.
Public health informatics training needsAn informatics-savvy health department requires PHI competencies not just among PHI specialists but also among workers, program area managers, and executive leadership.22 workforce . Specifically, non-PHI specialists reported significantly larger gaps for the ability to “identify appropriate sources of data and information to assess the health of a community” and “collect valid data for use in decision making.” Similar levels of discordance were observed for the competencies pertaining to quality improvement and evidence-based approaches. The discordance suggests that health departments should examine ways to enhance training for PHI-related competencies throughout their workforce , perhaps with assistance from PHI specialists.
Since our prior analysis of PH WINS, academic training options in PHI have increased, including graduate certificates,23 , 24 25 , 26 27 28
On the contrary, training for public health practitioners has become more limited since the 2014 PH WINS. Previously, the Centers for Disease Control and Prevention (CDC) offered an extramural, interprofessional education program (referred to as SHINE), which included training in place for public health agency staff, as well as fellowship positions throughout the country, but that initiative lost funding in 2017. At the same time, cuts in funding from the CDC to informatics programs in the large, national public health associations have greatly reduced their activities to build and support the existing network of PHI practitioners. Some opportunities still exist. Postgraduate fellowships in PHI are still offered for work within the CDC,29 30 Public Health Informatics Institute31 32
Limitations
Depending on how respondents interpreted the PH WINS questionnaire, their role or program may be misclassified. For example, employees with an epidemiology degree may self-identify as epidemiologists, despite primarily serving an informatics role. Given the PH WINS sampling frame, our findings are not generalizable to LHDs serving populations of less than 25 000. Furthermore, due to the small proportion of self-reported PHI, employees at BCHC and OHD demographic- and work-related estimates were unstable and therefore omitted. The small proportion of self-reported PHI employees also limited the ability to adjust comparisons of characteristics such as salary and training skills gaps for potentially confounding variables, including supervisory role, years in public health, and education. Differences in the sampling frames between 2014 and 2017 included different participating SHA-COs and inclusion of decentralized SHA employees in 2017. Although an agency-linked data set would be preferred for examining changes between the 2 surveys, each analysis was response-weighted to represent the same target population (ie, SHA-CO workforce ).
The selected training needs survey questions were not strictly informatics competencies. Rather, they represented broader public health business processes and services that may be enhanced through the application of informatics. While these competencies are representative of desired skills for noninformatics jobs roles, they do not provide detailed assessment of training needs for PHI specialists. Future studies should include questions more specific to PHI, for example, designing, implementing, and evaluating information systems; use of methods in capturing, storing, exchanging, and using data; and applying technologies and standards to enhance timeliness, completeness, and accuracy. Additional PHI-specific competencies have been suggested by Wholey and colleagues.19
Implications for Policy & Practice
The PHI specialist's role continues to be rare in public health agencies, and those filling that role tend to have less public health experience and be less well compensated than staff in other technically focused positions.
PHI specialists' skills tend to be well matched to the data and informatics needs of public health agencies.
The increased dissatisfaction among PHI specialists since 2014 indicates the importance of reversing the recent decrease of federal investment in state and local public health informatics .
Relative dissatisfaction with pay and relatively sparse leadership roles point to a need for greater focus on developing and retaining people in the PHI role.
Public health information technology specialists and information system managers, workers in the public health sciences, and workers in the clinical and laboratory roles have unmet needs in data and informatics skills.
Conclusion
The second iteration of PH WINS monitored the growth and maturation of the SHA PHI workforce and established a baseline among mid- and large-sized LHDs. Despite the trend of increasing demand for informatics in public health, the percentage of the PHI workforce within SHAs remained relatively stable between the 2014 and 2017 PH WINS. While PHI specialists tended to possess the data and informatics skills necessary for their job, our results suggest that the broader public health workforce needs additional informatics training.
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