Public health workforce development, particularly the identification and provision of training, has historically been studied with a discipline/program-specific or skill-specific focus.1–6 Numerous organizations have explored the capacity and skills of segments of the public health workforce, such as studies seeking to understand the ability of respondents to conduct epidemiologic investigations or disseminate findings.7 This siloed approach to studying the governmental public health workforce's discipline-specific training needs and skill gaps echoes the funding mechanisms of state and local governmental public health agencies.8
Over the past decade, however, the demands on governmental public health agencies have been rapidly evolving.1 , 8–10 The field has been and continues to be challenged by the dynamically changing needs of the populations they serve and by an aging workforce facing growing issues with recruitment and retention.11 , 12 Governmental public health agencies are also adapting to and aligning with national movements such as Public Health 3.0 and accreditation of public health agencies through the Public Health Accreditation Board.9–11 It is in this context that there is a growing call for workforce development studies that address the current capacity and future needs of the public health workforce.
Despite this increased focus on the changing roles and demands of the governmental public health workforce, less is known about the crosscutting strategic and business skills of the governmental public health workforce that are necessary to be responsive to the dynamic practice environment.1 , 10 The 2014 Public Health Workforce Interests and Needs Survey (PH WINS 2014) provided the first nationally representative data of state health agency workers, capturing the perspectives of more than 10 000 state health agency workers from 37 states related to their attitudes, morale, perspectives on their workplace environment, and their crosscutting training needs.11 Top areas of training need included influencing policy development, understanding the relationships between policies and public health challenges, and assessing factors that influence specific public health problems.11 While PH WINS 2014 provided critical baseline data about the state health agency workforce, these training needs were assessed broadly and generally and the assessment could not be applied toward the requirements of voluntary accreditation. Furthermore, the practice community found translating and acting on findings related to training needs from PH WINS 2014 to be challenging, particularly in operationalizing the areas in the general findings with the fundamental public health workforce skills that vary across career stages (nonsupervisor, supervisor/manager, executive, etc).13
To improve upon the training needs assessment in PH WINS 2014, the Association of State and Territorial Health Officials (ASTHO) and the de Beaumont Foundation convened a workgroup to redesign the training needs assessment for the 2017 fielding of PH WINS to ensure that the training needs assessment was useful, standardized, and built upon best practices. Members of the workgroup represented various stakeholders including state-based governmental public health practitioners, federal agencies, regional public health training centers, and other national partners that support public health workforce development to better identify and target the training and development need of the governmental public health workforce. The full list of workgroup members may be found in the Appendix. Through an iterative process, the training needs assessment in PH WINS 2017 was significantly updated to reflect the most critical skills of the governmental public health workforce, with the goal of assessing the top training needs across 3 distinct self-reported workforce tiers: nonsupervisory, supervisory, and executive staff.* The purpose of this article is to describe the top crosscutting training needs across the governmental public health workforce.
Development of the 2017 PH WINS training needs assessment
Following an environmental scan to identify existing instruments, processes, and frameworks/competency models widely adopted in the field, 5 guiding frameworks or competency models were identified as central to development of the revised training needs assessment in PH WINS 2017. The environmental scan findings became the basis for an iterative review process that involved the identification and prioritization of the following 8 focus areas for inclusion in the training needs assessment:
- Effective communication
- Use of data for decision making
- Cultural competency/competence
- Budgeting and financial management
- Change management
- Systems and strategic thinking
- Develop a vision for a health community
- Cross-sectoral partnerships
As with prioritization of the focus areas, a systematic approach was used to identify, develop, and revise skills for inclusion in the instrument. Existing needs assessment instruments used in the field were examined to identify relevant and actionable skills aligning with the 8 focus areas in the 2017 PH WINS training needs assessment. Items were modified to reflect the nature of the governmental public health workforce and the expected progression of responsibility and application of skills across 3 self-reported workforce tiers from description and identification for nonsupervisory staff; application for supervisors/managers; and maintenance or oversight for executives. Cognitive testing was conducted on the adapted skill items, and items were revised accordingly. The 3-tier-specific assessments were pilot tested to evaluate instrument usability and flow. The final instrument included 2- to 4-tier-specific skills within each focus area. Table 1 shows each focus area and related skills by workforce tier.
Sample and analysis
PH WINS, in its second fielding in 2017, is a nationally representative survey of employees in state health agencies and medium to large local health departments. There are 4 primary domains in the survey: workplace engagement, the training needs assessment, emerging concepts in public health, and demographics. PH WINS 2017 was administered online between September and December 2017. Approximately 102 000 invitations to participate were sent across 3 survey frames: state health agency workers in 47 participating states; workers from 26 member agencies of the Big Cities Health Coalition, a project of the National Association of County and City Health Officials (NACCHO) representing leaders of health departments in large urban areas; and employees in a nationally representative sample of medium- to large-sized local health departments with at least 25 staff members and serving a population of at least 25 000. The survey was conducted as a census in participating health departments. In total, 47 604 individuals responded to PH WINS 2017, and after accounting undeliverable e-mails, the response rate was 47% across all frames.14 The population studied in this analysis comprises the 41 817 of 43 697 respondents who indicated they were permanently employed by their health department, which represents 97% of all respondents. The full methods of PH WINS are detailed elsewhere in this supplement.14
The training needs assessment question stem, drawn from PH WINS 2014, asked respondents' self-perception of the importance of each skill in their day-to-day work and their proficiency in the specific skills in a matrix table. The 4-point Likert scale for importance ranged from not important to very important. The skill-level scale included 5 response options including not applicable, unable to perform, beginner, proficient, and expert. In line with previous PH WINS analyses, training needs were determined by combining self-reported skill importance and proficiency.11 Self-perceived skill gaps were noted by a dichotomous variable. Respondents who reported a skill to be of high importance (“somewhat important” or “very important”) to their current position and who also reported a low level of proficiency for that item (“unable to perform” or “beginner”) were coded as having a skill gap for that skill.
Data were analyzed using Stata Statistics/Data Analysis, version 15 (StataCorp LP, College Station, Texas). To account for the complex PH WINS survey design, STATA survey commands employing replicate weights and balanced repeated replication for variance estimation were used to calculate point and variance estimates for specified statistics and cross-tabulations. Findings reported later include both point estimates and their associated 95% confidence interval (CI).
Across all tiers, most respondents reported that each skill included in the instrument was somewhat important or very important to their day-to-day job (range is 66%-99% for all skills across all tiers). Table 2 displays the estimated percentage of respondents who reported at least 1 skill gap for at least 1 skill item within each focus area. Across all tiers, the focus areas with the highest self-reported training needs were budget and financial management (55%; 95% CI, 53-56), systems and strategic thinking (49%; 95% CI, 47-50), developing a vision for a health community (44%; 95% CI, 43-46), and change management (43%; 95% CI, 41-45). Furthermore, P values associated with the design-based F statistic based on the corrected weighted Pearson χ2 statistic show there was a statistically significant difference in self-reported skills gaps across tiers for all focus areas.
Fifty-five percent of nonsupervisors (95% CI, 54-56) and 56% of supervisors/managers (95% CI, 54-58) reported a budget and financial management skill gap compared with 46% (95% CI, 40-51) of executives (Table 3). More than half of supervisors/managers also reported a systems and strategic thinking skill gap (56%; 95% CI, 54-57), with nearly half of executives (46%; 95% CI, 40-51) and nonsupervisors (46%; 95 CI, 45-48) also reporting skill gaps in that area. Among nonsupervisors, skill gaps were also frequently noted across change management (44%; 95% CI, 41-46) and developing a vision for a healthy community (43%; 95% CI, 42-45). Supervisors/managers also reported frequent skills gaps for developing a vision for a healthy community and change management (50%; 95% CI, 48-50; and 43%; 95% CI, 41-44, respectively).
Top training needs by skill
While the skills were tailored across workforce tiers, it is possible to make general observations about training needs across the tiers. The top 2 training needs for nonsupervisors and supervisors/managers, with more than 40% of respondents reporting skill gaps, were related to financial analysis methods and funding mechanisms, with 41% and 42%, respectively, of respondents in those tiers also reported a skill gap related to agency business plans (Table 3). Nearly a third of executives reported a skill gap related to funding mechanisms and agency business plans, and a third of executives reported a skill gap around influencing policies external to the organization that address social determinants of health. Respondents across tiers also reported skill gaps related to strategic planning, drivers that influence public health programs and services, and engagement of community members in the design and implementation of community programs.
The field of governmental public health has been shifting from delivery of clinical services toward policy and systemic changes, including partnering with and across sectors, to address existing and emerging public health challenges. This shift requires significant changes in the practice of public health and the requisite skills needed by the workforce.8 , 15 It is critical that the state and local governmental public health workforce, as the key player in promoting and protecting the health and well-being nationwide, is proficient not only in traditional public health skills but also in crosscutting strategic skills to address this evolving approach to public health practice.10 While previous research primarily focused on discipline-specific skills for specific professions within health departments, this study using PH WINS 2017 data provides a comprehensive national picture of both broad categories and specific strategic skills needed by the workforce, and the current self-reported state of gaps in the workforce's skills. Staff likely have expertise in their programmatic and scientific areas, but the data make clear that there are significant, systemic gaps in skills and public health training in key areas. While it is heartening that the majority of the workforce, regardless of the setting and supervisory level, identified nearly all of the skills in PH WINS as important for their day-to-day work, the large percentages reporting gaps in critical skills limit the field's ability moving forward to protect and advance population health.
The public health landscape is evolving, and with increased emphasis on the interrelationships of other systems on health, the workforce needs to be agile and skilled in collaborating and working across sectors to address the social determinants of health. However, the current workforce self-reports significant gaps in the skills needed to negotiate this changing landscape. Gaps in change management and systems and strategic thinking skills, particularly among those in supervisory and executive positions within health departments who are often setting the vision and culture for their agencies, point to potential challenges in realizing the future direction of public health as envisioned in Public Health 3.0.8 As the chief health strategists for their departments, it is essential that executives are equipped with the skills needed to work across sectors, including the health care system, to take action to improve community and population health systematically and proactively; significant self-reported gaps exist in policy development, cross-sectoral partnerships, systems and strategic thinking, and change management, all of which are critical for the role of chief health strategist.
More than half of the workforce self-identified training needs in at least one budgeting and financial management skill, which is consistent with previous research on gaps in the business skills of the workforce and the need for financial management competencies for the public health workforce.16 , 17 In the current era of limited financial resources, it is essential that budgeting and financial management skills, particularly related to the description and application of financial analysis methods and identification and leveraging of a variety of funding mechanisms, are emphasized and developed in the current and future workforce to ensure a maximization of those resources. With new opportunities and methods of maximizing funding, it may be challenging to leverage these creative or innovative uses of funding with limited proficiency related to budgeting and financial management across all segments of the workforce.18
The training needs assessment in PH WINS 2017 provides the first national and nationally representative data on self-reported training needs for the state health agency and local health department workforce—from health department to health department, across state and local health departments, there are common critical skill gaps. The results from this assessment point to the need for a specific and targeted national workforce training agenda, as the top areas of training needs remain consistent regardless of supervisory status and regardless of setting as presented elsewhere in this supplement. While there are a number of training needs assessments in the field that are specialized in nature, limited funds for training and the clear alignment of training needs across all segments of the workforce suggest that efficiencies of scale should be leveraged to align and identify common direction for a national training agenda for these strategic skills, as echoed by other research in the field.19
Academic, training, and practice partner organizations involved in the provision of training for the current workforce should prioritize the identification and development of relevant training opportunities using principles of and best practices for adult learning that are specific to the field of governmental public health in the top areas of training needs. Partners in schools and programs of public health training the future public health workforce should focus on the development of crosscutting strategic skills in addition to the technical skills of specific disciplines in public health. As leaders in state and local health departments, health officials can support training and growth in their current workforce and invest in recruiting and retaining well-trained staff and support development of current staff to advance skills when promoting from within. It is critical that national leaders in public health with a responsibility to promote and protect the health and well-being of the nation ensure that the workforce is well equipped to address the emerging and evolving challenges of public health and that the nation's health agencies are working at their optimal level to ensure that healthy agencies can lead to healthy people.
There are several limitations to consider in interpreting the results of this study. The data presented are nationally representative but reflect the responses of the state and local health departments that participated in the survey and may not be reflective of state and local health departments that did not participate, including smaller local health departments that did not meet the inclusion criteria for the survey as described elsewhere in this supplement. In addition, if individual respondents were different from nonrespondents within participating state health agencies and local health departments, nonresponse bias could have occurred.
Another limitation to this study is that the training needs assessment reflects self-reported importance and proficiency in skills by respondents and is not necessarily indicative of job performance. However, research has shown that in some cases of self-assessment of skills, proficiency is often overestimated by those who have limited proficiency, which may indicate that there are in fact even more widespread training needs than identified in the results.20
These findings identify a number of areas of gaps in crosscutting skills that, along with technical and discipline-specific skills, are essential for the current and future workforce to be able to address evolving challenges in public health. With nationally representative data on training needs for the state and local health department workforce from PH WINS 2017, these findings suggest that there are opportunities for state health agencies and local health departments, as well as partners in the field, to prioritize staff development through training on budgeting and financial management and systems and strategic thinking.
Implications for Policy & Practice
- The 2017 fielding of PH WINS provides a national benchmark for crosscutting training needs for the state and local governmental public health workforce.
- The largest areas of training need for the workforce are in budgeting and financial management, systems and strategic thinking, change management, and developing a vision of a health community.
- Areas of training need persist regardless of supervisory status.
- Given the consistency in training needs, public health leaders should focus on developing these skill areas throughout the workforce.
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* Supervisory levels are defined as follows: Executive: member of Senior Executive Service or equivalent; Supervisor: employee is responsible for employees' performance appraisals and approval of their leave but does not supervise other supervisors; Manager: employee is in a management position and supervises 1 or more supervisors; Nonsupervisor: employee does not supervise other employees.
Appendix Workgroup Members
Ashley Edmiston, MPH, NACCHO; Jennifer McKeever, MSW, MPH, National Network of Public Health Institutes; Nikki Rider, ScD, MPP, Consultant; Wendy E. Braund, MD, MPH, MSEd, FACPM, University of Pittsburg; James (Jim) Cunningham, PhD, The University of Arizona; Brenda Joly, PhD, MPH, University of Southern Maine; J. P. Leider, PhD, Leider Consulting LLC; Melissa B. Moore, MSW, MBA, Health Resources and Services Administration; Jim Pearsol, MEd, Pearsol Consulting LLC; Thomas Reizes, New York State Department of Health; Kate Wright, EdD, MPH, Saint Louis University School of Public Health; Brian C. Castrucci, DrPH, MA, the de Beaumont Foundation; Elizabeth Gould, DrPH, ASTHO; Kyle Bogaert, MPH, ASTHO.