Staffing Local Health Departments in Minnesota—Needs, Priorities, and Concerns

Abstract

Context: 

The roles and responsibilities of local health departments (LHDs), as well as the hiring challenges they face, have changed since the pandemic started.

Objectives: 

To explore (1) staffing needs and priorities of LHDs in Minnesota, and (2) financial and community-level factors impeding health departments from maintaining optimal staffing.

Design, Setting, and Participants: 

A cross-sectional online survey was administered via Qualtrics in July 2022 to city and county health departments in Minnesota (97% participation rate). It included both open- and close-ended questions concerning staffing needs and priorities of LHDs and challenges to hiring after the pandemic started.

Results: 

Staffing priorities of LHDs included public health nurses, community health workers, and health planners/researchers/analysts. Hiring concerns included creating new permanent positions, offering competitive salaries, and filling open positions. Inadequate funds made it difficult to create new permanent positions and offer competitive salaries. External factors such as lack of affordable or reliable childcare, housing, and transportation also contributed to hiring challenges.

Conclusions: 

There is a need to increase staffing levels of the Minnesota public health enterprise by filling vacant positions and creating new positions. Increasing the public health workforce requires adequate sustainable funding along with creative solutions.

The COVID-19 pandemic exacerbated challenges present within an already damaged public health enterprise. Before the pandemic impacted the United States in March 2020, the public health enterprise endured turnover and widespread dissatisfaction due to competition from the private sector and burnout among employees.^1,2 Workforce surveys before the pandemic documented practitioners' dissatisfactions and intentions to leave their positions.^1,3 Since the COVID-19 pandemic started, the public health workforce has experienced additional work-related stresses including negative sentiment, bullying, and other harassment.^4–6 Recent surveys have shown that the pandemic “piled onto” an already encumbered public health enterprise, weakening it further through employee departures, thus increasing the need for new workers.^7,8

Minnesota's public health system has long experienced similar challenges. Between 2007 and 2019, the local public health workforce in Minnesota showed an overall workforce decline of approximately 11%, an impact made worse as populations increased.⁸ Most of this decline occurred between 2008 and 2012.^8,9 Reasons for leaving the workforce included seeking higher pay, transitioning to other sectors, career advancement, and moving to other communities.⁸ In a 2019 Minnesota local public health agency survey, respondents indicated a high need to fill positions including program-specific positions (87%), directors (27%), and assessment and planning professionals (26%).¹⁰ After remaining relatively stable between 2013 and 2019, the Minnesota local public health workforce reduced by another 3.8% from 2019 to 2020, presenting additional challenges in responding to the COVID-19 pandemic.^8,9

The COVID-19 pandemic drew attention and investments, albeit short-term, to update public health systems. New investments are being made in public health systems through federal grants such as the Centers for Disease Control and Prevention's Strengthening US Public Health Infrastructure, Workforce, and Data Systems, and other grants funded through special appropriations such as the Coronavirus Aid, Relief, and Economic Security (CARES) Act to address consequences of increasing unemployment and economic disruption following COVID-19.¹¹ Yet, little research has been conducted to identify strategies to invest these funds optimally and help health departments address staffing gaps. Our article contributes to understanding the gaps and challenges to enable local health departments (LHDs) to determine how to best utilize the funds invested in them. More specifically, in this article, we investigate (1) which public health positions are presently (ie, 2 years after the COVID-19 pandemic began impacting the United States) in high demand and (2) the barriers to maintaining adequate staffing levels at LHDs. This research and similar work¹² will assist governmental public health leaders to identify concerns and strategies to improve workforce recruitment and retention.

Methods

The research team developed a cross-sectional, Web-based survey that was administered via Qualtrics (Provo, Utah) to members of the Local Public Health Association of Minnesota (LPHA). The survey instrument was informed by previous studies, which explored public health workforce gaps and the impacts of the COVID-19 pandemic and workforce gaps on the governmental public health enterprise.¹² The survey instrument also drew upon reporting systems set up by the state health agency (Minnesota Department of Health) to enable LHDs to answer the survey based on existing job classifications. The survey was developed to complement, rather than duplicate, other public health enumeration surveys such as the National Association of City and County Health Officials (NACCHO) Forces of Change,¹³ Public Health Workforce Interests and Needs Survey (PH WINS),¹⁴ and annual Minnesota Department of Health reporting surveys.

To maximize participant comprehension and consistency of survey questions and choices with research aims, the lead researcher conducted cognitive interviews with 3 former local health officials. During the cognitive interviews, interviewees were presented with the survey questions one by one and asked to explain their interpretation of the question, answer it, and elaborate on how they arrived at their answer. The cognitive interviews revealed that new staffing needs at LHDs arise from both the attrition of existing staff and the need for new positions that reflect the changing roles and responsibilities of LHDs. However, several Minnesota LHDs need authorizations from the city or county board of commissioners, other public officials, or unions before recruiting permanent employees. Therefore, our study examined both the need to create or authorize additional full-time equivalent (FTE) positions and fill authorized existing, currently vacant positions. The survey was then pretested by 6 former public health officials (3 recently retired public health officials in addition to the 3 cognitive interview participants) and refined using their feedback.

The survey included both closed- and open-ended questions. Responses to closed-ended questions were tabulated to present descriptive statistics, and open-ended questions were analyzed inductively¹⁵ by creating descriptive themes to provide insight into quantitative trends. All survey questions were optional (ie, participants could choose to skip any questions they did not wish to answer), leading to different response rates for individual questions.

The survey was fielded to LPHA member agencies. LPHA represents all city and county health agencies in Minnesota. Two health departments did not receive the survey since they contract with another LHD to provide several services in their jurisdiction. The health agency that provides services on behalf of these 2 health departments to their jurisdictions answered the survey, taking into account the staffing needs and challenges of providing services to all 3 jurisdictions. The survey was completed by LHD directors, administrators, or their authorized representatives and took respondents about 20 to 25 minutes to complete. It was administered via a personalized e-mail link and remained open for 3 weeks between June and July 2022. Seventy of 72 city and county health agencies in Minnesota participated in the survey, leading to a participation rate of 97%. Two departments declined to participate in the survey, citing a lack of staffing capacity.

In this article, we present results from 3 sections of the survey.

1. Staffing needs and priorities of LHD in Minnesota: For each position, respondents were asked whether they needed to fill vacant FTE positions, whether they needed to create additional FTE positions, and whether the position was not a priority for their agency in the next 12 months. In a follow-up question, respondents were then presented with all occupations they reported a need to fill existing FTE positions or create additional FTE positions in their agency and were asked to pick their top 3 priorities.
2. Funding and nonfunding constraints impeding health departments from maintaining optimal staffing: Respondents were asked whether inadequate funding, restrictions on using available funding, or other funding constraints contributed to different hiring challenges. This was followed by an open-ended question allowing respondents to elaborate on funding challenges other than inadequate funds their agencies face.
3. Community-level external factors contributing to difficulties for health departments to fulfill staffing needs: Respondents were asked to identify the extent to which different factors in the community contributed to the hiring challenges they face at their agency.

All survey data were exported from Qualtrics and imported into Stata version 17.1 (College Station, Texas) to tabulate descriptive statistics. Open-ended questions were inductively coded using thematic analysis^15–17 in Microsoft Excel (Microsoft Corporation, Redmond, Washington). The study was not deemed to be human subjects research and was exempted from institutional review board approval (STUDY #00014840).

Results

The key findings of this article address the staffing needs and priorities of LHDs, financial constraints to hiring facing LHDs, and the external barriers to recruitment facing LHDs.

Staffing needs and priorities of local health departments

Respondents reported a need to both fill vacant positions and create new positions (Figure). Most health departments reported a need to fill vacant public health nurse (PHN), public health educator (PHE), and administrative support staff positions (Figure). The need to create additional positions was highest for health planners/researchers/analysts (HPRAs), community health workers (CHWs), and PHNs. Additional FTE positions were also needed for communications or press information officers (PIOs), public health informaticians, and epidemiologists. While participants indicated a high need to create additional positions and fill vacant positions for CHWs, HPRAs, and PHNs, they only indicated a need to fill vacant positions and not create new ones for communications or PIOs, public health informaticians, and epidemiologists (Figure).

FIGURE: Staffing Needs of Local Health Departments^aAbbreviations: LHD, local health department; PHN, public health nurse; PIO, press information officer.^an refers to the number of respondents who answered the question asked of each position, so the figure is to be interpreted as out of 67 respondents, 43% LHDs indicated that they need to fill existing vacant PHN positions and 34% indicated that they need to create additional PHN positions. This figure is available in color online (www.JPHMP.com).

Of the 67 agencies that reported a need for PHNs, 43% identified vacancies while 34% reported a need to create new positions. Similarly, of the 65 agencies that reported a need for CHWs, some respondents reported a need to fill existing CHW positions (9%) but more reported needing to create additional CHW positions (35%). For HPRAs, 12% of agencies reported a need to fill existing positions compared with 36% needing to receive authorizations to create new HPRA positions. Finally, while only 3% of agencies reported a need to fill existing communications or PIO positions, 30% reported needing to receive authorizations for these positions.

Following the identification of vacancies and positions needing to be created, participants identified their top hiring priorities (Table 1). Overall, 59 agencies identified their top 3 needs from occupations selected in the prior question, though denominators for each occupation were a function of respondent selection. Of the 46 agencies reporting staffing needs for PHNs, 78% prioritized PHNs among the top 3 positions needed. Other high staffing priorities were reported among CHWs (72% of 29 agencies), HPRAs (53% of 30 agencies), PHEs (55% of 20 agencies), and communications or PIOs (52% of 21 agencies). While a small number of agencies reported a need (either fill existing positions or create new positions) for some positions such as mental health counselors and environmental scientists and specialists, 54% of these agencies reported these positions to be among their top 3 priorities.

TABLE 1 - Staffing Priorities of Local Health Departments^a

Position	Frequency	%
Public health nurse (n = 46)	36	78.26%
Community health worker (n = 29)	21	72.41%
Health planner/researcher/analyst (n = 30)	16	53.33%
Public health educator (n = 20)	11	55.00%
Communications officer/PIO (n = 21)	11	52.38%
Environmental scientist and specialist (n = 11)	6	54.55%
Mental health counselor (n = 11)	6	54.55%
Administrative support (n = 19)	6	31.58%
Epidemiologist (n = 10)	5	50.00%
Public health informatician (n = 16)	5	31.25%
Administrative/business professional (n = 8)	4	50.00%
Medical and public health social worker (n = 10)	3	30.00%
Other nurse (n = 13)	3	23.08%
Interpreter (n = 14)	3	21.43%
Health administrator (n = 5)	2	40.00%
Public health dental worker (n = 7)	2	28.57%
Public health program specialist (n = 13)	2	15.38%
Public health physical therapist (n = 1)	1	100.00%
Paraprofessional (n = 9)	1	11.11%
Public health nutritionist (n = 10)	1	10.00%
Other public health professional (n = 12)	1	8.33%
Licensure/inspection/regulatory specialist (n = 3)	0	0.00%
Occupation safety and health specialist (n = 1)	0	0.00%
Public health physician (n = 1)	0	0.00%

Abbreviations: FTE, full-time equivalent; PIO, press information officer.

^an indicates the number of respondents who were offered this item as a choice. Participants were offered this item as a choice only if they reported a need to fill vacant FTE or create additional FTE for this position at the agency in a previous question.

Financial constraints to hiring

Financial constraints were found to worsen the hiring challenges facing LHDs (Table 2). While inadequate funds posed a barrier to many respondents, they also reported facing other financial constraints including restrictions on using available funds. For instance, 64% of responding LHDs reported that inadequate funds kept them from creating new permanent positions, 30% reported that restrictions on using available funds kept them from creating new positions, and another 13% LHDs reported other funding constraints. Similarly, the inability to offer competitive salaries was a combination of inadequate funds (52%), restrictions on using available funds (28%), and other funding challenges (27%).

TABLE 2 - Challenges to Increase Workforce Capacity Before the COVID-19 Pandemic^a

	Inadequate Funds		Restrictions Using Available Funds		Other Funding Challenges
	Freq	%	Freq	%	Freq	%
Create new full-time or part-time permanent positions (n = 69)	44	63.77%	21	30.43%	9	13.04%
Offer competitive salaries (n = 67)	35	52.24%	19	28.36%	18	26.87%
Offer training opportunities (n = 65)	19	29.23%	19	29.23%	5	7.69%
Create new contract/temporary positions (n = 65)	19	29.23%	17	26.15%	7	10.77%
Provide office space, equipment, or supplies (n = 65)	15	23.08%	10	15.38%	3	4.62%
Fill open positions (n = 68)	15	22.06%	14	20.59%	14	20.59%
Convert temporary to permanent positions (n = 65)	13	20.00%	9	13.85%	8	12.31%

^an refers to the number of respondents who answered the question. All survey questions were optional (ie, participants could choose to skip any questions they did not wish to answer), leading to different response rates for individual questions.

Respondents' comments about restrictions to using available funds and other funding challenges in the follow-up open-ended question (n = 42) shed light on policy and administrative challenges agencies face (Table 3). The top 4 themes developed were (1) competitive wages (n =16), (2) support from local governmental boards (n = 15), (3) the need for more or sustainable funding (n =13), and (4) challenges related to union contracts and agreements (n =11).

TABLE 3 - Themes, Definitions, and Illustrative Quotes^a

Theme	Definition	Example Quote
Competitive wages (n = 16)	LHDs' inability to offer competitive wages impeding their ability to recruit and retain employees	“We [respondent's organization] are not competitive in salary or benefits, and all salary studies done by the vendors are done in comparison to other [public health] departments which is not helpful. We need to be able to compete for PH nurses with the private non-profit sector hiring nurses such as hospitals and [long-term care facilities].”
Support from local governmental boards (n = 15)	Interrelationship between LHDs and the rest of the local government administration and other agencies particularly for revenue and other financial decisions	“We are unable to convert contract positions to full-time permanent FTEs without guaranteed funding. Must be approved by the board and that often does not get approved.”
Need for more or sustainable funding (n = 13)	References to restrictions imposed by grants and short-term funding streams	“When trying to obtain temporary staffing positions, the attention to having to pay unemployment once the grant has ended has been a limitation to the desire to construct these positions.”
Challenges related to union contracts and agreements (n = 11)	Challenges of navigating union contracts and agreements	“Our [human resource] systems and multi-union environment pose challenges with appropriate classification of positions, ability of staff to supervise others at the same salary grade, and allowing for promotional opportunities. We also have to work with restrictive policies on hardware and equipment purchases that can make remote work difficult for certain positions.”

Abbreviations: FTE, full-time equivalent; LHD, local health department; PH, public health.

^an refers to the number of respondents who cited this theme out of the 42 respondents who answered the question.

The most predominant theme, competitive wages, included comments about LHDs' inability to offer competitive wages impeding their ability to recruit and retain employees. For instance, one respondent stated,

We [respondent's organization] are not competitive in salary or benefits, and all salary studies done by the vendors are done in comparison to other [public health] departments which is not helpful. We need to be able to compete for PH nurses with the private non-profit sector hiring nurses such as hospitals and [long-term care facilities].

The second theme, support from local governmental boards, captured the interrelationship between LHDs and the rest of the local government administration and other agencies. Respondents commented that their health departments often cannot hire staff without approvals from other public (elected or appointed) officials. The theme also included quotes that illustrated the dependency of health departments on local public entities for at least a part of their revenue. This was illustrated by a respondent's comment, “We are unable to convert contract positions to full-time permanent FTEs without guaranteed funding. Must be approved by the board and that often does not get approved.” Another respondent answered, “County Board of Commissioners are hesitant to approve temporary positions, so unless we can prove that the funding is ongoing staff requests are not approved.”

The need for sustainable or more funding was the third theme and included references to restrictions imposed by grants and short-term funding streams as one participant said,

The way we are able to use funds (especially the family health grants) really limits us. We hire staff to fulfill the grant and then the grant decreases the funding without any way for us to fill in that funding. It makes it really hard to find the right people to navigate the grants and the work when they are constantly changing how we approach the work we do.

The comments here also illustrated the challenges of hiring without stable revenue streams as another participant stated, “When trying to obtain temporary staffing positions, the attention to having to pay unemployment once the grant has ended has been a limitation to the desire to construct these positions.”

The fourth, and final, theme described the challenges of navigating union contracts and agreements. Findings in this theme provided evidence of the complex administrative systems that LHDs must navigate to create adequate staffing positions in their department and fill them up. For example, a participant stated,

Our [human resource] systems and multi-union environment pose challenges with appropriate classification of positions, ability of staff to supervise others at the same salary grade, and allowing for promotional opportunities. We also have to work with restrictive policies on hardware and equipment purchases that can make remote work difficult for certain positions.

External factors contributing to hiring challenges

Respondents also reported external barriers to hiring (Table 4). Most respondents (n = 69) provided feedback on each factor presented to them. Lack of affordable or quality childcare (99% responded that it was a concern to some extent, to a large extent, or to a very large extent), housing (87%), and transportation (81%) were the most cited community-level factors impacting employee recruitment challenges. Almost all respondents agreed that childcare was a concern for potential employees to a very large extent (39%), to a large extent (29%), and to some extent (30%). Similarly, affordable housing was a concern to a very large extent (29%), to a large extent (32%), and to some extent (26%). Finally, reliable transportation was a concern for respondents to a very large extent (6%), to a large extent (20%), and to some extent (55%).

TABLE 4 - External Factors Contributing to Hiring Challenges^a

	Not at All		To Some Extent		To a Large Extent		To Very Large Extent		Don't Know
	Freq	%	Freq	%	Freq	%	Freq	%	Freq	%
Affordable housing (n = 69)	4	5.80%	18	26.09%	22	31.88%	20	28.99%	5	7.25%
Reliable transportation (n = 69)	7	10.14%	38	55.07%	14	20.29%	4	5.80%	6	8.70%
Affordable, quality health care services (n = 69)	22	31.88%	28	40.58%	9	13.04%	3	4.35%	7	10.14%
Quality public schools (n = 69)	36	52.17%	19	27.54%	5	7.25%	1	1.45%	8	11.59%
Affordable or quality childcare (n = 69)	1	1.45%	21	30.43%	20	28.99%	27	39.13%	0	0.00%
Broadband Internet (n = 69)	22	31.88%	26	37.68%	11	15.94%	2	2.90%	8	11.59%
Shopping and entertainment (n = 69)	16	23.19%	24	34.78%	13	18.84%	5	7.25%	11	15.94%
Parks, outdoor recreational facilities (n = 69)	37	53.62%	19	27.54%	3	4.35%	1	1.45%	9	13.04%
Jobs for partners, family members (n = 69)	8	11.59%	30	43.48%	14	20.29%	7	10.14%	10	14.49%
Affordable cost of living (n = 69)	8	11.59%	28	40.58%	16	23.19%	11	15.94%	6	8.70%
Favorable weather (n = 68)	23	33.82%	22	32.35%	7	10.29%	0	0.00%	16	23.53%
Clean environment (n = 69)	47	68.12%	9	13.04%	2	2.90%	0	0.00%%	11	15.94%
Safe working environment (n = 69)	47	68.12%	11	15.94%	4	5.80%	0	0.00%	7	10.14%
Higher education, CE for employees (n = 68)	16	23.53%	35	51.47%	11	16.18%	1	1.47%	5	7.35%

Abbreviation: CE, continuing education.

^an refers to the number of respondents who answered the question. All survey questions were optional (ie, participants could choose to skip any questions they did not wish to answer), leading to different response rates for individual questions.

Discussion

LHDs in Minnesota reported a substantial need to fill vacant PHN, PHE, and administrative support positions as well as create additional CHW, HPRA, and PHN positions. The critical need to fill PHN positions in Minnesota is consistent with studies nationally that have documented the challenges to filling PHN positions in LHDs for the past several years^18–20 despite the marked decline of PHNs as a proportion of the total governmental public health workforce.²¹ Conversely, CHWs have increased as a proportion of the workforce in recent years. The need for CHWs has grown as communities wrestle with inequities and social determinants of health challenges²² and LHDs shift from clinical services to community-based prevention programs.²³ In Minnesota, many health departments have not traditionally employed CHWs as part of their workforce but now seek to increase these positions possibly to tap into the community-building capacity and expertise of CHWs who can directly reach residents.²⁴ Finally, evidence-based decisions are paramount to LHDs addressing population health needs²⁵ and, as the COVID-19 pandemic illustrated, HPRAs are foundational to being successful in these endeavors.

Although our study provides some nuance to prioritized positions discussed earlier, health departments indicated needing to create additional positions for almost every job category. However, substantial barriers impede workforce expansion efforts. More than half of our survey respondents indicated not having adequate funds to create new permanent positions or offer competitive salaries, the latter of which is important for state and local governmental public health workforce recruitment and retention.^26,27 Previous research has identified various recruitment and retention mechanisms, many of which are nonfinancial such as flexible work schedules, ability to innovate, autonomy/employee empowerment, and ability to telecommute.²⁸

A unique contribution of this article is that it furthers our understanding of factors external to public health departments that affect their ability to recruit workforce. The biggest challenges to employee recruitment identified in this study by respondents were affordable or quality housing and childcare. This is not just a public health problem, nor a public sector employer problem, but a national issue—and one particularly felt in rural and urban core jurisdictions. Affordable and quality housing is essential to attract workers to any location.²⁹ As an increasing number of employers allow their employees to work remotely, small- and mid-sized cities that offer affordable housing have seen growth in recent months.³⁰ In addition, for the first time since 1998, housing-related motivations such as wanting to own a home, a bigger home, or a cheaper home were the most common reasons for intercounty migrations.³⁰ Although rural Minnesota had programs and policies to facilitate affordable housing, these have declined over time.²⁹ One primary reason for affordable housing challenges is that affordable housing developers face costs not experienced by market-rate developers such as increased complexity in financing affordable projects and needing to manage multiple funding sources adding requirements and project delays.³¹ Furthermore, when housing developers are unable to absorb construction costs (which are caused by numerous inequities), housing shortages are exacerbated.³²

Affordable, quality childcare is also a historically prevalent challenge to the labor market and is the most common challenge discussed among single parents.³³ If a health department is in an area with limited access to affordable childcare, families, especially lower-income women, may likely overlook the position because it could be a significant obstacle for them in holding the position. Lack of affordable childcare also affects employers through productivity loss caused by absenteeism, where 29% of working parents experience at least one childcare breakdown a month.³³ To lessen this burden, governmental programs exist for childcare³⁴ and research has explained why and how governmental subsidy childcare programs can be expanded.³⁵ Previous research has also found that companies with family-friendly benefit programs have employees with higher levels of self-efficacy and overall organizational commitment.³³ Thus, agencies that are able to invest in family-friendly benefit programs, such as providing childcare assistance, may find significant financial and nonfinancial returns in investments.

Finally, this study is not without its limitations. Although occupations named in this study aligned with Minnesota's annual reporting surveys, it is possible that respondents interpreted occupations differently. In addition, agency needs and priorities were identified by agency representatives and not through a consensus at the agency level. Thus, it is possible that future research using different methods to identify needs and priorities might yield different results. The high participation rate (97%) nonetheless allows us to draw strong inferences on Minnesota's public health workforce priorities and challenges, which likely translates to other states nationwide.

Implications for Policy & Practice

• These findings serve as a guide to the public health enterprise to develop targeted material to advocate for new positions and redefine workforce needs based on the new roles and responsibilities LHDs have assumed since the pandemic started. However, several health departments need approvals from their local boards before receiving authorizations for these positions. One approach to overcome this barrier would be for the public health enterprise and their partners—such as local, state, or national public health associations—to develop and promote quality communications and advocacy materials to inform political authorities about the importance of these positions.
• This study highlighted the significance of adequate long-term funding to offer competitive wages to recruit and retain health officials and documented other challenges such as policies restricting the usage of existing funds and external factors such as lack of childcare also contributing to the staffing shortages of health departments. While salary is a primary factor to address recruitment challenges, holistic, employee-centered approaches to recruitment and retention are merited, as are policies to support agencies to be competitive for top talent. Given the limited funding and revenues streams available to LHDs, they may consider offering nonmonetary perks such as childcare referrals and work flexibility to attract and retain employees.