Angela J. Beck

Building an Effective Workforce: A Systematic Review of Public Health Workforce Literature

CONTEXT The Robert Wood Johnson Foundation commissioned a systematic review of public health workforce literature in fall 2010. This paper reviews public health workforce articles published from 1985 to 2010 that support development of a public health workforce research agenda and address four public health workforce research themes: size and composition, effectiveness and health impact, demand, and policy. EVIDENCE ACQUISITION PubMed, ERIC, and Web of Science databases were used to search for articles; Google search engine was used to identify gray literature. The study used the following inclusion criteria: (1) the document was published in the U.S.; (2) the main theme(s) of the article address public health workforce research or relate to at least one of the four workforce research themes; and (3) the article focuses on the domestic workforce. EVIDENCE SYNTHESIS A total of 126 public health workforce articles and gray literature documents were analyzed in this review, including 34 related to effectiveness and health impact, 32 summary articles, 30 articles on size and composition, 20 articles about demand, and 10 policy articles. The primary sources for identifying articles were PubMed (66%); Google (28%); and Web of Science (6%). CONCLUSIONS The majority of public health workforce articles are descriptive in nature; few empirical studies about the public health workforce have been published in the peer-reviewed literature. Future research should consider use of organizational theories to develop workforce capacity models for public health and development of quantifiable output measures on which to base models that incorporate workforce demand.

Enumeration of the Governmental Public Health Workforce, 2014

Background Regular assessment of the size and composition of the U.S. public health workforce has been a challenge for decades. Previous enumeration efforts estimated 450,000 public health workers in governmental and voluntary agencies in 2000, and 326,602 governmental public health workers in 2012, although differences in enumeration methodology and the definitions of public health worker between the two make comparisons problematic. Purpose To estimate the size of the governmental public health workforce in 14 occupational classifications recommended for categorizing public health workers. Methods Six data sources were used to develop enumeration estimates: five for state and local public health workers and one for the federal public health workforce. Statistical adjustments were made to address missing data, overcounting, and duplicate counting of workers across surveys. Data were collected for 2010–2013; analyses were conducted in 2014. Results The multiple data sources yielded an estimate of 290,988 (range=231,464–341,053) public health workers in governmental agencies, 50%, 30%, and 20% of whom provide services in local, state, and federal public health settings, respectively. Administrative or clerical personnel (19%) represent the largest group of workers, followed by public health nurses (16%); environmental health workers (8%); public health managers (6%); and laboratory workers (5%). Conclusions Using multiple data sources for public health workforce enumeration potentially improves accuracy of estimates but also adds methodologic complexity. Improvement of data sources and development of a standardized study methodology is needed for continuous monitoring of public health workforce size and composition.

Challenges to Recruitment and Retention of the State Health Department Epidemiology Workforce

BACKGROUND With nearly one quarter of the combined governmental public health workforce eligible for retirement within the next few years, recruitment and retention of workers is a growing concern. Epidemiology has been identified as a potential workforce shortage area in state health departments. PURPOSE Understanding strategies for recruiting and retaining epidemiologists may help health departments stabilize their epidemiology workforce. The Council of State and Territorial Epidemiologists conducted a survey, the Epidemiology Capacity Assessment (ECA), of state health departments to identify recruitment and retention factors. METHODS The ECA was distributed to 50 states, the District of Columbia (DC), and four U.S. territories in 2009. The 50 states and DC are included in this analysis. The State Epidemiologist completed the organizational-level assessment; health department epidemiologists completed an individual-level assessment. Data were analyzed in 2010. RESULTS All states responded to the ECA, as did 1544 epidemiologists. Seventeen percent of epidemiologists reported intent to retire or change careers in the next 5 years. Ninety percent of states and DC identified state and local government websites, schools of public health, and professional organizations as the most useful recruitment tools. Top recruitment barriers included salary scale, hiring freezes, and ability to offer competitive pay; lack of promotion opportunities and merit raise restrictions were main retention barriers. CONCLUSIONS Although the proportion of state health department epidemiologists intending to retire or change careers during the next 5 years is lower than the estimate for the total state public health workforce, important recruitment and retention barriers for the employees exist.

Public Health Workforce Taxonomy

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012–2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection.

Assessment of epidemiology capacity in state health departments, 2001-2006

OBJECTIVES To assess the number of epidemiologists and national epidemiology capacity, the Council of State and Territorial Epidemiologists surveyed state health departments in 2001, 2004, and 2006. This article summarizes findings of the 2006 assessment, analyzes trends in epidemiology workforce, and examines statistical associations between the number of epidemiologists and measures of capacity. METHODS The on-line surveys collected information from 50 states and the District of Columbia about the number of epidemiologists employed, their training and educational background, program capacity, organizational structure, and funding sources. The State Epidemiologists and/or their designees answered the questionnaire. RESULTS The number of epidemiologists in state health departments increased approximately 40 percent from 2001 to 2006. All programs except occupational health experienced increase in the number of epidemiologists; the greatest increase occurred in bioterrorism programs. Estimated epidemiology capacity increased in all programs except environmental health and occupational health. The Epidemiology Capacity Assessment survey indicates that state health departments need 30 percent more epidemiologists. A linear correlation existed between the number of epidemiologists and state population. CONCLUSIONS Federal emergency preparedness funding supported most of the increase in epidemiologists, which could fall as funding decreases. To function at full capacity, states need approximately one epidemiologist per 100 000 population for all program areas. Current estimates of workforce capacity need to be refined.

Trends and characteristics of the state and local public health workforce, 2010-2013

OBJECTIVES We assessed state and local public health workforce characteristics by occupational category from 2010 to 2013. We also examined health department characteristics to determine whether workforce size and composition varied across these domains. METHODS We analyzed Association of State and Territorial Health Officials (2010, 2012) and National Association of County and City Health Officials (2010, 2013) profile study data, including 47 state health departments and 2005 and 1953 local health departments (LHDs) in 2010 and 2013, respectively. We determined number of workers and percentage of change by occupation, population size, geographic region, and governance structure. RESULTS The LHD workforce remained stable between 2010 and 2013. In states, the workforce decreased by 4%, with notable decreases in public information (-33%) and public health informatics (-29%); state health departments in small (-9%), New England (-13%), and centralized (-7%) states reported the largest decrease in number of workers. CONCLUSIONS Study findings provide evidence of a shifting public health workforce profile, primarily at the state level. Future research should seek to explain changing workforce patterns and determine whether they are planned or forced responses to changing budgets and service priorities.

The public health nurse workforce in U.S. State and local health departments, 2012

Objective. Public health nurses (PHNs) represent the single largest group of public health practitioners working in U.S. state and local health departments. Despite the important role of PHNs in the delivery and administration of public health services, little research has been conducted on this group and relatively little is known about PHN education, training, and retirement intentions. We describe the findings of a nationally representative survey of PHNs working in state and local health departments by characterizing their educational background and plans for retirement. Methods. An advisory committee convened by the University of Michigan Center of Excellence in Public Health Workforce Studies developed the Public Health Nurse Workforce Survey and disseminated it in 2012 to 50 U.S. state and 328 local health departments. Results. The 377 responding state and local health departments reported an estimated 34,521 full-time equivalent registered nurses in their employ, with PHNs or community health nurses as the largest group of workers (63%). Nearly 20% of state health department PHNs and 31% of local health department PHNs were educated at the diploma or associates degree level. Approximately one-quarter of PHNs were determined to be eligible for retirement by 2016. Professional development and promotion opportunities, competitive benefits and salary, and hiring procedures were among the recruitment and retention issues reported by health departments. Conclusion. PHNs were reported to have highly variable occupational classifications and educational backgrounds in health departments. Additional training opportunities are needed for PHNs with diploma and associates degrees. A shortage of PHNs is possible due to retirement eligibility and administrative barriers to recruitment and retention.

Factors Associated With Participation in a University Worksite Wellness Program

INTRODUCTION Healthcare reform legislation encourages employers to implement worksite wellness activities as a way to reduce rising employer healthcare costs. Strategies for increasing program participation is of interest to employers, though few studies characterizing participation exist in the literature. The University of Michigan conducted a 5-year evaluation of its worksite wellness program, MHealthy, in 2014. MHealthy elements include Health Risk Assessment, biometric screening, a physical activity tracking program (ActiveU), wellness activities, and participation incentives. METHODS Individual-level data were obtained for a cohort of 20,237 employees who were continuously employed by the university all 5 years. Multivariate logistic regression was used to assess the independent predictive power of characteristics associated with participation in the Health Risk Assessment, ActiveU, and incentive receipt, including employee and job characteristics, as well as baseline (2008) healthcare spending and health diagnoses obtained from claims data. Data were collected from 2008 to 2013; analyses were conducted in 2014. RESULTS Approximately half of eligible employees were MHealthy participants. A consistent profile emerged for Health Risk Assessment and ActiveU participation and incentive receipt with female, white, non-union staff and employees who seek preventive care among the most likely to participate in MHealthy. CONCLUSIONS This study helps characterize employees who choose to engage in worksite wellness programs. Such information could be used to better target outreach and program content and reduce structural barriers to participation. Future studies could consider additional job characteristics, such as job type and employee attitudinal variables regarding health status and wellness program effectiveness.

Mapping student response team activities to public health competencies: are we adequately preparing the next generation of public health practitioners?

This article compares activities of the University of Michigan School of Public Health Public Health Action Support Team (PHAST) to the Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists Applied Epidemiology Competencies (AECs) to determine the utility of using the competencies to assess extracurricular student training. We mapped the activities from eight PHAST trips occurring from 2006 to 2009 to the 34 AECs for Tier 1 epidemiologists by examining project activities to determine how closely they aligned with the AECs. PHAST trips provided students with opportunities to address 65% of the AECs; 29% of the AECs were addressed by all eight trips. The domains of AECs most often addressed by PHAST trips were leadership and systems thinking, cultural competency, and community dimensions of practice. Mapping PHAST trips to the AECs was useful for all public health students, not just epidemiologists in training.

Epidemiology Competencies and Preventive Medicine Residencies: Do They Mix and Map?

Objectives. This article maps the program requirements of the University of Michigan preventive medicine residency (PMR) to the newly established Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists Competencies for Applied Epidemiologists in Governmental Public Health Agencies (AECs) to determine the feasibility and utility of using these competencies to assess the training of physician epidemiologists. Methods. The academic and practicum requirements of the PMR are mapped against the 38 AECs for Tier 2, or mid-level epidemiologists. The process of mapping was done by reviewing academic course syllabi/content and practicum tasks to determine how closely they aligned with the AECs. This process allowed us to identify competencies that are relative training strengths and weaknesses of the residency. Results. Overall, the current program requirements of the PMR generally satisfy the AECs, although one competency was not met in either the academic or practicum year, and another was only met in a single, required academic course. The areas in which AECs were fulfilled by many activities in the residency were in domain 1 (assessment and analysis) and domain 2 (basic public health sciences). The areas in which competencies were met by few activities were primarily in domain 6 (financial and operational planning and management) and domain 7 (leadership and systems thinking). Conclusions. We found that the process of mapping an academically rigorous epidemiology training program (the PMR) to the AEC was feasible and useful. It permitted us to identify training strengths and gaps in our program and consider modifications that will strengthen the level of competency of our physician graduates.