But this process only reflected the expert opinion of public health leaders, not necessarily the opinions of workers in the trenches. We needed to hear from public health workers directly.
That is a quote from an editorial by Paul Jarris and Katie Sellers (1) in the newly released supplemental issue of the Journal of Public Health Management and Practice (JPHMP), which is devoted to the results of the 2014 Public Health Workforce Interests and Needs Survey (PH WINS). The authors were speaking to the fact that public health leaders were convened in 2013 to identify the top challenges for the public health workforce over the next three to five years along with the competencies workers would need to address those challenges. PH WINS was the important next step taken by the de Beaumont Foundation and the Association of State and Territorial Health Officials (ASTHO) to hear from public health workers.
PH WINS is the first nationally representative individual-level survey of the workforce in state health agencies (SHA). Its three main goals were to (2):
- Inform future workforce development investments
- Establish a baseline to evaluate future workforce development efforts
- Explore workforce attitudes, morale and climate
Approximately 25,000 invitations to participate were emailed directly to central office employees in 37 SHAs. The 15 minute survey was Web-based. Only individuals who were permanently employed by a state agency and worked in a central office were included in the final sample of 10,246 respondents (3).
Questions asked of participants fell into the categories of training needs, workplace environment/job satisfaction, perceptions about eight national trends in public health, and respondent demographics. Limitations to the study findings included non-response bias due to the 46% response rate and the lack of participation by 13 states (2).
Findings (ranging from not surprising to disturbing)
Race/ethnicity: PH WINS researchers found that the public health workforce is comprised predominately of older white females, which will not surprise anyone who has worked in a public health agency. I was surprised to learn, however, that the percent of African American and Asian public health workers, but not Hispanics/Latinos, reflects the percentages of those groups within the general population (2). That suggests progress has been made in diversifying the workforce. It would be interesting to know if the race/ethnicity findings hold up at the state and regional levels.
Public health education: A disturbing finding is that only 17% of the public health workforce has any degree in public health and 66.7% have no formal certifications of any kind (4). It is understandable that workers in support roles (e.g., administrative assistants, budget analysts) might not need formal public health training, but Leider et al (4) found that fewer than one in four managers and executives had a degree in public health. As noted by Castrucci et al (5), public health workforce shortages have been forecasted for two decades, and the workforce has been effected by aging, layoffs and attrition, and fewer new graduates entering state and local public health. But 17%? Would any other profession tolerate such a lack of training? How can we move the discipline forward without a workforce grounded in basic public health concepts and principles?
Pay: Not surprising were the findings that only 48% of the public health workforce was somewhat or very satisfied with their pay (2) and that respondents who were satisfied were less likely to have intentions of leaving their positions in the coming year (6). The good news about pay is that the earnings gap is less in state public health between women and men compared to all work nationally. Castrucci et al (6) found that women earned 90 to 95 cents on the dollar in SHAs compared to men; this contrasts with 78 cents on the dollar for all work nationally. People of color also earn 90 to 95 cents on the dollar in state health agencies compared to non-Hispanic whites. The troubling news is that these pay gaps grow at higher supervisory levels. Future research that examines perceptions about equity in pay will likely yield interesting results. (Note to researchers: Non-clinical epidemiologists will give you an earful about the pay inequity between themselves and medical epidemiologists who do the same work.)
Castrucci et al (6) call for further research about factors that explain why gaps in governmental public health are lower than in other sectors. The structured, annual step increases for government salaries likely contributes substantially to the lower pay gap, but in my opinion, the inflexibility of those advances has a dark side with regard to performance in governmental public health. It creates a disincentive to work. Why put in a champion effort on a project, for example, and receive just a pat on the back or a paper certificate when the guy (or gal) in the next cubicle does nothing yet receives the same annual step increase? In the private sector, great work is rewarded with bonuses, trips, salary increases, etc. Only 39% of the PH WINS respondents feel that creativity and innovation are rewarded within their organizations (7). Governmental public health needs to find monetary rewards for exceptional work to help retain talent. Dealing with non-performers would also go a long way to increasing workplace morale.
Intent to leave within a year and job satisfaction: A finding that surprised even the researchers (given all that public health practice has been through in recent years) was that 79% of the respondents reported being somewhat or very satisfied with their jobs (2). This finding did not ring true for me when juxtaposed against another result: 27% of the respondents plan to leave their current position in the coming year with only 5% of that figure being due to retirement (2). The PH WINS researchers also estimate that 38% of the respondents will depart by 2020 (2). That many people just don’t leave their jobs when they are satisfied with their positions.
My first thought about this conundrum was that the question asked of respondents did not measure the concept of job satisfaction; rather, it may have measured whether respondents felt their work was of value. But I read about how the survey instrument was developed (3), and the methodology seemed sound. My second thought was that we are seeing the effects of nonresponse bias due to the lack of information from the 56% of respondents who did not complete the survey and the 13 states that did not participate. The researchers make a valid point in stating that the large final sample size (10,246) enhances generalizability of the results (3), but it is also easy to imagine email surveys being ignored by people who are disgruntled with their job or pay or supervisor or work organization.
It is unfortunate that characteristics of individuals who did and did not complete the survey cannot be compared to a greater extent. Perhaps the characteristics of the 27 participating and 13 non-participating state agencies could be contrasted in a future report. The information from ASTHO’s state health profile (8) could serve as a data source for that effort.
The influence of hierarchy: One topic I would like to see addressed with greater subtlety in future research is the influence of hierarchy on satisfaction with one’s pay, job, organization, and opportunities for advancement. Government agencies can be rigidly hierarchical and brutally political. This is exacerbated in governmental public health by the presence of the medical hierarchy within its culture. Physicians continue to wield (and often expect) significant power and influence, regardless of their official position. Nurses are next in line followed by other clinicians, such as veterinarians. Individuals with the least power are non-clinicians even though they may have advanced degrees, many years of experience, and the skills necessary for the survival of the discipline (e.g., health informatics). PH WINS researchers touched upon the topic of hierarchy by looking at supervisory level, but they may find further enlightening results by comparing those with and without clinical degrees. The challenges of working within rigid hierarchies may also be a factor in the findings that just 65% of PH WINS respondents are satisfied with their organizations (2) and that organizational support is more closely related to job satisfaction than supervisory support (7).
Additionally, that respondents report low proficiency in influencing policy development (35%), preparing a program budget with justification (27%), and understanding the relationship between a new policy and many types of health problems (30%) (2) is not surprising if looked at through the lens of vertically-structured organizations. Most budgets are completed by management, aided by fiscal staff, and policy decisions and direction are the purview of leadership. Staff may be asked to give some input but are otherwise not heavily involved in the process. Future research might back up a step and ask respondents if they are even given the opportunity to participate in such activities before determining that there are training gaps in these areas.
As I read through the journal’s articles, it was hard for me not to feel despair and imagine government public health as Sisyphus pushing his metaphorical boulder up the mountain. It is difficult to imagine government public health “rebuilding and retooling the workforce,” as stated by Hunter (9), and adapting best practices from entrepreneurs and tech firms, as suggested by Jarris and Seller (1), within their bureaucracies. Aside from the PH WINS findings, other known challenges facing governmental public health include:
- The average length of time on the job for state health officials, the leaders of governmental public health agencies, is only 3.4 years (median = 1.8 years) (8), making it very difficult for these individuals to affect change
- Federal funding for public health has remained flat and public health at the state and local levels have experienced drastic budget cuts (10)
- 42% (n=20) of U.S. SHAs exist within larger umbrella agencies (8), which likely compounds bureaucratic constraints
- Over recent years, trust in government has been at historic lows and was at 24% in 2014 (11), making it unlikely that the public will suddenly start supporting governmental public health.
The PH WINS authors recognize that the changes they suggest are a “tall order” to ask of governmental public health (1). But opportunities can be found in the midst of great challenges. The departure of over a third of the workforce by 2020 has the potential to start the process of breaking down stale attitudes, biases, and practices, and to bring in individuals with fresh perspectives, energy, and the skills needed to advance the discipline. The finding that younger staff in health departments are attaining higher levels of education, including in public health (4), also provides a glimmer of hope.
If the ‘ask’ is of governmental public health alone, however, then the rebuilding and retooling will not occur. Instead, the “redoubling of effort and close collaboration,” mentioned by Baker (12), must come from many sectors. Business, academia, health care, media, legislators, funders, advocacy groups, government, and public health workers themselves all have roles to play. The challenge will require many years of focus on a singular task: revitalizing, and holding accountable, governmental public health. It will also require the routine fielding of surveys like PH WINS to measure our progress and inform corrective actions.
It’s your turn
The JPHMP supplemental issue about PH WINS is rich with information, and I’ve only touch upon a few findings in this blog post. I highly recommend that you take some time to review the various articles, editorials, and commentaries, and consider what the findings mean for you and your agency. You can download the articles for free at the journal’s Website.
Also, let me know what you think. Like a lot of good research, PH WINS raises more questions than it answers.
- Do the findings ring true for you?
- What information would you like to see gathered in future research on this topic?
Share your thoughts with other readers by entering your comments below, and be sure to sign up to receive future blog postings.
All the best! Kathy
1) Jarris PE, Sellers K. A strong public health workforce for today and tomorrow. J Public Health Management Practice. 2015; 21(6 Supp), S3-S4.
2) Seller K, Leider JP, Harper E, et al. The Public Health Workforce Interest and Needs Survey: the first national survey of state health agency employees. J Public Health Management Practice. 2015; 21(6 Supp), S13-S27.
3) Leider JP, Bharthapudi K, Pineau V, et al. The methods behind PH WINS. J Public Health Management Practice. 2015; 21(6 Supp), S28-S35.
4) Leider JP, Harper E, Bharthapudi K, et al. Educational attainment of the public health workforce and its implications for workforce development. J Public Health Management Practice. 2015; 21(6 Supp), S56-S68.
5) Castrucci BC, Leider JP, Liss-Levison R, et al. Does money matter: earnings patterns among a national sample of the US state governmental public health agency workforce. J Public Health Management Practice. 2015; 21(6 Supp), S69-S79.
6) Liss-Levison R, Bharthapudi K, Leider JP et al. Loving and leaving public health: predictors of intentions to quit among state health agency workers. J Public Health Management Practice. 2015; 21(6 Supp), S91-S101.
7) Harper E, Castrucci BC, Bharthapudi K, et al. Job satisfaction: a critical, understudied facet of workforce development in public health. J Public Health Management Practice. 2015; 21(6 Supp), S46-S55.
8) Association of State and Territorial Health Officials. ASTHO profile of state public health: volume three. June 2014. Available at: http://www.astho.org/profile/. Accessed November 2, 2015.
9) Hunter EL. Rebooting our boots on the ground. J Public Health Management Practice. 2015; 21(6 Supp), S1-S2.
10) Trust for America’s Health. Investing in America’s health: a state-by-state look at public health funding and and key health facts: 2014. Available at: http://healthyamericans.org/report/114/. Accessed November 2, 2015.
11) Pew Research Center. Public trust in government, 1958-2014. Available at: http://www.people-press.org/2014/11/13/public-trust-in-government/. Accessed October 30, 2015.
12) Baker EL. Addressing urgent public health workforce needs: building informatics competency and strengthening management and leadership skills. J Public Health Management Practice. 2015; 21(6 Supp), S5-S6.