Seven Years, 3 Surveys, a Changed World: The State Public Health Workforce 2014-2021

Abstract

Context:

The COVID-19 pandemic and other public health challenges have increased the need for longitudinal data quantifying the changes in the state public health workforce.

Objective:

To characterize the state of governmental public health workforce among state health agency (SHA) staff across the United States and provide longitudinal comparisons to 2 prior fieldings of the survey.

Design:

State health agency leaders were invited to have their workforce to participate in PH WINS 2021. As in prior fieldings, participating agencies provided staff lists used to send e-mail invitations to employees to participate in this electronic survey.

Setting and Participants:

State health agency staff.

Main Outcome Measures:

PH WINS 2021 maintains the 4 primary domains from 2014 and 2017 (ie, workplace engagement, training needs assessment, emerging public health concepts, and demographics) and includes new questions related to the mental and emotional well-being; the impact of the COVID-19 pandemic on staff retention; and the workforce's awareness of and confidence in emerging public health concepts.

Results:

The percentage of SHA staff who self-identify as Black, Indigenous, and people of color increased from 30% (95% confidence interval [CI]: 29%-32%) to 35% (95% CI: 35%-37%) between 2014 and 2021. Staff younger than 31 years accounted for 11% (95% CI: 10%-12%) of the SHA workforce in 2021 compared with 8% in 2014 (95% CI: 8%-9%). From 2014 to 2021, staff who self-identify as a woman increased from 72% (95% CI: 71%-74%) to 76% (95% CI: 75%-77%). Overall, 22% (95% CI: 21%-23%) of the SHA workforce rated their mental health as poor/fair.

Conclusion:

The 2021 PH WINS results represent unique and current perspectives on the SHA workforce and can inform future public health infrastructure investments, research, and field practice to ensure a strong public health system.

The COVID-19 pandemic has placed unprecedented pressures on the state and territorial public health workforce, straining an already underfunded public health system1 and pushing a workforce with a history of stretching limited resources beyond its capacity. The impacts of these strains on the workforce have been magnified by a constant shift in job responsibilities to fit the changing pandemic landscape,2 communication challenges stemming from the politicization of public health recommendations by elected officials and the public,3,4 and even threats to public health officials' personal safety.5–7

Although a sizeable body of research describes the troubling impacts of the pandemic on frontline health care workers, similar research on the public health workforce has been limited. Available data indicate that rates of stress, burnout, and mental health conditions are high among state public health workers,8,9 accelerating already high rates of turnover among state public health workers and leaders.10

Even prior to the pandemic, there were concerning trends in the governmental public health workforce related to high rates of turnover among workers and leaders11,12; underrepresentation of Black, indigenous, and people of color (BIPOC); women in leadership positions11–13; training needs around critical skills14,15; and emerging public health issues.16,17

Conducted in 2014, 2017, and for a third time in 2021, the Public Health Workforce Interests and Needs Survey (PH WINS) presents a unique opportunity to understand not only the current state of the state and local public health workforce in the context of the COVID-19 pandemic but also a longitudinal view of the workforce's changing composition and needs for more than 7 years and 3 iterations of the survey.11,18 In this article, we present data on demographics, job satisfaction and engagement, and mental health status of the state public health agency workforce, and make recommendations for recruitment and retention of this important asset.

Methods

The 2021 PH WINS was sent to 137 446 individuals in the governmental public health workforce representing 47 state health agencies (SHAs), 29 member departments of the Big Cities Health Coalition, and 262 local health departments. The PH WINS was fielded between September 13, 2021, and January 14, 2022, during which it received 44 732 responses, 35% of eligible respondents. Balance repeated replication weights were constructed to account for the complex design and adjust for nonresponse. Complete details of the 2021 PH WINS methodology can be found in another article in this issue, and the 2014 and 2017 methodologies are available elsewhere.

This descriptive study uses data from the 2014, 2017, and 2021 PH WINS to examine changes in the SHA governmental public health workforce. In 2014, 33 SHAs participated, and 47 participated in 2017 (New Jersey, Oregon, and Colorado declining to participate) and 2021 (Tennessee, Georgia, and West Virginia). The overall PH WINS samples include SHAs with staff that work at a centralized office, local offices, or both. This study sample includes only SHA-centralized office staff. The number of central office staff included for each survey fielding is 10 246 (2014), 17 136 (2017), and 14 957 (2021). State health agencies were included in the analytic sample regardless of the number of years of participation. Data for 2021 include nonpermanent employees, which were excluded from the 2014 and 2017 SHA frame. Washington, District of Columbia, is considered part of the Big Cities Health Coalition and is not included in this study sample.

In 2014 and 2017, the instrument focused on 4 primary domains: workplace engagement, training needs assessment, emerging public health concepts, and demographics. Changes were made to the 2021 PH WINS to assess the impact of the COVID-19 pandemic on the workforce, improve data quality, and align with current research standards. Main changes include new questions related to the mental and emotional well-being of the workforce; the impact of the COVID-19 pandemic on staff's intention to leave or stay at their organization; and the workforce's awareness of and confidence in addressing critical public health concepts and racism as a public health crisis through their work.

For this study, age was dichotomized into less than 31 years and 31+ years. The race/ethnicity variable was dichotomized into White and BIPOC to evaluate broad changes in the diversity of the SHA governmental public health workforce in addition to a detailed breakdown of race and ethnicity. Black, indigenous, and people of color includes respondents who self-identified as any race except White, including 2 or more races. Self-reported mental or emotional health was dichotomized to poor/fair and good/very good/excellent. Responses to the questions “I have felt bullied, threatened, or harassed by individuals outside of the health department because of my role as a public health professional,” and “I have felt my public health expertise was undermined or challenged by individuals outside of the health department,” as well as variables related to perceptions about organization, supervisor, and workplace were dichotomized to strongly disagree/disagree/neither and agree/strongly agree. Satisfaction variables were similarly dichotomized (very dissatisfied/somewhat dissatisfied/neither and somewhat satisfied/very satisfied). Reported symptoms of probable posttraumatic stress disorder (PTSD) were dichotomized into “yes probable PTSD” (3 or more symptoms) or “no probable PTSD” (less than 3 symptoms), consistent with the methodology used in the Primary Care PTSD Screen for Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) (PC-PTSD) developed by the US Department of Veterans Affairs to screen for PTSD.19

Data were managed and analyzed in Stata 15.1 (StataCorp LLC, College Station, Texas). Rao Scott design-adjusted χ² analysis was used for cross-sectional comparisons between survey fieldings, and descriptive statistics are provided.

Results

Demographics and workforce characteristics

With each fielding of the PH WINS, the SHA governmental public health workforce has become younger and more diverse. The percentage of staff who identify as BIPOC increased from 30% (95% confidence interval [CI]: 29%-32%) in 2014 to 35% (95% CI: 35%-37%) in 2021, largely driven by an increase in staff who self-identify as Hispanic or Latino (6%, 95% CI: 6%-7% in 2014 vs 11%, 95% CI: 11%-12% in 2021) (see Supplemental Digital Content Table 1, available at http://links.lww.com/JPHMP/B72). The 2021 SHA workforce was significantly younger compared with 2014, with 11% (95% CI: 10%-12%) younger than 31 years compared with 8% in 2014 (95% CI: 8%-9%). The percentage of staff who self-identify as a woman increased from 72% (95% CI: 71%-74%) to 76% (95% CI% 75%-77%) from 2014 to 2021. Staff self-identifying as some other gender (added in 2017) increased from 1% (95% CI: 0%-1%) in 2017 to 2% (95% CI: 2%-2%) in 2021. The increase in staff self-identifying as a woman was largely driven by an increase among supervisors, managers, and executives (68%, 95% CI: 66%-70% in 2014 vs 74%, 95% CI: 72%-75% in 2021) (see Supplemental Digital Content Appendix Table 1, available at http://links.lww.com/JPHMP/B69).

Educational attainment has remained relatively constant; however, in 2021, staff younger than 31 years were more likely to have attained a master's degree (46%, 95% CI: 44%-49%) than those 31+ years of age (35%, 95% CI: 34%-36%) (see Supplemental Digital Content Appendix Table 1, available at http://links.lww.com/JPHMP/B69). Staff younger than 31 years were also more likely to have a specialized degree in public health (33%, 95% CI: 31%-36%) than staff 31+ years of age (16%, 95% CI: 15%-17%).

Workplace satisfaction and engagement

A majority of the 2021 SHA workforce was satisfied with their job (77%, 95% CI: 77%-78%) and organization (66%, 95% CI: 65%-67%), but less than half were satisfied with their pay (49%, 95% CI: 48%-50%) (see Supplemental Digital Content Table 2, available at http://links.lww.com/JPHMP/B73). Overall, satisfaction has remained constant; however, differences emerge by supervisory status and age. Job and organizational satisfaction among supervisors, managers, and executives decreased from 85% (95% CI: 83%-86%) and 68% (95% CI: 65%-70%), respectively, in 2014 to 77% (95% CI: 76%-79%) and 63% (95% CI: 61%-64%), respectively, in 2021 (see Supplemental Digital Content Appendix Table 2, available at http://links.lww.com/JPHMP/B70). Staff younger than 31 years were less satisfied with their pay than staff 31+ years of age (45%, 95% CI: 43%-48% vs 50%, 95% CI: 49%-51%) (see Supplemental Digital Content Appendix Table 3, available at http://links.lww.com/JPHMP/B71).

Respondents were asked to rate their level of agreement with several items related to perceptions of their organization, workplace, and supervisors (see Supplemental Digital Content Table 2, available at http://links.lww.com/JPHMP/B73). Levels of agreement for most items have remained relatively stable. In 2021, most staff agreed with the statements “The work I do is important” (93%, 95% CI: 93%-94%), and “I am determined to give my best effort at work every day” (92%, 95% CI: 91%-92%). Two-thirds of the SHA workforce (66%, 95% CI: 65%-67%) agreed with the statement “My organization prioritizes diversity, equity, and inclusion,” a new item added in 2021 PH WINS. Traditionally, the lowest levels of agreement have been observed for “Creativity and innovation are rewarded”; “Communication between senior leadership and employees is good”; and “My training needs are assessed,” but agreement for all 3 items significantly increased in 2021 compared with 2014.

Certain perceptions differ by supervisory status and age. Among nonsupervisors, positive perceptions of their organization and workplace significantly increased in 2021 compared with 2014, and perceptions about their supervisors have remained consistently high across all 3 years. The percentage of supervisors, managers, and executives agreeing with several markers of organizational perception fell from 2014 to 2021 (see Supplemental Digital Content Appendix Table 2, available at http://links.lww.com/JPHMP/B70). The percentage of those who agree with “Communication between senior leadership and employees is good in my organization” fell from 47% (95% CI: 45%-49%) in 2014 to 42% (95% CI: 40%-43%) in 2021. Perceptions of workplace and supervisor changed little among this group, with 1 exception. The percentage of those who agree with “I feel completely involved in my work” decreased from 87% (95% CI: 86%-80%) in 2014 to 82% (95% CI: 81%-83%) in 2021. By age, staff younger than 31 years consistently reported higher levels of agreement with almost all satisfaction and perceptions items than staff 31+ years of age (see Supplemental Digital Content Appendix Table 3, available at http://links.lww.com/JPHMP/B71).

Intent to leave

The percentage of the SHA workforce who intend to leave their organization within the next 5 years (excluding retirements) increased from 22% (95% CI: 21%-23%) in 2014 to 28% (95% CI: 27%-29%) in 2021 (see Supplemental Digital Content Table 3, available at http://links.lww.com/JPHMP/B74). This was driven by an increase in the percentage of supervisors, managers, and executives who intend to leave (18%, 95% CI: 16%-20%) in 2014 versus 30% (95% CI: 28%-31%, data not shown) in 2021. A smaller but still significant increase was observed among nonsupervisors.

Among SHA staff who intend to leave, pay was the most frequently reported reason for leaving (49%, 95% CI: 47%-50%). Workload/burnout was reported by 41% (95% CI: 40%-43%), up from 23% (95% CI: 22%-24%) in 2017. Stress was reported by 35% (95% CI: 34%-37%), up from 23% (95% CI: 22%-24%) in 2017. Staff not intending to leave their organization reported that they are staying because of benefits (67%, 95% CI: 66%-68%), job stability (58%, 95% CI: 57%-59%), and flexibility (56%, 95% CI: 55%-57%).

Public health concepts

Participants were asked to rate their level of awareness of and confidence in addressing 5 public health concepts in their work: health equity, social determinants of equity, social determinants of health, structural racism, and environmental justice. Definitions of each public health concept were provided in PH WINS for respondents to review before answering.

Awareness among SHA staff ranged from 70% (95% CI: 69%-71%) reporting feeling “very aware” of health equity to 43% (95% CI: 42%-44%) reporting feeling “very aware” of environmental justice (see Supplemental Digital Content Table 4, available at http://links.lww.com/JPHMP/B75). Notably, 62% of the workforce reported feeling “very aware” of social determinants of health, and slightly more than half (52%, 95% CI: 51%-53%) reported feeling “very aware” of structural racism.

Confidence in applying these concepts in their work among SHA staff was lower than reported awareness and ranged from 43% (95% CI: 42%-44%) reporting feeling “very confident” in their ability to address health equity in their work to 26% (95% CI: 25%-27%) reporting feeling “very confident” in their ability to address environmental justice in their work. A large percentage of the workforce reported feeling “very confident” in their ability to address social determinants of health (42%, 95% CI: 41%-43%). Despite a high percentage of awareness of structural racism, only 29% (95% CI: 29%-30%) of the workforce reported feeling “very confident” in their ability to address this concept in their work. Fewer reported feeling “very confident” in addressing social determinants of equity (28%, 95% CI: 27%-29%).

Well-being

Participants were asked to respond to a series of questions related to their mental and emotional well-being (see Supplemental Digital Content Table 5, available at http://links.lww.com/JPHMP/B76). Overall, 22% (95% CI: 21%-23%) of the SHA workforce rated their mental or emotional health as poor or fair; 14% (95% CI: 14%-15%) agreed with the statement “I have felt bullied, threatened, or harassed by individuals outside of the health department because of my role as a public health professional”; and 29% (95% CI: 28%-30%) agreed with the statement “I have felt my public health expertise was undermined or challenged by individuals outside of the health department.”

Differences were observed by supervisory status, gender, and age. More than a third (37%, 95% CI: 36%-39%) of supervisors, managers, and executives have felt undermined or challenged by individuals outside of the health department compared with 26% (95% CI: 25%-27%) among nonsupervisors. Staff self-identifying as some other gender were more likely to report poor/fair mental health (34%, 95% CI: 28%-40%) than staff self-identifying as a man (21%, 95% CI: 20%-23%) or a woman (22%, 95% CI: 21%-23%). Staff younger than 31 years were more likely to report poor/fair mental health (33%, 95% CI: 31%-36%) than staff 31+ years of age (21%, 95% CI: 20%-22%) and more likely to have experienced bullying/harassment (40%, 95% CI: 37%-42% among those younger than 31 years vs 29%, 95% CI: 28%-29% among those 31+ years of age).

Staff were also asked 4 questions related to the impact of the COVID-19 pandemic on their mental health to measure the prevalence of probable PTSD. Reporting 3 out of 4 symptoms would indicate probable PTSD. Overall, 24% (95% CI: 24%-25%) of the SHA workforce reported 3 out of 4 symptoms, indicating probable PTSD. This percentage was lowest among staff identifying as a man (20%, 95% CI: 18%-21%) and highest among staff younger than 31 years (38%, 95% CI: 35%-41%).

Discussion

With new and renewed interest in the public health workforce and historic investments in the governmental public health infrastructure, PH WINS 2021 provides critical insight into the SHA workforce during their COVID-19 pandemic response and across 3 survey fieldings. The data from the most recent survey—particularly its findings related to shifting workforce demographics and clear differences between workforce segments in engagement and well-being measures—should serve as guideposts to inform the future of SHA workforce development initiatives and priorities in the postpandemic years. These key findings included the following:

• An increasing majority of the workforce are women.

• There has been an influx of younger staff.

• Nonsupervisory staff report greater engagement than their supervisory counterparts.

• Job satisfaction remains high, though there are declining trends and large differences between nonsupervisors and supervisors/managers.

• High numbers of workers have experienced at least 1 symptom of PTSD.

Several key demographic characteristics of the workforce have stayed relatively constant across years of the survey, including the small proportion of the workforce with a degree in public health. However, there are notable demographic shifts, including larger proportions of women in the workforce and in supervisory positions, larger proportions of employees with advanced degrees, and employees younger than 31 years. The proportion of BIPOC staff has also increased from 30% to 35%, bringing the state public health workforce closer to estimates of the overall US workforce.20 Given the well-established positive impact of having public health workforces reflect the communities they serve,21–23 health agency leaders could explore new approaches to continuing to build a diverse workforce, such as partnerships with institutions and communities with high percentages of students or residents of color.

Women and employees younger than 31 years reported more symptoms of PTSD than men, more tenured staff, and older staff. These findings suggest that increased attention to the workforce's emotional well-being is needed, particularly among new employees and women. In addition, the impact of the COVID-19 pandemic broadly on women in the workforce has been profound, with women more likely to report forgoing work to care for others and being more likely to report that gender-based violence had increased during the pandemic.24 With even more women working in SHAs in 2021 than in 2014 and 2017, there may be need for health agency leaders and policy makers to implement and maintain appropriate flexibility to support women in their workforce.

New mental health and well-being data from 2021 offer an important look at the resilience of a strained workforce. Despite examples of threats, harassment, and political undermining of public health officials,3–7 a relatively small proportion of respondents reported having felt bullied, threatened, harassed, or undermined. Those reporting such experiences tended to be those in supervisory and leadership positions. Younger staff, while not reporting these challenges as frequently, did tend to report poorer mental health outcomes and a higher reported likelihood to leave. Although recent polling suggests that younger generations are more likely to leave their roles regardless of industry,25–27 there is evidence to suggest that high rates of burnout and other mental health outcomes among younger public health workers could pose a retention threat28,29 unique to public health's frontline position in the pandemic response. In the short-term, governmental public health leaders should ensure that managers and supervisors are equipped to create a workplace environment that is person-centered and culturally competent. One such program is ASTHO's Public Health Hope, Equity, Resilience, and Opportunity (HERO)*—a new resource aimed at supporting both individual and organizational resilience in governmental public health agencies. In the long-term, leaders should work with researchers to examine how these age and tenure differences compare with other fields to inform ongoing staff well-being and retention efforts.

Declines in job satisfaction were pronounced for supervisors, managers, and executives, despite generally positive shifts in engagement measures from 2014 to 2021. This may be attributable in part to the higher rates of bullying, harassment, and threats experienced by those in supervisory and other leadership positions. The SHA leaders should expand and promote resiliency resources in addition to working with national partners through programs such as the Johns Hopkins Bloomberg School of Public Health's STOP! Partner Group† toward preventing similar incidents of harassment and violence in the future.30,31

Despite the pressures placed on the SHA workforce throughout the pandemic, the proportion considering leaving their roles for reasons other than retirement is lower in 2021 than in 2017—perhaps because there may have been significant attrition during the initial wave of the pandemic and prior to the survey fielding. Research has shown spikes in health official turnover in 2020,7 and reports from state and local health officials suggest that this may have been mirrored in the SHA workforce overall.32–34 Informed retention efforts will be of critical importance to ensure that the state public health workforce is prepared for future public health emergencies. As expected given recent research,8–10 there were significant increases among staff considering leaving who cited workload/burnout, stress, and lack of flexibility as reasons compared with 2017. Notably, however, employees younger than 31 years cited more traditional reasons for leaving such as pay, lack of opportunities for advancement, and job satisfaction. In addition to the aforementioned mental health and well-being efforts, the SHA leaders should prioritize fostering an organizational culture that supports employee development, offers opportunities for advancement, and builds in flexibility as retention tools for the growing proportion of the workforce that is younger and early career.

One way to support the development of future leaders is to leverage the highly engaged workforce younger than 31 years, who responded more positively to engagement items than the workforce 31+ years of age. As noted elsewhere in this supplement, nonsupervisors demonstrated greater confidence in addressing emerging public health concepts such as social determinants of equity, structural racism, and environmental justice in their work than supervisors and other leaders, presenting an opportunity to engage nonsupervisors through expanded roles in these important areas. Harnessing the engagement of this growing younger segment of the workforce and their interest in social issues35 is a significant opportunity for health agencies as they pivot for the future.

Limitations

There are several limitations to this study. First, this is a descriptive, multi–cross-sectional study, and therefore, causal inferences should not be drawn from any of the analyses presented. Second, the SHAs that participated in PH WINS across fieldings varied, which may have impacted the generalizability of the earlier data; data were weighted to account for this limitation. Third, the data presented represent only SHA central office employees and are not generalizable to local governmental health department employees. Fourth, 2021 marks the first fielding to incorporate nonpermanent employees, which may impact year-to-year comparisons if permanent and nonpermanent employees differ in significant ways. Fifth, as in previous fieldings of the survey, the study responses were self-reported and many items reported reflect staff sentiment, introducing perception into the findings, especially pertaining to training needs. Sixth, while several new fields offer insight into areas such as mental health and well-being, the pandemic's impact, and new public health concepts, year-to-year comparisons on these new fields are not possible. Seventh, there is the potential for nonresponse bias, particularly given the timing of the survey being fielded in late 2021 well over a year into the COVID-19 pandemic, specifically related to potential underreporting of staff turnover, intent to leave, poor mental health outcomes, and harassment due to staff leaving in earlier stages of the pandemic.

Implications for Policy & Practice

• Workforce policies and practices should be modernized, including those that address flexibility of work schedules, remote work options, and family-friendly supports. These actions would enhance recruitment and retention, create a larger pool of workers, and address needs of a workforce dominated by young employees who identify as women.

• Partnerships should be strengthened with historically Black colleges and universities and other institutions with high percentages of students of color in order to increase the number of BIPOC professionals entering and excelling in the field of public health. Intentional recruitment strategies to attract BIPOC populations to public health should be implemented.

• Intentionally supporting and investing in the generally highly engaged younger workforce is essential to building the next generation of health agency leaders and retaining high performers. To equip the younger workforce with the competencies needed to become future leaders, access to training, mentoring, and growth opportunities is needed.

• Holistic behavioral health support should be made available to address burnout and employee well-being. Leaders and supervisors should be equipped to create a workplace environment that is person-centered and culturally competent and to guide employees to needed resources.

Conclusion

There is a unique opportunity, particularly with the influx of younger professionals into the SHA workforce and with historic investments in public health infrastructure, to prioritize policy and organizational changes to bolster the workforce. Potential opportunities include adopting and institutionalizing modern workplace policies to support flexibility and providing opportunities for career advancement—including relevant training, technology and development experiences that align with the needs of a changed public health system, and a more contemporary public health workforce. This approach must be paired with support for current and future leaders, given the supervisory and above workforce's experiences with burnout, stress, and harassment, as well as their lower job satisfaction and engagement. Leadership and supervisors play critical roles in establishing an organizational culture of well-being and resilience. Emerging out of the pandemic, it will be imperative for health agencies to implement evidence-based practices to address mental health concerns, aid in overall recruitment and retention efforts, and boost collective morale to protect the workforce of the future.

Supplementary Material

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