Recovery and Resiliency in 29 Big Cities: Results From the 2021 Public Health Workforce Interests and Needs Survey

Abstract

Context:

Big Cities Health Coalition member health departments (BCHC HDs) serve more than 61 million people across their jurisdictions, nearly 20% of the US population. As such, they have particular challenges and opportunities in how they do their work. This article focuses on BCHC HDs that participated in the 2021 Public Health Workforce Interests and Needs Survey (PH WINS) and describes workplace perceptions, training needs, COVID-19 efforts, and well-being.

Objective:

To describe key characteristics of the governmental public health workforce among BCHC HDs, including demographics, perceptions, and needs.

Design:

Using a subsample of data from the 2021 PH WINS that included 29 BCHC HDs, descriptive statistics on many of the topics covered by the 2021 PH WINS were analyzed and compared with the 2017 PH WINS.

Setting:

Twenty-nine BCHC HDs in cities across the United States.

Participants:

In total, 7922 of 29 661 staff members (response rate of 27%) from participating BCHC HDs.

Results:

Most BCHC HD respondents self-identified as a woman (76%, 95% confidence interval [CI]: 75%-77%), and as Black, Indigenous, and people of color (69%, 95% CI: 68%-70%), similar to findings from the 2017 PH WINS (75%, 95% CI: 74%-76%; 67%, 95% CI: 66%-69%, respectively). Most respondents believe that their organization prioritizes diversity, equity, and inclusion (70%, 95% CI: 69%-72%). Thirty percent (95% CI: 29%-32%) intend to leave their organizations within 1 year, and 18% (95% CI: 17%-19%) plan to retire within 5 years. Staff connect their work with agency goals and priorities (86%, 95% CI: 85%-87%) and are determined to give their best effort every day (91%, 95% CI: 90%-91%).

Conclusion:

As the need for an all-encompassing focus on COVID-19 lessons, BCHC HDs should continue to focus on prioritizing staff retention, enhancing communication between senior staff and employees, and fostering an environment where innovation and creativity are rewarded.

In 2020, 86% of the population in the United States lived in urban areas, as defined by the US Census.1 The Big Cities Health Coalition (BCHC) is a forum for the largest metropolitan health departments in the United States to exchange strategies and advance equity to promote the health of the more than 61 million people they serve across their 35 jurisdictions.1 Although several of the BCHC member cities experienced slight population declines from 2020 to 2021, they remain the most populous cities in the nation.2 As such, BCHC health departments (BCHC HDs) will continue to play a vital role in protecting the overall health of the nation.

Cities in the United States have always shown themselves to be the future of health. Over the last 2 decades, in particular, city health and elected leaders have risen to address the unique challenges facing the communities that they serve. In New York City, the nation's first “publicly recognized” overdose prevention centers were stood up in November of 2021 and since then have averted more than 390 potential overdoses.3 In Chicago, the Department of Health created a “tree tool” to work with their partners across city government on a tree equity, initiative to address both environmental justice and climate change.4 These innovations have continued throughout the COVID-19 pandemic from health officials in the Bay Area of California uniting to jointly issue the nation's first “stay at home” order5 to the Houston Health Department's early adoption of wastewater surveillance to track coronavirus in the water.6 Furthermore, cities implemented aggressive mitigation measures during the early days of the COVID-19 pandemic to ensure the safety of those experiencing homelessness7 and address long-standing race and ethnic disparities.8,9

Despite being better resourced than smaller local health departments,10 BCHC HDs still face a number of long-standing systems-level challenges that impact their ability to provide public health services, such as staffing shortages, recruitment and retention challenges, and an aging workforce rapidly reaching retirement.11,12 Much of this can be traced back to limited funding and the “boom and bust” funding cycle for governmental public health systems.11 Local policies, such as noncompetitive salaries and cumbersome government hiring practices, remain barriers to truly achieving a skilled and competent workforce.13,14 In addition, COVID-19 response has caused more stress and burnout among an already stretched governmental public health workforce.15 The demands of this emergency response on BCHC HDs have resulted in lost gains made in combatting critical issues in public health, such as substance use disorder, as large portions of the workforce were deployed to COVID-19 response activities.16

This article shares findings from the 2021 Public Health Workforce Interests and Needs Survey (PH WINS) among participating BCHC HDs. Where applicable, comparisons were also made to results from the 2017 PH WINS. These data will help BCHC HDs and key stakeholders better understand the workforce's strengths and gaps and can guide future investments to improve its ability to respond to community health needs. Specifically, this article describes the workforce characteristics of BCHC HDs, their perceptions on job satisfaction, workplace environment, training needs, ability to address pressing issues in public health, and the impact of the COVID-19 pandemic response.

Methods

The 2021 PH WINS was sent to 137 446 individuals in the governmental public health workforce representing 47 state health agencies, 29 BCHC HDs,* and 262 (non-BCHC) local health departments. The survey 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,17 and the 2014 and 2017 methodologies are available elsewhere.18,19

This descriptive study uses data from the 2017 and 2021 PH WINS to examine changes in the BCHC governmental public health workforce. In 2017, 26 BCHC HDs participated, and 29 participated in 2021. The number of BCHC staff included for each survey fielding is 7453 (2017) and 7922 (2021). The BCHC HDs were included in the analytic sample regardless of the number of years of participation. The response rate for the BCHC sample was 43.4% in 2017 and 26.7% in 2021. Data for 2021 include both permanent and nonpermanent employees. Washington, District of Columbia, is a member of both the BCHC and the Association of State and Territorial Health Officials (ASTHO). Therefore, it is included in this study sample, as well as the complementary national analytic sample.†

In 2014 and 2017, the PH WINS 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 <31 years and 31+ years. The race and ethnicity variable was dichotomized into White and Black, Indigenous, and people of color (BIPOC) to evaluate broad changes in the diversity of the BCHC 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.

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 DSM-IV (PC-PTSD) developed by the US Department of Veterans Affairs to screen for PTSD.20

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

Data from the 2017 and 2021 PH WINS demonstrate the racial and ethnic diversity of the BCHC workforce. In both survey years, more than two-thirds of staff identified as BIPOC (2017: 67%, 95% confidence interval [CI]: 66%-69%; 2021: 68%, 95% CI: 67%-69%) (Table 1). In 2021, 32% of the workforce self-identified as White (95% CI: 31%-33%). This is a departure from the public health workforce at the state level where two-thirds (66%, 95% CI: 64%-66%) self-identified as White.21

TABLE 1. Demographic and Workforce Characteristics of the Big Cities Health Coalition Governmental Public Health Workforce, 2017 and 2021^a.

	2017		2021
Genderb
Man	24	23-25	22	21-24
Woman	75	74-76	76	75-77
Some other way	1	1-1	2	2-2
Race and ethnicityb
American Indian or Alaska Native	0	0-0	1	0-1
Asian	12	12-13	15	14-16
Black or African American	22	21-23	24	22-25
Hispanic or Latino	26	25-27	24	23-25
Native Hawaiian or other Pacific Islander	1	1-1	0	0-1
White	33	31-34	32	31-33
Two or more races	7	6-7	5	5-6
Race and ethnicity collapsed
White	33	31-34	32	31-33
BIPOC	67	66-69	68	67-69
Age, yb
Up to 25	3	2-3	3	3-4
26-34	19	18-20	19	18-21
35-44	24	23-25	27	26-29
44-54	27	26-28	24	23-25
55-64	23	22-24	21	19-22
65-74	5	4-5	5	4-5
≥75	0	0-0	0	0-1
Age collapsed, yb
<31	12	11-13	13	12-14
31+	88	87-89	87	86-88
Highest educational degree attainedb
No college degree	16	15-17	11	10-12
Associates	11	10-11	8	7-8
Bachelors	36	35-37	35	34-37
Masters	31	30-32	38	37-40
Doctoral	6	6-7	8	7-8
Public health degree (bach/mast/doc)
Yes	19	18-20	20	19-21
Supervisory statusb
Nonsupervisors	73	72-74	71	70-72
Supervisors, managers, and executives	27	26-28	29	28-30
Employment statusb
Contractor providing third-party services to the health department	2	1-2	7	6-8
Permanent staff employed directly by the health department	95	94-95	85	84-86
Intern employed directly by the health department	1	0-1	1	0-1
Temporary staff employed directly by the health department	3	3-4	7	6-7
Federal employee detailed to the health department	0	...	0	0-1
Tenure in current position, yb
0-5	59	58-60	66	65-67
6-10	16	15-17	14	13-15
11-15	10	10-11	7	7-8
16-20	8	7-9	6	5-6
21+	7	6-7	7	7-8
Tenure in current agency, yb
0-5	43	42-44	51	49-52
6-10	17	16-18	17	16-18
11-15	14	13-15	11	10-12
16-20	13	12-13	9	8-10
21+	14	13-15	13	12-13
Tenure in public health practice, yb
0-5	30	29-31	35	34-37
6-10	18	17-19	19	18-20
11-15	15	14-16	14	13-15
16-20	14	13-15	11	10-12
21+	23	21-24	20	19-21
Tenure in public health management, yb
0-5	31	27-34	37	33-41
6-10	22	19-25	25	21-28
11-15	19	16-22	14	11-17
16-20	14	12-17	13	10-16
21+	15	12-18	12	10-14
Annualized salaryb
<$25 000	1	0-1	0	0-0
$25 000-$35 000	9	9-10	3	3-4
$35 000.01-$45 000	16	15-17	10	9-10
$45 000.01-$55 000	16	15-17	13	12-14
$55 000.01-$65 000	14	13-15	14	13-15
$65 000.01-$75 000	11	10-12	13	12-14
$75 000.01-$85 000	10	10-11	11	10-12
$85 000.01-$95 000	8	7-8	10	10-11
$95 000.01-$105 000	6	6-7	9	8-10
$105 000.01-$115 000	4	3-4	6	5-6
$115 000.01-$125 000	2	2-2	3	3-4
$125 000.01-$135 000	1	1-1	3	2-3
$135 000.01-$145 000	1	0-1	2	1-2
>$145 000	2	1-2	4	3-4
Job classification (categories)b
Administrative	33	32-35	27	26-28
Clinical and lab	27	26-28	27	25-28
Public health sciences	37	36-38	44	43-45
Social services and all other	3	3-3	2	2-3
Primary program area (categories)b
Chronic disease and injury	6	6-7	5	4-5
Communicable disease	14	13-15	29	28-30
Environmental health	13	12-13	8	7-9
Maternal and child health	14	13-15	10	9-11
Other health care	11	10-11	17	16-19
All hazards	2	1-2	2	1-2
Assessment	9	8-10	7	6-7
Communications	5	4-5	2	1-2
Organizational competencies	20	19-21	17	16-18
Other	7	6-8	4	3-4

Abbreviation: BIPOC, Black, Indigenous, and people of color.

^aEstimates shown as estimate (95% confidence interval) by year.

^bStatistically significant differences, in aggregate, across years for a given item at P < .05.

The age and gender distribution of the BCHC workforce remained relatively stable between survey years. In 2021, 76% of the BCHC workforce self-identified as a woman (95% CI: 75%-77%). Furthermore, 73% of all supervisors, managers, and executives self-identified as a woman (95% CI: 71%-75%) (see Supplemental Digital Content Appendix Table 1, available at http://links.lww.com/JPHMP/B88). Nearly, the entire responding workforce was older than 31 years (87%, 95% CI: 86%-88%).

The distribution of educational attainment in 2021 significantly differed from the 2017 distribution, driven by an increase in the percentage of staff with a master's degree in any field (see Supplemental Digital Content Appendix Table 2, available at http://links.lww.com/JPHMP/B89). In 2021, 38% (95% CI: 37%-40%) of the BCHC workforce reported having a master's degree, up from 31% (95% CI: 30%-32%) in 2017 (Table 1).

Certain workforce characteristics shifted between the 2017 and 2021 PH WINS. Notably, the percentage of permanent staff employed directly by the health department fell to 85% (95% CI: 84%-86%) in 2021 from 95% (95% CI: 94%-95%) in 2017 (Table 1). Conversely, the percentage of contractors and temporary staff increased between 2017 and 2021. Likewise, the 2021 BCHC workforce was less tenured than their 2017 counterparts: staff reporting 0 to 5 years tenure in current agency, 43% (95% CI: 42%-44%) in 2017 versus 51% (95% CI: 49%-52%) in 2021.

The percentage of the BCHC workforce who worked in a communicable disease program area more than doubled between 2017 (14%, 95% CI: 13%-15%) and 2021 (29%, 95% CI: 28%-30%). The percentage of staff working in other health care increased to 17% (95% CI: 16%-19%) in 2021, up from 11% (95% CI: 10%-11%) in 2017. The proportion of staff in nearly every other program area decreased between 2017 and 2021.

Workplace satisfaction

The majority of the BCHC workforce in 2021 was satisfied with their job (76%, 95% CI: 75%-77%) and organization (65%, 95% CI: 64%-66%), and just more than half were satisfied with their pay (53%, 95% CI: 51%-54%), which fell slightly from 2017 (Table 2). The lowest levels of agreement were observed for “Communication between senior leadership and employees is good” (45%, 95% CI: 44%-47%) and “Creativity and innovation are rewarded” (43%, 95% CI: 42%-44%). These lower ranked workplace perceptions are largely consistent with previous PH WINS results (Table 2).

TABLE 2. Satisfaction and Perceptions About Organization, Supervisor, and Workplace Among the Big Cities Health Coalition Governmental Public Health Workforce, 2017 and 2021^a.

	2017		2021
Satisfaction
I am satisfied with my job.b	81	80-82	76	75-77
I am satisfied with my organization.b	71	70-72	65	64-66
I am satisfied with my pay.b	59	58-60	53	51-54
Perceptions about organizationc
Employees learn from one another as they do their work.	83	82-84	82	81-83
My organization prioritizes diversity, equity, and inclusion.	...	...	70	69-71
Supervisors work well with employees of different backgrounds.	72	70-73	70	69-71
Supervisors in my work unit support employee development.	71	70-72	69	68-71
I recommend my organization as a good place to work.b	72	71-73	65	64-66
Employees have sufficient training to fully utilize technology.	54	53-56	53	52-54
Communication between senior leadership and employees is good.b	48	47-49	45	44-47
Creativity and innovation are rewarded.b	45	44-47	43	42-44
Perceptions about supervisorc
My supervisor treats me with respect.b	83	82-84	85	85-86
My supervisor and I have a good working relationship.b	82	81-83	83	82-84
My supervisor provides me with opportunities to demonstrate my leadership skills.	68	67-69	68	67-69
Perceptions about workplacec
The work I do is important.b	95	94-95	93	92-94
I am determined to give my best effort at work every day.b	94	94-95	91	90-91
I know how my work relates to the agency's goals and priorities.b	89	88-90	86	85-87
I feel completely involved in my work.b	83	82-84	77	75-78
I am satisfied that I have the opportunities to apply my talents.b	69	67-70	67	65-68
I have had opportunities to learn and grow in my position.b	70	69-71	67	66-69
My training needs are assessed.b	54	53-55	50	49-52

^aShown as estimate (95% confidence interval). Estimate represents percentage of staff who say that they are “somewhat/very satisfied” (satisfaction items) or “agree/strongly agree” (perceptions items) with a particular item in a given year.

^bDifferences between years are statistically significant at P < .05.

^cSorted from least to greatest based on 2021 estimates.

Despite overall positive workplace perceptions in 2021, agreement with all workplace items decreased between 2017 and 2021 PH WINS. The percentage of staff agreeing with the statement “I feel completely involved in my work” fell from 83% in 2017 (95% CI: 82%-84%) to 77% in 2021 (95% CI: 75%-78%). Several markers of positive perception of organization also declined, including “I recommend my organization as a good place to work” (72% in 2017, 95% CI: 47%-49% vs 65% in 2021, 95% CI: 64%-66%).

Intent to leave

The percentage of the BCHC workforce who intend to leave their organization within the next 5 years (excluding retirements) increased slightly between 2017 (28%, 95% CI: 27%-29%) and 2021 (30%, 95% CI: 29%-32%) (Table 3). An additional 18% (95% CI: 17%-19%) of the workforce intend to retire in the next 5 years, just down from 19% (95% CI: 18%-20%) in 2017.

TABLE 3. Intent to Leave Organization and Reasons for Staying/Leaving Among the Big Cities Health Coalition Governmental Public Health Workforce, 2017 and 2021^a.

	2017 Estimate		2021 Estimate
Intent to leave organizationb
All staff	28	27-29	30	29-32
Supervisory status
Nonsupervisors	28	27-29	29	28-31
Supervisors, managers, and executivesb	27	25-30	34	31-36
Race and ethnicity
Whiteb	28	26-30	34	32-37
BIPOCb	27	26-29	29	27-30
Age, y
<31b	40	37-44	42	39-46
31 +b	26	24-27	28	27-30
Intent to retire (all staff)b	19	18-20	18	17-19
Top 5 reasons for leavingc
Payb	41	39-43	47	45-49
Lack of opportunities for advancementb	46	44-49	45	42-47
Organizational climate/culture	...	...	44	42-46
Work overload/burnoutb	25	23-27	43	41-45
Stressb	25	23-27	39	36-41
Top 5 reasons for stayingc
Benefits (eg, retirement contributions/pensions, health insurance)	...	...	65	63-66
Job stability	...	...	60	59-62
Job satisfaction	...	...	41	39-43
Pride in the organization and its mission	...	...	41	40-43
Satisfaction with your supervisor	...	...	41	40-43

Abbreviation: BIPOC, Black, Indigenous, and people of color.

^aEstimates shown as estimate (95% confidence interval) by year.

^bDifferences between years are statistically significant at P < .05.

^cSorted from least to greatest based on 2021 estimates.

Unlike 2017, intent to leave significantly varied by supervisory status and race and ethnicity in 2021. Among supervisors, managers, and executives, 34% (95% CI: 31%-36%) intend to leave compared with 29% (95% CI: 28%-31%) of nonsupervisors. Staff who self-identified as White were more likely to intend to leave (34%, 95% CI: 32%-37%) than those who self-identified as BIPOC (29%, 95% CI: 27%-30%).

Among BCHC staff who intend to leave in 2021, pay was the most frequently reported reason for leaving (47%, 95% CI: 45%-49%). Workload/burnout was reported by 43% (95% CI: 41%-45%), up from 25% (95% CI: 23%-27%) in 2017. Stress was reported by 39% (95% CI: 36%-41%), up from 25% (95% CI: 23%-27%) in 2017. Staff not intending to leave their organization reported that they are staying because of benefits (65%, 95% CI: 63%-66%), job stability (60%, 95% CI: 59%-62%), and job satisfaction (41%, 95% CI: 39%-43%).

Public health concepts

In the 2021 PH WINS, 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 for respondents to review before answering related questions.

Awareness among BCHC staff ranged from 80% (95% CI: 79%-81%) reporting feeling “very aware” of health equity to 53% (95% CI: 51%-54%) reporting feeling “very aware” of environmental justice (Table 4). Sixty-six percent (95% CI: 65%-68%) reported feeling “very aware” of structural racism. Notably, the percentage of BCHC staff who reported confidence in applying these concepts in their work was lower than awareness and ranged from 55% (95% CI: 53%-56%) reporting feeling “very confident” in their ability to address health equity in their work to 33% (95% CI: 32%-35%) reporting feeling “very confident” in their ability to address environmental justice in their work.

TABLE 4. Awareness of and Confidence in Addressing Public Health Concepts Among the Big Cities Health Coalition Governmental Public Health Workforce, 2021^a.

	Overall Awareness			Overall Confidence
Health equity
Not at all	2	2-2	I do not know this concept	1	1-2
Not much	4	4-5	Not confident	9	8-9
A little	14	13-15	A little confident	36	34-37
Very aware	80	79-81	Very confident	55	53-56
Social determinants of equity
Not at all	6	5-7	I do not know this concept	3	3-4
Not much	13	12-14	Not confident	18	17-19
A little	28	27-29	A little confident	41	40-43
Very aware	54	52-55	Very confident	38	36-39
Social determinants of health
Not at all	3	3-4	I do not know this concept	2	1-2
Not much	7	7-8	Not confident	11	11-12
A little	18	17-19	A little confident	34	33-35
Very aware	71	70-72	Very confident	53	51-54
Structural racism
Not at all	5	4-5	I do not know this concept	2	2-3
Not much	8	7-9	Not confident	15	14-16
A little	21	20-22	A little confident	39	38-40
Very aware	66	65-68	Very confident	44	42-45
Environmental justice
Not at all	6	5-6	I do not know this concept	4	3-4
Not much	13	12-14	Not confident	22	20-23
A little	29	28-30	A little confident	42	40-43
Very aware	53	51-54	Very confident	33	32-35

^aEstimates shown as estimate (95% confidence interval) by year.

Furthermore, 81% (95% CI: 80%-82%) of BCHC respondents believed that “addressing racism as a public health crisis” should be a part of their work at their health department, and more than half of respondents reported being engaged “some” (34%, 95% CI: 32%-35%) or “a lot” (17%, 95% CI: 16%-18%) with efforts to address racism as a public health crisis in their HD (Table 5). However, less than half of respondents felt that they had adequate funding for this work and almost two-thirds of the respondents (63%, 95% CI: 61%-64%) reported needing additional training to address racism as a public health crisis in their communities.

TABLE 5. Addressing Racism as a Public Health Crisis Among the Big Cities Health Coalition Governmental Public Health Workforce, 2021^a.

To what extent have you been engaged in efforts to address racism as a public health crisis in your health department?
Not at all	24	23-26
Very little	25	24-26
Some	34	32-35
A lot	17	16-18
Do you believe that addressing racism as a public health crisis should be a part of your work at the health department?
No	19	18-20
Yes	81	80-82
Do you feel that you have adequate funding to address racism as a public health crisis?
Disagree	27	26-28
Somewhat disagree	28	27-30
Somewhat agree	34	32-35
Agree	11	10-12
Which of the following do you need to address racism as a public health crisis?b
Training in these areas	63	61-64
More community engagement	41	39-42
More support from agency leadership	36	35-38
Additional staff capacity (ie, number of staff and/or ability of staff)	30	29-32
Acknowledgment by those working within the agency	28	27-30
More support from elected leaders	28	26-29
Nonmonetary resources (ie, know-how, time, equipment)	25	24-27
Other (please specify)	6	5-7

^aEstimates shown as estimate (95% confidence interval) by year.

^bSorted from least to greatest based on 2021 estimates. Respondents were prompted to select up to 3 options.

Well-being

Despite the demands of the COVID-19 pandemic, three-quarters (75%, 95% CI: 74%-76%) of the BCHC workforce said that their mental or emotional health was “excellent,” “very good,” or “good” (Table 6). A quarter (25%, 95% CI: 24%-26%) rated their mental or emotional health as “poor” or “fair”; 13% (95% CI: 12%-14%) felt “bullied, threatened, or harassed”; and 27% (95% CI: 26%-28%) agreed that their “public health expertise was undermined or challenged.”

TABLE 6. Self-Reported Measures of Mental or Emotional Health by Age, Gender, Race, and Ethnicity Among the Big Cities Health Coalition Governmental Public Health Workforce, 2021^a.

Age, y	<31		31+		Overall
Good to excellent mental healthb	63	60-67	77	76-78	75	74-76
Poor/fair mental healthb	37	33-40	23	22-24	25	24-26
I have felt bullied, threatened, or harassedb	17	14-20	12	11-13	13	12-14
I have felt that my public health expertise was undermined or challengedb	36	32-39	26	24-27	27	26-28
Probable PTSD (3 or more reported symptoms)b	38	35-42	27	26-29	29	27-30
Gender	Man		Woman		Some Other Way
Good to excellent mental healthb	78	75-80	75	74-76	53	43-63
Poor/fair mental healthb	22	20-25	25	24-26	47	37-57
I have felt bullied, threatened, or harassedb	16	14-18	12	11-13	20	13-29
I have felt that my public health expertise was undermined or challengedb	26	24-29	26	25-28	44	34-54
Probable PTSD (3 or more reported symptoms)b	25	23-28	29	28-31	43	33-53
Race and ethnicity	White		BIPOC
Good to excellent mental healthb	71	68-73	77	76-79
Poor/fair mental healthb	29	27-32	23	21-24
I have felt bullied, threatened, or harassedb	15	13-17	12	11-13
I have felt that my public health expertise was undermined or challengedb	39	36-41	21	20-23
Probable PTSD (3 or more reported symptoms)b	34	31-36	26	25-28

Abbreviations: BIPOC, Black, Indigenous, and people of color; PTSD, posttraumatic stress disorder.

^aEstimates shown as estimate (95% confidence interval) by year.

^bDifferences between groups are statistically significant at P < .05.

Differences in self-rated mental and emotional well-being were observed by age, gender, and race/ethnicity. Staff younger than 31 years were more likely to report poor/fair mental health (37%, 95% CI: 33%-40%) than staff older than 31 years (23%, 95% CI: 22%-24%) and more likely to have experienced bullying/harassment (17%, 95% CI: 14%-20% among those younger than 31 years vs 12%, 95% CI: 11%-13% among those older than 31 years).

Nearly half of the staff self-identifying as some other gender reported poor/fair mental health (47%, 95% CI: 37%-57%) compared with 22% (95% CI: 20%-25%) of the staff self-identifying as men and 25% of the staff self-identifying as women (95% CI: 24%-26%). By race and ethnicity, 29% (95% CI: 27%-32%) of the staff who self-identified as White rated their mental health as poor/fair compared with 23% (95% CI: 21%-24%) of the staff who self-identified as BIPOC.

The 2021 PH WINS participants 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.20 Overall, 29% (95% CI: 27%-30%) of the BCHC workforce reported 3 out of 4 symptoms, indicating probable PTSD. The BCHC respondents were slightly more likely to report probable PTSD than their state (24%, 95% CI: 24%-25%) and other local (24%, 95% CI: 22%-24%) colleagues.21 Staff self-identifying as White were more likely than their BIPOC colleagues to have probable PTSD, 34% (95% CI: 31%-36%) compared with 26% (95% CI: 25%-28%), respectively.

Discussion

Results from the 2021 PH WINS quantify the initial effects of the COVID-19 pandemic on the governmental public health workforce and show that the BCHC HD workforce is generally resilient but in need of continued critical support. Data from the 2021 PH WINS follow similar trends from the 2017 PH WINS, suggesting that the impact of COVID-19 pandemic response on the workforce's composition and perceptions of their workplace environment was relatively minor. However, with nearly one-third of the BCHC HD workforce reporting symptoms of probable PTSD from their COVID-19 pandemic response efforts, addressing and supporting the mental health and well-being of the workforce should be prioritized.

In addition, issues of recruitment and retention, improving communication between senior leadership and staff, and fostering a culture of creativity remain areas in need of immediate attention. A huge influx of surge staff—contract staff doubled between 2017 and 2021 PH WINS—also led to workforce challenges related to training, hiring, and bringing new people up to speed on the response.

The field of public health at large has a shared goal of having the public health workforce “reflect the community it serves.”22 As in years past, the BCHC HD workforce remains racially and ethnically diverse with large majorities of staff and leadership identifying as BIPOC. This is almost the exact opposite of the demographic breakdown among the state health agency governmental public health workforce, where two-thirds of respondents self-identified White, particularly among supervisors.21 This is an important strength of the BCHC HD workforce, which brings different perspectives and life views to health departments that serve incredibly diverse populations in the nation's largest cities.

Despite the demands of the COVID-19 pandemic, and other competing challenges, the BCHC HD workforce remains committed to their work and mission. However, issues with retention and workplace environment require attention to sustain a strong and well-skilled workforce. Although the number of contracted staff has doubled between 2017 and 2021, a recent report found that at least 80 000 additional full-time staff members are needed throughout the nation's governmental public health departments at the local and state levels to simply provide foundational public health services.23 With nearly one-third of the BCHC HD workforce intending to leave their organization in the next 5 years, recruitment and retention efforts should remain a top priority among leaders in BCHC HDs.

Trends in retirement and retention among the BCHC HD workforce track with results from the 2017 PH WINS with respondents reporting that the COVID-19 pandemic had little effect on their decisions to stay, leave, or retire from their organizations. This was surprising—and encouraging—given the high levels of stress and burnout reported by the overall governmental public health workforce due to COVID-19 response efforts15 and suggests other factors driving their intent to leave. Government bureaucracy often makes innovating and being creative difficult, and while local government is often more nimble than others, rewarding creativity remained a challenge for the BCHC HD workforce. Improving this aspect of workplace environment could improve overall employee satisfaction and retention and thus should continue to be an area of focused improvement.24

The BCHC HD workforce overwhelmingly cites benefits and job stability as the main reasons to stay. This was unsurprising, given that government service is known for consistency in benefits and work expectations (notwithstanding the current pandemic environment). Yet, nearly half of the BCHC HD workforce identifies organizational climate/culture and lack of opportunities for advancement as main reasons for leaving. The BCHC HD leaders should consider efforts to improve organizational culture and communication between supervisory levels in their decision-making processes related to employee satisfaction and retention.

As in years past, the BCHC HD workforce identified budget and financial management systems, strategic thinking, and change management as its top training need (see Supplemental Digital Content Appendix Table 3, available at http://links.lww.com/JPHMP/B90). As the COVID-19 response and recovery dictates a transformed and truly modern public health system, these skills are becoming even more important, and key steps taken to leverage federal resources to fund critical positions should free up local resources for training and development. Organizationally, the BCHC staff work with lead health officials to fill identified gaps in training and regularly convene a senior deputies cohort to provide training and peer networking for those in the pipeline of future health department leadership. During the height of the COVID response, the BCHC members spent time discussing how best to recognize staff for their efforts, as well as their mental health needs.

Training needs are also relevant when thinking about how best to address racism as a public health crisis25 and other health equity priorities. The BCHC workforce unequivocally feels that their health departments have a role to play in not just eliminating disparate health outcomes but also addressing long-standing structural inequities but they lack adequate funding and training to move the needle in this important space. To begin to help BCHC HDs address gaps in knowledge and funding, the BCHC staff are working with partners to figure out the best next steps to support and guide BCHC HDs in future activities to combat structural racism. Although there is much energy around recognizing racism as a public health crisis, mores support is needed to move to action.

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 BCHC members that participated in the 2017 and 2021 PH WINS varied: 26 BCHC members participated in 2017 and 29 BCHC members participated in 2021. Generalizability of these findings may be limited to participating BCHC members and not the entire workforce if there are significant differences between participating and nonparticipating agencies. However, balanced repeated replication weights were applied to account for nonresponse. Third, the 2021 PH WINS incorporates nonpermanent employees, which may impact year-to-year comparisons if there are significant differences between permanent and nonpermanent employees. Fourth, most PH WINS responses were self-reported leaving them subject to inherent bias, such as social desirability bias, and to nonresponse bias due to the survey's timing in the field. The survey was fielded during the COVID-19 pandemic response, and the resulting response rate among BCHC participants was 23.7%, much lower than the 2017 response rate of 43.4%. Data from the 2021 PH WINS may overrepresent staff not directly involved in the response and exclude staff who did not have time to respond. Sixth, data on reasons for staying, awareness of and confidence in public health concepts, and self-reported mental and emotional well-being are available only for 2021, and therefore, there is no way to evaluate change over time.

Implications for Policy & Practice

• Retirement and retention in Big Cities Health Coalition member health departments (BCHC HDs) remain largely the same since 2017 but require the attention of leaders. The HDs should prioritize opportunities for advancement, cultivating organizational climate/culture, and improving internal communications where they can.

• The BCHC workforce continues to identify training deficiencies in budget and financial management systems, strategic thinking, and change management. Continued federal resources to fund critical positions and investing in training and professional development are important, as well as dedicated local resources where possible.

• The BCHC workforce remains mission driven, clearly seeing how their actions affect the work of their health department and by extension, their communities.

• Although the BCHC HD workforce believes that they have a role to play in addressing racism as a public health, they have few dedicated resources and training to combat this pressing issue in their communities. Funding and resources to guide their work in this area are critical.

Conclusion

The number of BCHC HDs participating in PH WINS has increased with each subsequent fielding, providing agencies and stakeholders with a snapshot of the workforce while informing national workforce development priorities for urban health practice11 and the field at large. Having a well-trained and well-resourced governmental public health workforce is critical to protecting and improving the health of the population. Collection and analysis of data about the workforce's interests and needs are important to monitoring trends in progress and accelerating action for a stronger workforce particularly as the country and the field recover from the effects of the COVID-19 pandemic. The BCHC HDs should continue prioritizing staff retention, enhancing communication between supervisors and nonsupervisors, and fostering an environment where innovation and creativity are rewarded to support their workforce in their efforts to serve all communities so that they may thrive.

Supplementary Material

jpump-29-s022-s001.docx ^{(24.9KB, docx)}

jpump-29-s022-s002.docx ^{(25.3KB, docx)}

jpump-29-s022-s003.docx ^{(25.2KB, docx)}