Abstract
Background and Objectives:
Public health workforce recruitment and retention continue to challenge public health agencies. This study aims to describe the trends in intention to leave and retire and analyze factors associated with intentions to leave and intentions to stay.
Design:
Using national-level data from the 2017 and 2021 Public Health Workforce Interests and Needs Surveys, bivariate analyses of intent to leave were conducted using a Rao-Scott adjusted chi-square and multivariate analysis using logistic regression models.
Results:
In 2021, 20% of employees planned to retire and 30% were considering leaving. In contrast, 23% of employees planned to retire and 28% considered leaving in 2017. The factors associated with intentions to leave included job dissatisfaction, with adjusted odds ratio (AOR) of 3.8 (95% CI, 3.52-4.22) for individuals who were very dissatisfied or dissatisfied. Odds of intending to leave were significantly high for employees with pay dissatisfaction (AOR = 1.83; 95% CI, 1.59-2.11), those younger than 36 years (AOR = 1.58; 95% CI, 1.44-1.73) or 65+ years of age (AOR = 2.80; 95% CI, 2.36-3.33), those with a graduate degree (AOR = 1.14; 95% CI, 1.03-1.26), those hired for COVID-19 response (AOR = 1.74; 95% CI, 1.49-2.03), and for the BIPOC (Black, Indigenous, and people of color) (vs White) staff (AOR = 1.07; 95% CI, 1.01-1.15). The leading reasons for employees' intention to stay included benefits such as retirement, job stability, flexibility (eg, flex hours/telework), and satisfaction with one's supervisor.
Conclusions:
Given the cost of employee recruitment, training, and retention of competent employees, government public health agencies need to address factors such as job satisfaction, job skill development, and other predictors of employee retention and turnover.
Implications:
Public health agencies may consider activities for improving retention by prioritizing improvements in the work environment, job and pay satisfaction, and understanding the needs of subgroups of employees such as those in younger and older age groups, those with cultural differences, and those with skills that are highly sought-after by other industries.
Keywords: intentions to leave, intentions to stay, job satisfaction, ongoing upskilling, pay satisfaction, public health workforce, retention
Robust public health infrastructure, including a competent workforce, is critical to support the changing public health enterprise. Rapidly evolving public health practice is accompanied by the growing demand that the public health workforce perform evidence-based, accountable, and high-quality public health services.1 Accountable public health practice, aligned with the national standards of performance proposed by the Public Health Accreditation Board (PHAB) 2022 standards, requires a paradigm shift to Public Health 3.0.2 Public health must aim to not only ensure population health for communities across the United States but also do so efficiently while mitigating health inequities and associated health disparities and address the emerging challenges from novel diseases and emerging threats.2 Such emerging threats are exemplified by COVID-193 and its aftermath, including mental health issues4 and risks of worsening health inequities.5 While public health threats such as COVID-19 have drawn attention to inadequacies in public health infrastructure, they have also heightened awareness about the importance of the role of public health and led to an elevated interest in public health careers.2,6–10 To prepare for and efficiently deal with emerging threats while meeting the expectations of higher standards for public health practice, both local health departments (LHDs) and state health agencies must engage in training and retaining the workforce. Accordingly, understanding workforce retention issues has become critically important.
Annual governmental public health employee turnover rates are high. Recent surveys of the governmental workforce have indicated that an increasing proportion of public health employees intend to leave the public health workforce in the near term.11,12 Although the exact costs of turnovers may be difficult to estimate, they can be detrimental, given the ongoing challenges associated with recruitment, skill development, and training of new employees.6,13,14 Studies of employee retention and turnover have identified a myriad of factors associated with employees' decision to stay or leave. Leider and colleagues12 summarized factors associated with turnover (actual separation), including job dissatisfaction and pay dissatisfaction, as well as employee characteristics such as being younger than 36 years or older than 55 years, having a tenure of 5+ years, and being an executive (compared with nonsupervisors). Similarly, in a study focused on intentions to leave, Sellers and colleagues15 found that dissatisfaction with job and pay, lower than agency median of organizational support and employee engagement, and higher than agency median of burnout were associated with higher odds of reporting an intention to leave. Recent studies of public sector employees have also found high turnover generally,16,17 and similar predictors of turnover intentions including job satisfaction, pay satisfaction, professional development/promotion/ongoing skill development opportunities, loyalty to the organization, a sense of accomplishment/shared decision making/liking one's job, and length of tenure.18
Given the competition for skilled workers with public health expertise in the job market and ongoing recruitment challenges within governmental public health agencies, recruitment of employees to fill vacancies will be challenging.19 Furthermore, loss of institutional knowledge due to turnovers and inadequate succession planning may pose additional challenges.20,21 Therefore, incentivizing retention of the existing public health employees remains imperative. Strategies to incentivize retention will have to address the “push factors” (ie, reasons provided for wanting to leave) and promote the “pull factors” (ie, reasons employees report for wanting to stay). It is important to create data-driven evidence about the role of those factors in employees' decisions to leave and stay in the public health workforce. To our knowledge, this is the first study to examine public health employees' intentions to remain in their jobs and their correlates.
The current study contributes to the existing workforce retention and recruitment literature by describing the trends in intention to stay and leave and/or retire. It also examines factors associated with intentions to leave and intentions to stay using the most current national data from the Public Health Workforce Interests and Needs Survey (PH WINS) 2021. Findings will be of interest to health officials and directors and individuals leading workforce recruitment and retention initiatives.
Methods
Sample and data
This article utilizes data from the 2017 and 2021 PH WINS. PH WINS is an individual-oriented, nationally representative survey of public health practitioners across local and state health departments in the United States conducted every 3 years since 2014. In 2017 and 2021, respondents who indicated intent to leave or retire were asked about their reasons for leaving. In 2021, respondents who indicated the intent to stay were asked to provide their reasons for staying. These are the focal points of analysis in this article. The sampling design and fielding approach for PH WINS are detailed elsewhere.22 In brief, respondents were invited to participate across both state health agencies and LHDs using a mix of certainty sampling and stratified probability-based sampling, with balanced repeated replication weights to account for complex sampling design and nonresponse. In 2021, a total of 137 447 staff members were invited and 44 732 responded (32% response rate). In 2017, a total of 92 946 were invited in the comparable analytic frame and 43 669 responded (47% response rate).
Variables of interest and analysis
The major domains of PH WINS include workplace perceptions (including intent to leave and job satisfaction), training needs, and demographics. In addition to adding intent to stay and reasons for staying, 2 domains were added in 2021: Health Equity and COVID-19. This article compares intent to leave due to retirement or for reasons other than retirement among respondents in 2017 and 2021. This necessarily is an analysis, then, of staff who have not yet quit or retired or otherwise left their organization. Inferential comparisons are made between 2017 and 2021 using a Rao-Scott adjusted chi-square. The responses in 2017 and 2021 should be viewed as multiple cross-sectional and not longitudinal. In addition, logistic models were fit to examine correlates of intention to leave or retire. The covariates of interest included job satisfaction, pay satisfaction, gender, age, race/ethnicity, highest degree attained, tenure in organization, supervisory status, setting, and program area. In addition, confirmatory factor analysis of workplace perceptions yielded 3 factors, which were used in the model (worker engagement, organizational support, and supervisor satisfaction) in line with previous research. Finally, the model utilized a dummy variable interacting year and COVID-19 deployment. Results are shown for a combined model. Data were analyzed in Stata MP 17.1 (StataCorp LLC, College Station, Texas).
Results
Sample characteristics by PH WINS year are presented in Supplemental Digital Content Appendix Table 1 (available at http://links.lww.com/JPHMP/B66). No significant differences exist across the survey years 2017 and 2021 samples. However, as shown in Table 1, in 2017, 23% of staff indicated they were planning to retire compared with 20% in 2021 (P < .001); 28% were considering leaving (excluding retirements) in 2017 compared with 30% in 2021 (P = .12) and 42% in 2017 compared with 41% in 2021 were considering leaving or planning to retire (P = .52). While plans to either leave or retire were consistent across years, the subgroup proportions considering leaving were different, especially by supervisory status, age, and educational attainment. More specifically, among supervisors, managers, and executives, 26% of staff said they were considering leaving in 2017 compared with 33% in 2021 (P = .002).
TABLE 1. Sample Characteristics by Intention to Leave, Retire, or Both Among State and Local Public Health Workers, 2017 and 2021.
| Intention to Leave | Intention to Retire | Intention to Leave or Retire | ||||
|---|---|---|---|---|---|---|
| 2017 | 2021 | 2017 | 2021 | 2017 | 2021 | |
| Overall | 23% | 20% | 28% | 30% | 42% | 41% |
| Setting | ||||||
| SHA-CO | 34% | 32%** | 23% | 21%** | 47% | 44%*** |
| BCHC LHD | 31% | 33%* | 20% | 18%* | 42% | 42% |
| Other LHD/RHD | 25% | 28% | 23% | 21%** | 39% | 39% |
| Supervisory status | ||||||
| Nonsupervisor | 29% | 30% | 21% | 19%** | 41% | 40% |
| Supervisor | 26% | 32%* | 27% | 22%** | 43% | 44% |
| Manager | 26% | 34%** | 29% | 27% | 42% | 48% |
| Executive | 26% | 31%* | 35% | 34% | 48% | 48% |
| Gender self-identification | ||||||
| Male | 70% | 66% | 75% | 79%*** | 55% | 55% |
| Female | 28% | 29% | 22% | 20%** | 41% | 40% |
| Some other way | 42% | 46% | 14% | 14% | 45% | 53% |
| Race | ||||||
| White | 28% | 30%* | 25% | 22%*** | 42% | 43% |
| BIPOC | 29% | 31% | 19% | 18% | 41% | 40% |
| Highest education | ||||||
| No college | 24% | 22%** | 26% | 25% | 39% | 35%** |
| Associate's degree | 27% | 25% | 24% | 26%* | 41% | 39% |
| Bachelor's degree | 29% | 31% | 22% | 20%** | 42% | 42% |
| Master's degree | 32% | 35% | 20% | 16%*** | 44% | 44% |
| Doctoral degree | 30% | 35%** | 24% | 23% | 44% | 47% |
| Age | ||||||
| <36 y | 32% | 37%* | 1% | 1% | 32% | 37% |
| 36-49 y | 26% | 28% | 3% | 3% | 28% | 30% |
| 50-64 y | 26% | 26% | 41% | 40% | 51% | 49%** |
| 65+ y | 40% | 44% | 87% | 84% | 84% | 77%** |
| Tenure in organization | ||||||
| 0-5 y | 31% | 31% | 8% | 8% | 35% | 36% |
| 6-10 y | 28% | 33% | 18% | 15% | 38% | 41% |
| 11-15 y | 27% | 29% | 23% | 24% | 40% | 41% |
| 16-20 y | 21% | 27% | 40% | 36% | 49% | 47% |
| 21+ y | 30% | 31% | 61% | 61% | 63% | 61% |
| Served in COVID-19 response (any role) | ||||||
| No | NA | 28% | NA | 22% | NA | 39% |
| Yes | 31% | 21% | 42% | |||
| Hired specifically for COVID-19 response | NA | 34% | NA | 9% | NA | 39% |
Abbreviations: BCHC, Big Cities Health Coalition; BIPOC, Black, Indigenous, and people of color; LHD, local health department; NA, not available; RHD, regional health department; SHA-CO, State Health Agency-Central Office.
aDifference between 2017 and 2021: ***P < .001, **P < .01, *P < .05.
Modest differences were observed in intent to leave for respondents by setting and reasons for leaving (Table 2; see Supplemental Digital Content Appendix Table 2, available at http://links.lww.com/JPHMP/B67, and Supplemental Digital Content Appendix Table 3, available at http://links.lww.com/JPHMP/B68), for example, among State Health Agency-Central Office (SHA-CO) respondents, 18% indicated lack of flexibility as a top reason for leaving compared with 23% of local respondents (P < .001); more substantive differences were observed by age and education. Thirty-nine percent of those considering leaving who were younger than 50 years indicated job dissatisfaction as a reason for leaving compared with 21% of those 50 years or older (P < .001). Pay was similarly of note for those younger than 50 years (59%), versus those 50 years and older (35%; P < .001), and burnout (younger than 50 years, 46%, vs 50 years and older, 33%; P < .001). Among those with a graduate degree who considered leaving, 35% indicated job satisfaction as a reason for leaving, 33% lack of opportunities for advancement, and 43% burnout. Among those with any COVID-19 deployment, 44% of those considering leaving cited stress compared with 34% of those without a COVID-19 deployment (P < .001); stress was a similarly frequently cited reason for leaving for those with any COVID-19 deployment (39%) versus those without deployment (32%; P < .001).
TABLE 2. Bivariate Analysis of Reasons for Leaving by Key Employee Characteristics, 2021a.
| 2021 | Setting | Any COVID-19 Deployment | Highest Degree Attained | Age <50 y | |||||
|---|---|---|---|---|---|---|---|---|---|
| State Health Agency | Local Health Department | No | Yes | Less Than Master's Degree | Master's or Doctoral Degree | No | Yes | ||
| Job satisfaction | 32% | 33% | 31%* | 30% | 32%* | 29% | 35%*** | 21% | 39%*** |
| Lack of acknowledgement/recognition | 28% | 28% | 28% | 25% | 29%** | 26% | 30%** | 23% | 31%*** |
| Lack of flexibility (flex hours/telework) | 21% | 18% | 23%*** | 21% | 22% | 18% | 26%*** | 14% | 26%*** |
| Lack of opportunities for advancement | 41% | 42% | 40% | 39% | 41%* | 38% | 44%*** | 28% | 49%*** |
| Lack of support | 29% | 30% | 29% | 27% | 30%** | 28% | 32%*** | 24% | 32%*** |
| Lack of training | 13% | 15% | 13%** | 14% | 13% | 14% | 13% | 9% | 16%*** |
| Leadership changeover | 16% | 17% | 16% | 13% | 17%*** | 15% | 18%*** | 14% | 18%*** |
| Other opportunities outside agency | 18% | 17% | 18% | 16% | 18%* | 16% | 20%*** | 10% | 23%*** |
| Pay | 50% | 49% | 50% | 51% | 49% | 51% | 48%** | 35% | 59%*** |
| Retirement | 14% | 14% | 13% | 17% | 13%*** | 16% | 11%*** | 34% | 1%*** |
| Satisfaction with your supervisor | 19% | 20% | 19% | 19% | 19% | 18% | 20%** | 16% | 21%*** |
| Stress | 37% | 35% | 38%** | 32% | 39%*** | 37% | 37% | 30% | 42%*** |
| Weakening of benefits (eg, retirement contributions/pensions) | 11% | 13% | 10%** | 11% | 11% | 11% | 11% | 8% | 13%*** |
| Work overload/burnout | 41% | 41% | 41% | 34% | 44%*** | 40% | 43%** | 33% | 46%*** |
aDifferences statistically significant at ***P < .001, **P < .01, *P < .05.
Similarly, Supplemental Digital Content Appendix Table 2 (available at http://links.lww.com/JPHMP/B67) presents the bivariate relationship between reasons for staying and key employee characteristics. Consistently, we found the largest differences among age groups: among those younger than 50 years, job stability (60%), supervisor satisfaction (50%), benefits (67%), and job flexibility (53%) were all highly cited reasons for staying. Among those respondents who indicated they were not considering leaving or retiring, modest differences were again observed for SHA-CO versus local, including around flexibility (56% vs 42%; P < .001) and satisfaction with one's supervisor (49% vs 43%; P < .001). Reasons for leaving and staying were assessed (Figure 1). The most prominent reasons for intention to leave include pay, lack of opportunities for advancement, work overload/burnout, and stress. The most prominent reasons staff report for intending to stay include benefits (eg, retirement), job stability, flexibility (eg, flex hours/telework), and satisfaction with one's supervisor.
FIGURE 1.
Proportion of Staffing Indicating Reasons for Considering Leaving Versus Reasons for Staying, 2021a
aRespondents were shown only reasons for leaving if they indicated they were considering leaving and, conversely, only reasons for staying if they did not indicate they were considering leaving.
Intention to leave or retire was characterized by the percentage of time respondents indicated they had spent on COVID-19 response (Figure 2). Overall, 30% of those spending less than 25% of their time on COVID-19 response indicated they were considering leaving compared with 39% of those who spent 75% to 99% of their time on COVID-19 deployment (P < .001). Among those who did not report COVID-19 deployment, 22% said they were planning to retire compared with 17% of those who reported spending 75% to 99% of their time on COVID-19 deployment (P = .01). A Cochrane-Armitage test for trend was statistically significant for considering leaving and planning to retire by relative amount of COVID-19 deployment (P < .001). A statistically significant departure from trend was identified among those considering leaving for those with 100% time spent on COVID-19 (P = .001) but not for considering retirement (P = .36).
FIGURE 2.
Intent to Leave and Retire, Associated With Percentage of Time Spent on COVID-19 Response, by Setting Abbreviations: BCHC, Big Cities Health Coalition; LHD, local health department; SHA-CO, State Health Agency-Central Office.
A logistic regression model was fit with the dependent variable, leaving for reasons other than retirement (Table 3). Respondents dissatisfied or very dissatisfied with their job had an adjusted odds ratio (AOR) of 3.8 (95% CI, 3.52-4.22) of indicating they would consider leaving their job. Similarly, employees with pay dissatisfaction had an AOR of 1.83 (95% CI, 1.59-2.11). Compared with the reference group of ages 50 to 64 years, those younger than 36 years had an AOR of 1.58 (95% CI, 1.44-1.73) of considering leaving; those 65+years had an AOR of 2.80 (95% CI, 2.36-3.33). Those with a graduate degree had a somewhat higher AOR of indicating they were considering leaving their organization (1.14; 95% CI, 1.03-1.26). All else equal, BIPOC (Black, Indigenous, and people of color) staff had an AOR of 1.07 compared with White staff of considering leaving (AOR = 1.01-1.15). Compared with 2017 PH WINS respondents, those hired solely for COVID-19 response had an AOR of 1.74 for considering leaving (95% CI, 1.49-2.03), whereas respondents indicating no COVID-19 response or some COVID-19 response did not have a statistically significantly different likelihood of indicating they were considering leaving compared with 2017, all else equal.
TABLE 3. Multivariate Relationship Between Intention to Leave and Employee Characteristics.
| AOR | 95% CI | P | |
|---|---|---|---|
| Job satisfaction | |||
| Neutral/Somewhat/Very satisfied | Ref | ||
| Dissatisfied/Very dissatisfied | 3.80 | 3.42-4.22 | <.001 |
| Pay satisfaction | |||
| Neutral/Somewhat/Very satisfied | Ref | ||
| Dissatisfied/Very dissatisfied | 1.83 | 1.59-2.11 | <.001 |
| Supervisor supporta | 0.72 | 0.7-0.74 | <.001 |
| Organizational supporta | 0.63 | 0.61-0.66 | <.001 |
| Employee engagementa | 0.78 | 0.75-0.81 | <.001 |
| Genderb | |||
| Male | Ref | ||
| Female | 0.81 | 0.74-0.88 | <.001 |
| Age | |||
| <36 y | 1.58 | 1.44-1.73 | <.001 |
| 36-39 y | Ref | ||
| 50-64 y | 0.97 | 0.91-1.04 | .37 |
| 65+ y | 2.80 | 2.36-3.33 | <.001 |
| Highest degree | |||
| Less than master's degree | Ref | ||
| Master's or doctoral degree | 1.14 | 1.03-1.26 | .01 |
| Tenure in organization | |||
| <5 y | Ref | ||
| 5 y+ | 0.89 | 0.78-1.01 | .08 |
| Supervisory status | |||
| Nonsupervisor | Ref | ||
| Supervisor or higher | 1.15 | 1.08-1.23 | <.001 |
| Race | |||
| White | Ref | ||
| BIPOC | 1.07 | 1-1.15 | .047 |
| Setting | |||
| State Health Agency | Ref | ||
| Big City Health Coalition | 0.96 | 0.9-1.02 | .17 |
| Other local health department | 0.79 | 0.67-0.94 | .007 |
| Program area | |||
| Administrative/clerical | Ref | ||
| Clinical and laboratory | 0.94 | 0.86-1.03 | .18 |
| Public health sciences | 1.03 | 0.97-1.1 | .33 |
| Social services and all | 0.96 | 0.77-1.19 | .69 |
| Other | |||
| Covid-19 response involvement | |||
| 2017 | Ref | ||
| 2021—Hired for COVID-19 response | 1.74 | 1.49-2.03 | <.001 |
| 2021—No COVID-19 response | 0.92 | 0.84-1 | .06 |
| 2021—Some COVID-19 response | 1.07 | 0.95-1.2 | .26 |
| Constant | 0.26 | 0.23-0.3 | <.001 |
Abbreviations: AOR, adjusted odds ratio; BIPOC, Black, Indigenous, and people of color.
aFactor variables. Differences statistically significant at ***P < .001, **P < .01, *P < .05.
bGender: Some other way—excluded because of small cell size.
Discussion
A generational reshuffling of the workforce is underway, and the public sector has not been spared.16 For some time, the public sector broadly has been outcompeted for talent by the private sector, owing largely to flexibility and pay differentials and, more recently, the weakening of public sector benefits. By all accounts, COVID-19 has exacerbated these trends in the public sector and, perhaps, within public health in particular.23,24 Public health agencies are expected to meet high bars, whether they are in ongoing COVID-19 response, the conceptual challenges of Public Health 3.0, or practically in the PHAB 2022 standards. Yet, meeting these challenges requires a workforce to do so. Efficient public health practice and administration require that threats to workforce retention be identified and then addressed. To generate empirical evidence about these threats and workforce retention issues, this study used data from the 2017 and 2021 PH WINS and examined intent to leave, corresponding reasons for leaving, and, in 2021, reasons for staying among the governmental public health workforce. This research also examined correlates of intention to leave or retire.
Comparing 2021 with 2017, findings indicate that there are not many notable changes in the characteristics of governmental public health employees who report the intention to leave and/or retire. Intention to leave is largely unchanged between 2017 and 2021, despite actual reported turnover in the media and elsewhere.17,25 This suggests high intention to leave even after the turnovers that have occurred throughout COVID-19, meaning there is still substantial potential for turnover-associated risk among health departments nationwide. Among noteworthy changes directly measured in this study between these survey periods, however, is the workforce with a supervisory status indicating a higher intention to leave than those not in a supervisory role. These managers and supervisors are often the glue that holds units and departments together. Greater intention to leave among those in supervisory roles means that staff reporting to them may not be supported as well as the leaders to whom they report. National recommendations that managers/supervisors devote time to creating inclusive, engaging work environments that incentivize staff to stay and thrive cannot be attended to if supervisors themselves are leaving.19
Another important change between these survey periods is in the reasons that individuals provided for intending to leave and/or retire. More specifically, overload/burnout and stress have been added to pay and lack of opportunities for advancement as key reasons for intention to leave and/or retire. In addition, key findings indicate that, among 2021 respondents, the higher percentage of time an individual spent toward the COVID-19 response, the higher the likelihood of reporting intention to leave and/or retire. Of exception were the 8% of staff in the analytic sample who said they spent all of their time on COVID-19, which may be explained by those individuals not having competing responsibilities as those who spent less than 100% time on COVID-19 response. The true nature of the impact of COVID-19 on intent to leave may not be obvious, however. After adjusting for other covariates in the multivariate logistic regression, those hired for a COVID-19 response position had increased odds of reporting intent to leave for reasons other than retirement, all else equal. Work overload/burnout, stress, and lack of opportunities for advancement were primary reasons for leaving more frequently among those who had COVID-19 deployment. Greater attention can be paid to onboarding individuals hired specifically for the COVID-19 response, given that roughly a third expressed an intention to leave. Intention to leave and/or retire is more common when individuals have simultaneous emergency response and routine public health activity roles.
Results from the multivariate model indicate that younger members of the governmental public health workforce, workers who have a higher level of education, and individuals who are BIPOC were significantly more likely to report intentions to leave their current jobs, which is consistent with trends elsewhere in the public sector.16 The combination of these 3 groups indicating their intention to leave is particularly problematic and worrisome, given the need and ongoing efforts to recruit a younger, more diverse, and highly skilled workforce, especially as public health focuses on racism and upstream solutions to address social determinants of health.26,27 Finally, the most frequent job classifications to express intent to leave were (1) policy analyst, (2) public health informatics specialist, (3) emergency preparedness/management worker, (4) public information specialist (ie, communications), (5) epidemiologist, and (6) disease intervention specialist/contact tracer. Each of these classifications plays an essential role not only in the ongoing COVID-19 response efforts but also in the provision of the Foundational Public Health Services.28
Despite that benefit packages (eg, retirement) have seen cuts over the last decade, benefits are one of the reasons governmental public health staff reported intending to stay. In addition, job stability and satisfaction with one's supervisor made the list of the most prominent reasons for staying. Work flexibility (eg, flex hours/telework), which has historically been less common within governmental public health prior to the COVID-19 response, was also a prominent reason provided for staying. Now that it is known that flex hours/telework are key factors in retention, finding ways to provide some amount of sustained work flexibility should be prioritized.
Limitations
There are a number of study strengths and limitations to note. First, this study uses data from the largest sample of governmental public health employees, to date, which included the highest proportion of LHD respondents to date. Among the limitations, however, is that it is unclear how much “churn” there has been in the workforce between the PH WINS data points. More specifically, it is unclear how many of the 2017 respondents departed their governmental public health position and how many employees were newly recruited between 2017 and 2021. Future studies are planned to explore this question. An additional limitation of note is that workforce safety/harassment was not included as an option on the survey question responses as a possible reason for intention to leave despite that it may have been a factor and is likely embedded as a reason for stress/burnout. Other limitations include that it is a multiple cross-sectional study of intent to leave among staff members who are still within the organization. It does not represent an examination of actual turnover.12 Given the substantial turnover observed elsewhere in the public sector, this is an important lens through which readers should view this analysis. Previous research has shown intent to leave or retire does not represent a one-to-one conversion of staff leaving, but that a high percentage of staff considering leaving do so, and that a lower percentage of staff not considering leaving do so. Finally, potentially for nonresponse bias and lower response rates in 2021 relative to 2017 may be problematic, though balanced repeated replication weights were employed to account for these issues.22
Implications for Policy & Practice
Communities depend on a diverse, engaged, and skilled governmental public health workforce. Innovations and best practices for public health employee recruitment and retention are needed.
Some public health skills are highly sought-after in other sectors, presenting a higher risk of loss of public health professionals with those skills doing foundational governmental public health work.
Given the burnout and stress caused by COVID-19–related additional work, government public health agencies will benefit from assessment of ways to inform and implement strategies for promoting employee satisfaction with job, pay, and the workplace environment.
Strategies to consider include salary adjustments and promotion opportunities to retain valuable employees, workload reductions, flexible/remote work policies, job rotations, and facilitating time off and backup support for time away.
Work flexibility (eg, flex hours/telework) was identified as a prominent reason for staying. As such, finding ways to provide some amount of sustained work flexibility should be prioritized.
It is imperative to support and mentor younger and BIPOC employees and increase the support of managers/supervisors.
Conclusions
Communities depend on a diverse, engaged, and skilled public health workforce. This study draws attention to the need to identify innovations and best practices for hiring and recruiting new employees into governmental public health. In addition, findings from this study added burnout and stress to the same list of reasons for reported intention to leave that we have known about since 2014.29 It is imperative that we find ways to address burnout and stress within the workforce. Considerations include workload reductions, encouraging employee time off, job rotations, and the provision of backup support for when employees take time off. Some of these same recommendations were included in the Bipartisan Policy Center's 2021 “Public Health Forward: Modernizing the U.S. Public Health System.” The call has been made, now is the time for action.30
Supplementary Material
Footnotes
The authors report no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (http://www.JPHMP.com).
Contributor Information
Jonathon P. Leider, Email: leider@umn.edu.
Gulzar H. Shah, Email: gshah@georgiasouthern.edu.
Valerie A. Yeager, Email: vyeager@iu.edu.
Jingjing Yin, Email: jyin@georgiasouthern.edu.
Kusuma Madamala, Email: Kusuma.Madamala@dhsoha.state.or.us.
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