Abstract
Objective:
Describe key characteristics of the rural local public health workforce on a national level, including in comparison to both the overall and urban local public health workforce.
Design:
Cross-sectional analysis of the 2024 Public Health Workforce Interests and Needs Survey (PH WINS) data.
Setting:
Local health departments (LHDs) serving rural and urban jurisdictions across the United States.
Participants:
The study sample included 172 679 weighted responses from individuals working in LHDs, and 33 214 of them were from rural-serving LHDs.
Main Outcome Measures:
Descriptive and bivariate statistics for measures across 4 areas, both overall and by rurality: demographic characteristics, educational background, position information, and intentions to stay or leave.
Results:
Greater portions of the rural local public health workforce were female and White relative to their urban counterparts. Compared to the urban workforce, the portions of the rural workforce without a public health degree and with clinical training were both greater. Tenure in position, agency, and public health practice also differed by rurality, with 19.6% of the rural workforce reporting the greatest tenure in public health practice (21 years or above) compared to 17.8% of the urban workforce. Intentions to stay, leave, or retire also differed by rurality, with 15.4% of the rural workforce reporting intentions to leave in the next year for reasons outside of retirement, compared to 21.6% of the urban workforce.
Conclusions:
Characteristics of the local public health workforce vary by rurality, extending prior research demonstrating differences between rural- and urban-serving LHDs across the nation. Findings should guide rural-focused strategies aimed at strengthening and sustaining the public health workforce.
Keywords: local public health, PH WINS, public health workforce, rural
Introduction
The US public health system comprises an array of public, private, and other entities that support the provision of essential services, particularly as they relate to assessment, policy development, and assurance.1,2 Within this “patchwork” system,3 governmental public health serves as a foundation.4,5 While agencies at the federal, state, and local levels have various roles in supporting public health,3,4 local health departments (LHDs) are often most integral to community-level services.6
With over 3000 LHDs, the characteristics of LHDs and the populations that they serve vary widely across the nation,7 with approximately half of LHDs serving rural populations,6 and approximately 10% of the US population being served by a rural LHD.7 Limited evidence highlights specific variation among LHDs based on rurality, such as a greater focus on direct clinical services6-9 and barriers to accessing technology and high-quality data,6 suggesting that rural-serving LHDs and their workforce may differ in important and meaningful ways relative to their urban counterparts.7 Rural-serving LHDs encounter the dual challenges of operating with limited resources and serving populations that generally experience worse health behaviors and outcomes.6,9Resource insufficiencies may stem from multiple factors, such as a limited tax base, types and distribution of revenue sources, and difficulty attaining economies of scale.6,10 Challenges also extend to the workforce, particularly in recruiting and retaining qualified public health staff. Rural-serving LHDs tend to have higher staffing-to-population ratios relative to urban-serving LHDs11,12; however, this relates to a relatively small staffing base with which to deliver essential services across larger geographic areas.9 According to estimates with varying scopes, around 15% of LHD employees work in rural areas, and small and rural LHDs usually have staff of less than 10 Full Time Equivalents.6,7,11 While their staff may be more proficient in various competencies,11 rural-serving LHDs’ staff may have less formal public health training, less public health practice experience, and be less racially and ethnically representative of the populations served in comparison to their urban counterparts.11-13 Echoing many such challenges, the Centers for Disease Control and Prevention’s recent Rural Public Health Strategic Plan identified strengthening the “rural public health infrastructure and workforce” as a priority area.14
While there is a growing recognition of the need to consider rurality in public health, our understanding of the rural local public health workforce nationally remains narrow, in part due to gaps in available data and analyses. Existing literature, for example, commonly reflects local public health workers on a national level with little focus on rurality, local public health workers within only large LHDs or defined geographic areas, agency-level analyses, or use of agency size and rurality interchangeably, which are not synonymous and may potentially mask considerations specific to rurality.11,15,16 Notably, variation in how rurality is defined represents a longstanding challenge for both public health research and practice, especially in public health, where jurisdictional boundaries differ.6,17 The use of multiple definitions likewise poses difficulties in both research and practice, making interpretation and comparisons challenging. Even when analyses aim to account for small and rural LHDs, sample sizes may be small, particularly at the level of individual workers, and response rates among rural populations and agencies are often lower than in urban areas. However, data on the rural public health workforce are increasingly available. National data from the Public Health Workforce Interests and Needs Survey (PH WINS) are pivotal in characterizing the local public health workforce, yet data specific to small and rural LHDs were limited until recently.15,16,18 In 2021, PH WINS was expanded to include workers at small (including rural) LHDs through a pilot program called PH WINS for All, though eligibility was restricted to select regions of the United States.18,19 In the most recent iteration of PH WINS in 2024, agencies of all sizes across the country were eligible to participate,20,21 making this the first national dataset representing the rural public health workforce. Overall, the perspectives of local public health workers within rural-serving LHDs across the nation are underexamined and often focus on rural challenges or gaps, highlighting a need for research aimed at characterizing this workforce and that leverages new research opportunities through the 2024 expanded fielding of PH WINS.
The purpose of the current study is to provide the first national description of the rural local public health workforce across the United States, with a focus on demographic, educational, and positional characteristics, as well as intentions to stay or leave their organizations. This study involves a cross-sectional analysis of 2024 PH WINS data, incorporating comparisons between the rural, overall, and urban workforces for additional context. Rurality was defined at the agency-level based on the agencies’ service area using Census designations.22 Study findings are intended to offer critical insights into the composition, challenges, and strengths of this workforce and, thus, inform investments and other strategies aimed at enhancing and sustaining this essential workforce.
Methods
Design and sample
This cross-sectional study used survey data from the 2024 PH WINS, developed and administered by the de Beaumont Foundation and the Association of State and Territorial Health Officials. This national, online survey was distributed to state and local public health workers across the country and achieved a 37% response rate. As noted previously, for the first time in the history of PH WINS, LHDs of all sizes from all regions were invited to participate, yielding a nationally representative sample of the full state and local public health workforce. Survey weights were developed to achieve national representation of the data. Additional details on the survey methodology are described elsewhere.20
Our sample for this analysis was restricted to individuals working in a local setting and considered permanent staff, contractors, or temporary staff (excluding interns and federal detailees). Both part- and full-time workers were included. We included full and partial responses, with results displaying the full sample of eligible individuals with responses to each item examined.
Measures
We describe the rural, urban, and total local public health workforce across 4 main areas of demographic characteristics–educational background, position information, and intentions to stay or leave. Demographic characteristics include: sex (ie, male or female); a combined measure of race and ethnicity (ie, identifying as White or Black, Indigenous, or People of Color); and age categories (ie, <31, 31-50, and 51+ years). Educational background includes the highest degree obtained (ie, no college, associate’s, bachelor’s, master’s, or doctoral), plus binary indicators for having formal public health training and for having clinical training. Clinical training is defined through degrees earned, job classification, or both. Degrees include associate’s in nursing, Bachelor’s of Science in Nursing, Master’s of Science in Nursing, Doctor of Veterinary Medicine/Veterinariae Medicinae Doctoris, Doctor of Medicine/Doctor of Osteopathic Medicine, Doctor of Pharmacy, or any international equivalent. Job classifications include public health dentist, public health/preventive medicine physician, public health veterinarian, pharmacist, physical/occupational/rehabilitation therapist, registered nurse—public health or community health nurse, registered nurse —unspecified, nurse practitioner, or licensed practical or vocational nurse. Position information includes: tenure in current position, tenure in current agency, and tenure in public health practice (ie, 0-5, 6-10, 11-15, 16-20, and 21 or more years); primary program area (ie, assessment and surveillance; chronic disease and injury prevention; clinical health care and social services; communicable disease control; communications and policy; emergency preparedness and response; environmental public health; maternal, child, and family health; organizational competencies; and other); supervisory status (ie, non-supervisor, supervisor, manager, and executive); employee type (ie, contractor, permanent staff, and temporary staff); and full- or part-time status. Lastly, intentions to stay or leave include not considering leaving in the next year, considering leaving their organization in the next year (excluding retirement), and considering retiring in the next year. Agency rural/urban status was informed by the percent of census blocks in the service area that are considered rural or urban based on the 2020 Census designations.22 If more than 50% of census blocks were rural, the agency was considered rural.
Analyses
We present descriptive and bivariate statistics of each measure overall and by agency rural/urban status and with a Bonferroni adjustment to account for the multiple comparisons. Survey weights were included, and only weighted counts are presented. Survey data were prepared and analyzed using Stata Version 19.5. This study was deemed non-human subjects research by the East Tennessee State University Institutional Review Board.
Results
Our sample included 172 678.6 weighted respondents (38 108 unweighted), 19.2% of which were in rural-serving agencies.
Demographic characteristics
While the overall local public health workforce was predominantly female, White, and aged 31-50, there were differences in sex and race and ethnicity by rurality (Table 1). A significantly greater portion of the rural workforce was female compared to the urban workforce (88.1% vs 80.5%, respectively, P < .001) and White (80.9% vs 54.5%, respectively, P < .001).
TABLE 1.
Demographic Characteristics of the Local Public Health Workforce by Rurality
| Rural, n (%) | Urban, n (%) | Total, n (%) | P Value | |
|---|---|---|---|---|
| Total | 33 214 (19.2) | 139 465 (80.8) | 172 679 (100.0) | |
| Sex | <.001 | |||
| Male | 3928 (11.9) | 26 911 (19.5) | 30 839 (18.0) | |
| Female | 29 085 (88.1) | 111 224 (80.5) | 140 309 (82.0) | |
| Race and ethnicity | <.001 | |||
| White | 26 562 (80.9) | 74 249 (54.5) | 100 811 (59.6) | |
| BIPOC | 6254 (19.1) | 61 969 (45.5) | 68 223 (40.4) | |
| Age, y | <.001 | |||
| <31 | 4611 (13.9) | 20 754 (14.9) | 25 365 (14.7) | |
| 31-50 | 15 822 (47.7) | 70 746 (50.8) | 86 568 (50.2) | |
| 51+ | 12 706 (38.3) | 47 655 (34.2) | 60 361 (35.0) |
Abbreviation: BIPOC, Black, Indigenous, or People of Color.
Educational background
The educational background and training of the local public health workforce differed by rurality (Table 2). Overall, the rural workforce generally had lower levels of education compared to the urban workforce. For example, 43.0% of the rural workforce reported having less than a bachelor’s degree compared to 27.6% of the urban workforce. In comparison, the portion of the rural workforce with an advanced degree (master’s or doctoral) was just over half that of the urban workforce (19.0% vs 33.8%, respectively). In addition, a significantly lower portion of the rural public health workforce had a public health degree (12.8% vs 22.1%, respectively, P < .001) and a significantly greater portion had clinical training (30.7% vs 21.7%, respectively, P < .001) compared to the urban workforce.
TABLE 2.
Educational Background of the Local Public Health Workforce by Rurality
| Rural, n (%) | Urban, n (%) | Total, n (%) | P Value | |
|---|---|---|---|---|
| Total | 33 214 (19.2) | 139 465 (80.8) | 172 679 (100.0) | |
| Highest degree attained | <.001 | |||
| No college degree | 6807 (20.6) | 21 340 (15.4) | 28 147 (16.4) | |
| Associates | 7412 (22.4) | 16 931 (12.2) | 24 343 (14.2) | |
| Bachelors | 12 525 (37.9) | 53 433 (38.6) | 65 958 (38.5) | |
| Masters | 5824 (17.6) | 40 942 (29.6) | 46 766 (27.3) | |
| Doctoral | 470 (1.4) | 5844 (4.2) | 6314 (3.7) | |
| Public health training | <.001 | |||
| No public health degree | 28 799 (87.2) | 107 903 (77.9) | 136 703 (79.7) | |
| Public health degree | 4238 (12.8) | 30 586 (22.1) | 34 824 (20.3) | |
| Clinical training | <.001 | |||
| No clinical training | 23 027 (69.3) | 109 156 (78.3) | 132 183 (76.5) | |
| Clinical training | 10 187 (30.7) | 30 309 (21.7) | 40 496 (23.5) |
Position information
Position information for the local public health workforce differed by rurality on all measures, aside from employee type (Table 3). The rural and urban workforce differed on tenure in current position, current agency, and public health practice (all P < .001). For example, 43% of the rural workforce reported the least (0-5 years) and 19.6% the greatest tenure (21 years or above) in public health practice compared to 40.9% and 17.8% of the urban workforce, respectively. Further, there were differences based on both supervisory and employment status. Approximately 9.1% of the rural workforce was part-time compared to 6.7% of the urban workforce, for example. Additionally, there were significant differences across primary program areas (P < .001, Figure 1). For example, in the rural workforce, 8.3% were working in assessment and surveillance activities, 6.3% in communicable disease control, and 24.8% in maternal, child, and family health services, compared to 13.2%, 10.1%, and 15.9% of the urban workforce, respectively.
TABLE 3.
Position Information for the Local Public Health Workforce by Rurality
| Rural, n (%) | Urban, n (%) | Total, n (%) | P Value | |
|---|---|---|---|---|
| Total | 33 214 (19.2) | 139 465 (80.8) | 172 679 (100.0) | |
| Tenure in current position, y | <.001 | |||
| 0-5 | 21 395 (65.3) | 93 793 (68.5) | 115 188 (67.9) | |
| 6-10 | 4842 (14.8) | 19 457 (14.2) | 24 299 (14.3) | |
| 11-15 | 2211 (6.8) | 8304 (6.1) | 10 515 (6.2) | |
| 16-20 | 1690 (5.2) | 6908 (5.0) | 8598 (5.1) | |
| 21 or above | 2602 (7.9) | 8424 (6.2) | 11 027 (6.5) | |
| Tenure in current agency, y | <.01 | |||
| 0-5 | 16 938 (52.6) | 73 299 (54.4) | 90 236 (54.1) | |
| 6-10 | 5203 (16.2) | 23 478 (17.4) | 28 681 (17.2) | |
| 11-15 | 3108 (9.7) | 11 815 (8.8) | 14 923 (8.9) | |
| 16-20 | 2724 (8.5) | 10 623 (7.9) | 13 347 (8.0) | |
| 21 or above | 4199 (13.1) | 15 484 (11.5) | 19 683 (11.8) | |
| Tenure in public health practice, y | <.001 | |||
| 0-5 | 13 811 (43.0) | 54 877 (40.9) | 68 688 (41.3) | |
| 6-10 | 5424 (16.9) | 25 738 (19.2) | 31 162 (18.8) | |
| 11-15 | 3557 (11.1) | 15 622 (11.7) | 19 179 (11.5) | |
| 16-20 | 3039 (9.5) | 14 013 (10.5) | 17 052 (10.3) | |
| 21 or above | 6291 (19.6) | 23 809 (17.8) | 30 100 (18.1) | |
| Supervisory status | <.001 | |||
| Non-supervisor | 24 376 (73.4) | 101 105 (72.5) | 125 481 (72.7) | |
| Supervisor | 5690 (17.1) | 22 672 (16.3) | 28 362 (16.4) | |
| Manager | 1894 (5.7) | 10 941 (7.8) | 12 835 (7.4) | |
| Executive | 1254 (3.8) | 4747 (3.4) | 6001 (3.5) | |
| Employee type | 1.0 | |||
| Contractor | 995 (3.0) | 4590 (3.3) | 5586 (3.2) | |
| Permanent staff | 31 153 (93.8) | 130 370 (93.5) | 161 523 (93.5) | |
| Temporary staff | 1065 (3.2) | 4505 (3.2) | 5570 (3.2) | |
| Full-time/part-time | <.001 | |||
| Part-time | 3025 (9.1) | 9372 (6.7) | 12 397 (7.2) | |
| Full-time | 30 188 (90.9) | 130 093 (93.3) | 160 282 (92.8) |
FIGURE 1.
Primary Program Area of the Local Public Health Workforce by Rurality. Figure displays self-reported primary program area by agency-level rurality.
Intentions to stay or leave
Intentions of the local public health workforce to stay, leave, or retire from their organization within 1 year differed significantly by rurality (P < .001), with 15.4% of the rural workforce reporting intentions to leave in the next year for reasons aside from retirement, compared to 21.6% of the urban workforce (Table 4). In comparison, 80.0% of the rural workforce are expected to stay in their organization within the next year, compared to 74.9% of the urban workforce.
TABLE 4.
Intentions to Stay or Leave Among the Local Public Health Workforce by Rurality
| Rural, n (%) | Urban, n (%) | Total, n (%) | P Value | |
|---|---|---|---|---|
| Total | 33 214 (19.2) | 139 465 (80.8) | 172 679 (100.0) | |
| Intentions to stay/leave | <.001 | |||
| Staying | 26 583 (80.0) | 104 516 (74.9) | 131 099 (75.9) | |
| Leaving in 1 y | 5129 (15.4) | 30 138 (21.6) | 35 267 (20.4) | |
| Retiring in 1 y | 1502 (4.5) | 4810 (3.4) | 6313 (3.7) |
Discussion
Local public health in rural settings differs from that in non-rural settings in terms of activities, funding, and infrastructure, including the workforce.6,11-13,23,24 This study uses the most recent data from PH WINS, capturing perspectives of the public health workforce within rural LHDs from across the United States. Similar to findings from the rural data collected in the 2021 PH WINS for All pilot and other evidence on the rural public health workforce,11,19 we estimate that approximately 19% of the public health workforce works in rural agencies and the rural workforce differs on nearly all demographic characteristics, education characteristics, position characteristics, and intentions to leave their current organization compared to the urban workforce. Importantly, employee type (contractor, permanent staff, or temporary staff) was the only characteristic considered that did not differ by rurality.
Rural/urban differences identified in this study highlight key challenges and strengths in this rural workforce, which could inform recruitment, retention, training, and other strategies aimed at addressing challenges and capitalizing on strengths of the rural workforce. While a focus on assets of rural communities has been increasingly common in recent years,25,26 there is limited work on assets of rural LHDs or rural public health. Identification of strengths in rural areas, in particular, may be useful for leveraging vital assets in rural areas to help support the unique needs and considerations in rural public health. While many of our findings echo previous evidence, this is the first nationally representative data of the rural workforce and provides baseline data without strong historical comparisons for reference.
First, we find differences in educational backgrounds among the rural and urban workforce, including that a greater portion of the rural workforce has clinical training but lower levels of formal public health training and overall levels of education. The greater clinical training generally aligns with the tendency of rural agencies to be more engaged in many direct clinical services.6-9,24 This clinical knowledge is not only valuable to their direct services but also brings an important lens toward population-based activities, including those related to Public Health 3.0, where public health agencies serve as the “chief health strategists,” working across sectors in their communities.5 Furthermore, as schools and programs of public health continue to expand, it is possible that the rates of formal public health training may change across LHDs, as these academic programs reach more into rural areas.27
Additionally, we find differences in the demographic characteristics of the rural and urban workforce. For example, greater portions of the rural workforce are women and White compared to the urban workforce. Previous studies have shown not only similar results (eg, a study using data from the 2021 PH WINS for All pilot)11 but also that rural-serving LHDs tend to be less representative of the populations that they serve in terms of race and ethnicity.12,13 The combination of a greater portion of the rural workforce that is White and the lower representation may reflect a potential area for investigation, as workforce representation and concurrence in the related field of health care and in the public sector are known to improve outcomes and build trust.28-32
Next, there are notable differences in tenure in current position, agency, and public health practice and intention to leave, which may inform the use of career ladders, recruitment, retention, and succession planning among LHDs. A greater portion of the rural workforce is at the beginning and at the end of their careers in public health compared to the urban workforce. Thus, understandably, a smaller portion of the rural workforce also described intentions to leave their organization in the next year, but a greater portion indicated intentions to retire in the next year, again echoing findings from the PH WINS for All pilot.11 It is possible that this reflects a strength of rural public health in supporting their workforce, highlighting a strength of rural LHDs; however, we are not able to causally assess what may be driving this difference. For example, it is possible that there are lower intentions to leave among the rural workforce because of factors such as greater job satisfaction or mentorship from seasoned public health staff, or because lack of other opportunities, but assessing causal reasons is beyond the scope of the current study. Further work in this area is needed to understand the rationale for staying or strategies for promoting retention that may be effective in rural settings in particular.
Lastly, we find that a sizeable portion of both the rural and urban local public health workforce is non-permanent or part-time workers. While there is no rural/urban difference in non-permanent workers, these findings quantify other key parts of the public health workforce that are also often overlooked. The use of non-permanent and part-time workers in both rural and urban settings may be a product of short-term funding, such as through the Public Health Infrastructure Grant (PHIG),33 of budget constraints, and of bureaucratic processes that can impact hiring processes. Like previous work describing unique characteristics and needs of the rural workforce,11 public health workers who are non-permanent or part-time may have different training needs, backgrounds, motivators, and career goals, which is important for informing training, recruitment, and retention efforts of both local agencies and academic and training programs. Continued recognition and understanding of the profound differences in composition and needs of the workforce across the country are key to tailoring approaches to effectively support the local workforce.
Limitations
Although this study provides the first characterization of the rural local public health workforce on a national level, some limitations should be noted. Given its cross-sectional design, this study is unable to estimate causality or determine the potential meaning of observed differences between the urban and rural local public health workforce. While PH WINS is designed to generate nationally representative data, the 2024 iteration achieved an overall response rate of 37%.20 Next, given the large sample sizes, there are instances where there are statistically significant differences that may not be practically meaningful (eg, nominal percentage point differences in supervisory status). Lastly, this study also uses a binary indicator of rurality, which may mask variation that exists across the rural/urban continuum. Furthermore, different measures of agency-level rurality have been used in the past, so this particular definition may not align with all other studies considering rurality. Notwithstanding limitations, this study provides a foundation for understanding key characteristics of the rural local public health workforce.
Implications for Policy & Practice
Recruitment, retention, training, and other strategies aimed at strengthening the rural local public health workforce should consider the marked differences between rural and urban public health workforce characteristics.
Trends in tenure in public health practice and intentions to stay and leave among the rural local public health workforce could highlight strengths and opportunities within rural-serving LHDs.
Having a large portion of the rural workforce at the end of their careers may offer deep expertise and institutional knowledge, and underscore the importance of career ladders, succession planning, and related strategic planning efforts in rural-serving LHDs.
Non-permanent and part-time workers represent an important but understudied part of the overall local public health workforce, as they may differ from their permanent and full-time peers in terms of recruitment, retention, and training needs.
Conclusion
This study is the first to examine demographic characteristics, educational background, position information, and intentions to stay or leave among the rural and urban local public health workforce using the 2024 PH WINS. We identify key differences in many of these areas that reflect strengths and potential opportunities to support the rural workforce. Findings may inform strategies tailored to the rural workforce, such as those related to training, recruitment, retention, and succession planning.
Footnotes
PH WINS was developed by the de Beaumont Foundation and the Association of State and Territorial Health Officials to understand the interests and needs of the state, local, and territorial government public health workforce in the United States and was fielded in 2014, 2017, 2021, and 2024. For more information, visit phwins.org.
Human participant compliance statement: The requirement of ethical approval for PH WINS 2024 was waived by the WCG Institutional Review Board (Western-Copernicus Group IRB) for studies involving humans.
This work is supported by funds made available from the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS), National Center for STLT Public Health Infrastructure and Workforce, through OE22-2203: Strengthening U.S. Public Health Infrastructure, Workforce, and Data Systems grant. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.
The authors declare that they have no conflicts of interest.
This study was deemed non-human subjects research from the Institutional Review Board at East Tennessee State University on April 8, 2025.
Contributor Information
Casey P. Balio, Email: balioc@etsu.edu.
Stephanie M. Mathis, Email: MATHISS@mail.etsu.edu.
Michael B. Meit, Email: meitmb@etsu.edu.
Betty Bekemeier, Email: bettybek@uw.edu.
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