Burnout, Belonging, and Mental Well-Being: Predictors of Turnover Intent Among Local Public Health Professionals

Abstract

We analyzed a nationally representative sample of local public health professionals (LPHPs) from varying jurisdiction sizes across the United States who responded to the 2024 Public Health Workforce Interests and Needs Survey (PH WINS). Our goal was to explore experiences of burnout; perceived belonging within an agency; self-rated mental and emotional well-being; and intentions to leave an organization. Results showed that burnout was negatively associated with and perceived belonging within an agency was positively associated with ratings of mental and emotional health. Each of these 3 variables were associated with an intent to leave an organization in the next year. We discuss implications to—and recommendations for mitigating—attrition of the nation’s local public health workforce after the size of the LPHP workforce rebounded following over a decade of decline.

Introduction

The government public health infrastructure in the United States has been particularly strained by underfunding and understaffing for almost 2 decades.1 At the local level, the COVID-19 pandemic, as well as the associated harassment and political pressures, amplified this strain leading to burnout and reduced mental and emotional health (MEH) among local public health professionals (LPHPs), as well as increased intentions to leave their organizations.2-5 These forces have only intensified post-pandemic with increased turnover rates at local health departments (LHDs) and heightened risk among LPHPs to leave the public health sector altogether.6 As LHDs are often the frontline providers of essential services in their communities, LPHP turnover can erode institutional knowledge, disrupt continuity of programs, and reduce the capacity of LHDs to deliver timely interventions—having direct implications for population health outcomes.

Current funding reductions, future funding uncertainty, staffing reductions, and turnover amplify stressors on LHDs. To ensure a well-trained, fully staffed, healthy, and responsive local public health workforce, it is imperative to understand how staff responses to stress, such as self-reported burnout, reduced MEH, and lowered perceptions of inclusivity, are associated with intent to leave the workforce.

Burnout among public health staff has been a recognized and pressing issue in public health systems management for nearly a decade.7 The WHO recognizes burnout as a syndrome “resulting from chronic workplace stress that has not been successfully managed” characterized by emotional exhaustion, increased cynicism towards work, and reduced professional productivity.8,9 Burnout is associated with negative impacts for employees, employers, the broader field of public health, and communities nationwide. When sustained over a long period of time, burnout has strong medical consequences for individuals ranging from depression to heart disease.10,11 Evidence from the 2021 Public Health Workforce Interests and Needs Survey (PH WINS) data shows that burnout was particularly high among public health staff during the pandemic, as indicated by the proportion of staff members reporting feelings of overwhelm, undervaluation, and emotional fatigue.5,6 The syndrome is associated with increased turnover, intent to leave a public health job, or the field of public health.6,12 For the broader field, burnout is a known threat to productivity—a driver of turnover.13 For communities, burnout—and thus, attrition—is a known threat to health and safety.

Prolonged stress, serial emergency responses, political scrutiny, burnout, and harassment may contribute to the mental well-being of the LHD workforce. During the pandemic and in its aftermath, symptoms of depression (30.8%), anxiety (30.3%), posttraumatic stress disorder (36.8%), and self-reported suicidal ideation (8.4%) were common among the governmental public health workforce over a 2-week period.14 Although these symptoms abated somewhat among LPHPs after the end of the pandemic, they remained elevated.15 Prolonged reduction in MEH presents a variety of challenges to the public health system; mental health conditions and burnout are associated with increased intent to leave a public health position, poor performance, and absenteeism.16

Perceptions of belonging within an organization provide both a potential predictor of workforce health and a buffer against workforce loss. Workplaces that foster a sense of belonging are perceived as more desirable by candidates, which can improve both recruitment and retention.17 There is indication from recent research that feelings of belonging in the workplace are strongly related to job satisfaction, which is in turn related to retention.18 Just as importantly, belonging is seen as both a driver of retention and worker well-being as well as a malleable factor for intervention.19

While the above factors are known to influence a variety of outcomes, little is known about the interplay of these factors on intent to leave among LPHPs. More importantly, understanding the association of these factors with specific avenues of leaving the local public health workforce may help the field better understand where specific changes can be employed to increase retention. The following study uses data from the 2024 Public Health Workforce Interest and Needs Survey (PH WINS) to explore (1) the association between self-reported burnout and perceived belonging with MEH; (2) the association between self-reported burnout, perceived belonging, and MEH with an intention to leave an organization; (3) whether self-reported burnout, perceived belonging, and MEH predict specific intentions related to leaving the workforce (eg, retiring, leaving public health, and leaving an organization for another position within public health)—individually and while controlling for one another; and (4) among those intending to leave an organization in the next year, whether levels of burnout, perceived belonging, and MEH are predictors of an intention to leave an organization.

Methods

Respondents and instrument

We examined data specifically on LPHPs from PH WINS 2024. PH WINS was distributed online to 159 627 members of the state and local government public health workforce from 48 state health agencies and 1178 LHDs of different sizes in 48 states between September 2024 and January 2025. The 2024 iteration of PH WINS included 219 large LHDs (staff size >25 and serving a population of >250 000), 424 medium LHDs (staff size >25 and serving a population of 25 000-250 000), and 535 small LHDs (staff size <25 or serving a population of <25 000). While the full sample responses included 56 595 individuals with a response rate of 37%, our study specifically focuses on individuals who worked at local (rather than state) agencies and includes 38 429 individuals from 1178 LHDs who answered at least 1 item of interest from our research questions. The 2024 survey included items on workplace environment and well-being, training needs, addressing public health issues, and workforce demographics. Full methods of the 2024 PH WINS are described elsewhere in this issue.

For our study, we examined 5 items from the 2024 survey: symptoms of burnout in response to “how would you describe your current level of burnout?” following a definition that included physical, mental, and behavioral symptoms; perceived belonging within an agency via agreement with the statement “I feel a sense of belonging at my agency”; self-reported rating of MEH (“In general, how would you rate your mental or emotional health?”); and intent-to-leave in response to “Are you considering leaving your organization within the next year?” with the follow-up question, “If so, what are you planning to do?” The first 3 items were measured on scales with text-descriptions of each item.

Sampling, weighting, and statistical analysis

This sample of LPHPs within LHDs was stratified by Health and Human Services region (10 regions) and jurisdiction population size (≤250 000 or >250 000). PH WINS 2024 data were weighted using national balanced repeated replication weights to adjust variance for the sampling design as well as non-response. We performed a logistic regression with burnout and perceived belonging as an independent variable and MEH as a dichotomous dependent variable to assess the role of those variables in MEH. Then, we performed a logistic regression with burnout, perceived belonging within an agency, and MEH as predictor of a dichotomous intent-to-leave. Finally, we ran a multinomial logistic regression with burnout, perceived belonging, and MEH as independent variables and intent to leave one’s job as a multi-categorical dependent variable, with “no intention to leave” as the reference group to assess the role of those independent variables in intent to leave. Each of these analyses was a multiple logistic or a multinomial logistic regression, so predictors were assessed while controlling for the other independent variables in the model.*

Results

Among all LPHP respondents, about 7 in 10 (70.9%) reported having 1 or more symptoms of burnout (51.7% reported they come and go away, 15.4% reported they won’t go away, and 3.7% reported they were completely burnt out and symptoms wouldn’t go away). Over 1 in 6 (18.4%) disagreed or strongly disagreed with the statement “I feel a sense of belonging at my agency” (14.5% and 3.9%, respectively). Over 1 in 6 LPHPs also reported negative MEH (2.7% rated their mental or emotional well-being as “poor,” 14.5% as “fair,” 34.2% as “good,” 34.4% as “very good,” and 14.3% as “excellent”). Finally, among all LPHP respondents, almost 1 in 4 (24.0%) reported they are considering leaving their LHD within the next year. Among those who reported that they were considering leaving their organization, 9.6% planned to leave for another public health job, 8.7% for a nonpublic health job, 3.7% to retire, 1.3% to pursue further education, and 0.7% to leave the workforce (see Table 1).

TABLE 1.

Burnout, Perceived Belonging Within an Agency, Mental/Emotional Well-Being, and Intent to Leave the Workforce Among Local Public Health Professionals

		95% CI
Measure	Percent (%)	Lower (%)	Upper (%)
Burnout (n = 38 412)
No symptoms of burnout	29.1	28.5	30.0
One or more symptoms of burnout that come and go away	51.7	51.1	52.4
One or more symptoms of burnout that won’t go away	15.4	14.9	16.0
Completely burnt out, symptoms won’t go away	3.7	3.4	4.0
Perceived belonging within an agency (n = 38 286)
Strongly agree	27.1	26.6	27.7
Agree	54.5	53.8	55.1
Disagree	14.5	14.0	15.1
Strongly disagree	3.9	3.7	4.1
Mental/emotional well-being (n = 38 429)
Positive	82.9	82.4	83.4
Excellent	14.2	13.8	14.6
Very good	34.4	33.8	35.0
Good	34.2	33.4	35.1
Negative	17.1	16.6	17.6
Fair	14.5	13.9	15.0
Poor	2.7	2.5	2.8
Intent to leave the workforce (n = 38 411)
No intent to leave the workforce	76.0	75.5	76.5
To retire	3.7	3.4	3.9
To pursue further education	1.3	1.2	1.5
To leave the workforce	0.7	0.6	0.8
To take another job in public health	9.6	9.2	10.0
To take another job not in public health	8.7	8.3	9.2

Question text for measures: “How would you describe your level of burnout [based on a provided definition],” “Please rate your level of agreement with…I feel a sense of belonging at my agency,” “In general, how would you rate your mental or emotional health,” and “Are you considering leaving your organization within the next year?” coupled with the follow-up question “If yes, what are you planning to do?”

Burnout, perceived belonging within an agency, and mental/emotional well-being

For the initial analysis, MEH was categorized into binary responses as “negative” and “positive” by combining “poor” and “fair” into a “negative” category, and “good,” “very good,” and “excellent” into a “positive” category. A logistic regression model was run (see Supplemental Digital Content Technical Appendix, available at http://links.lww.com/JPHMP/B595) to predict reported MEH based on burnout and agreement with feeling a sense of belonging at their agency. The logistic regression showed that burnout was significantly associated with MEH. As endorsement with the burnout scale increased, LPHPs had significantly lower odds of reporting positive MEH (OR = 0.22; 95% CI, 0.21-0.23). Odds of an LPHP reporting positive well-being decreased by 78% for every unit increase on the burnout scale, while controlling for perceived belonging. Perceived belonging within an agency was positively associated with MEH, and LPHPs had significantly higher odds of reporting positive MEH (OR = 1.58; 95% CI, 1.51-1.66). Odds of an LPHP reporting positive well-being increased by 58.2% for each unit increase of agreement with a sense of belonging within their agency, while controlling for burnout.

Burnout, perceived belonging within an agency, and mental/emotional well-being as predictors of intentions to leave an organization (binary logistic regression)

Second, we conducted a logistic regression model to predict an intention to leave an organization in the next year (yes/no) based on burnout, perceived belonging within an agency, and MEH. The logistic regression showed that burnout was positively associated with intending to leave an organization; with increasing severity of self-reported burnout, odds of intending to leave increased (OR = 2.14, 95% CI, 2.06-2.22). Odds of an LPHP intending to leave their organization increased more than 2-fold for each unit increase in the severity of burnout, while controlling for MEH and perceived belonging.

Perceived belonging within an agency was also associated with intending to leave an organization. LPHPs had significantly lower odds of intending to leave (OR = 0.44; 95% CI, 0.42-0.46) the more they perceived belonging. Odds of an LPHP intending to leave their organization decreased by 56.2% for each unit increase of agreement with a sense of belonging within their agency, while controlling for burnout and MEH.

MEH was associated with intentions to leave an organization as well; LPHPs with positive MEH had significantly lower odds of reporting an intention to leave their organization (OR = 0.78; 95% CI, 0.74-0.84). Odds of an LPHP reporting an intention to leave their organization in the next year decreased by 21.3% for those reporting positive MEH, while controlling for burnout and perceived belonging.

Burnout, perceived belonging within an agency, and mental/emotional well-being as predictors of intentions to leave an organization for other opportunities (multinomial logistic regression)

Last, a multinomial logistic regression model was run to predict the relative risk of intentions to leave an LHD for specific other opportunities based on the same 3 variables. Results showed that burnout was significantly associated with intent to leave the LHD for a variety of reasons (Table 2). As severity of burnout increased, LPHPs had higher relative risk of intending to take another public health job (relative risk ratio [RRR] = 2.22; 95% CI, 2.09-2.37), to take a nonpublic health job (RRR = 2.43; 95% CI, 2.25-2.62), to leave the workforce (RRR = 2.64; 95% CI, 1.86-3.75), to pursue further education (RRR = 1.86; 95% CI, 1.52-2.27), or to retire (RRR = 1.34; 95% CI, 1.19-1.50). These relationships were significant while controlling for perceived belonging and MEH.

TABLE 2.

Intentions to Leave an Organization, Predicted by Mental/Emotional Health (MEH), Burnout, and Perceived Belonging Within an Agency (N = 38 164)

		95% CI
Intention (reference = no intention to leave; 76.0%)	RRR	Lower	Upper	P
To retire (3.7%)
Positive MEH	1.37	1.12	1.67	<.01
Burnout	1.34	1.19	1.50	<.001
Perceived belonging within agency	0.74	0.66	0.83	<.001
To pursue further education (1.3%)
Positive MEH	0.62	0.46	0.83	<.01
Burnout	1.86	1.52	2.27	<.001
Perceived belonging within agency	0.54	0.46	0.63	<.001
To leave the workforce (0.7%)
Positive MEH	0.70	0.49	0.997a	.048
Burnout	2.64	1.86	3.75	<.001
Perceived belonging within agency	0.46	0.39	0.60	<.001
Intent to leave for another public health job (9.6%)
Positive MEH	0.74	0.67	0.83	<.001
Burnout	2.22	2.09	2.37	<.001
Perceived belonging within agency	0.43	0.40	0.45	<.001
Intent to leave for a nonpublic health job (8.7%)
Positive MEH	0.76	0.64	0.91	<.01
Burnout	2.43	2.25	2.62	<.001
Perceived belonging within agency	0.36	0.27	0.58	<.001

“RRR” is the relative risk ratio. Descriptive statistics are displayed in the left column to indicate the weighted proportion of the sample that indicated a particular intention related to leaving the workforce in the next year.

^aThree decimal points were presented to clarify that the null was rejected, including via CI.

Perceived belonging within an agency was also a significant predictor of intention not to leave for other opportunities while controlling for burnout and MEH. As agreement with perceived belonging within an agency increased, LPHPs had lower relative risk of intending to take another public health job (RRR = 0.43; 95% CI, 0.40-0.45), to take a nonpublic health job (RRR = 0.36; 95% CI, 0.27-0.58), to leave the workforce (RRR = 0.46; 95% CI, 0.39-0.60), to pursue further education (RRR = 0.54; 95% CI, 0.46-0.63), or to retire (RRR = 0.74; 95% CI, 0.66-0.83).

Like perceived belonging, MEH significantly predicted some, but not all, intention not to leave an organization for other opportunities while controlling for burnout and perceived belonging. Positive MEH was associated with lower relative risk of intending to take another public health job (RRR = 0.74; 95% CI, 0.67-0.83), to take a nonpublic health job (RRR = 0.76; 95% CI, 0.64-0.91), to leave the workforce (RRR = 0.70; 95% CI, 0.49-0.997), to pursue further education (RRR = 0.62; 95% CI, 0.46-0.83, or to retire (RRR = 1.37; 95% CI, 1.12-1.67). Of note, positive MEH was positively associated with intentions to retire versus stay, in contrast with the perceived belonging.

Discussion

Our findings show that over 7 in 10 LHD staff exhibited 1 or more symptoms of burnout, more than 1 in 6 did not perceive a sense of belonging at their agency, and more than 1 in 6 reported negative MEH. Furthermore, burnout and a sense of not belonging at an agency were associated with poorer MEH, and all 3 of these constructs predicted intention to leave an organization while controlling for one another: burnout was associated with higher risk of intending to leave the organization or the workforce, and perceived belonging as well as positive MEH (in most cases) were associated with lower risk of intending to leave an organization. In addition to previously studied phenomena including harassment,3 these variables are important predictors of potential workforce attrition.

Adding to a growing body of literature of mental and emotional well-being as critical determinants of workforce retention, this study reinforces the urgent need to address burnout, perceived belonging, and MEH within the local public health workforce. In 2021, more than 40% of public health employees who were considering leaving cited burnout as their reason.5 Furthermore, a 2023 systematic review found that studies of US and international public health professionals typically showed a burnout prevalence of greater than 50%.7 With over 70% of LPHPs reporting symptoms in 2024, burnout continues to be prevalent among the public health workforce, even after the COVID-19 pandemic.

Our results show that burnout was significantly associated with poorer MEH and a higher risk of intending to leave one’s organization, and this mirrors findings from earlier studies that chronic burnout can lead to emotional exhaustion and workforce shortages across health occupations.11,20 Notably, the impact of burnout extended across various exit pathways; individuals reporting higher levels of burnout were more likely to report intentions to leave for jobs both inside and outside public health, to pursue education, to retire, or to exit the workforce altogether. These findings suggest that burnout is a threat to workforce continuity rather than just a short-term occupational health concern.

However, perceived belonging may be a key protective factor against leaving an organization. LPHPs who reported stronger agreement with a sense of belonging within their agency had significantly higher odds of reporting positive MEH and lower risk of intending to leave across nearly all exit pathways. These findings suggest that interventions aimed at fostering belonging could serve as retention-strengthening strategies. Similarly, individuals with positive MEH had lower odds of planning to leave their organization, particularly for another job or to pursue education. This echoes findings from a 2023 survey showing that psychological well-being is linked to workforce retention.21 Notably, MEH was positively associated with intentions to retire, suggesting that those with higher psychological well-being may be better positioned to act on planned career transitions, although factors such as greater financial security could be at play as well.

Our findings have practical implications for the local public health workforce as well as public health infrastructure and policy. First, they reinforce the need for interventions at the individual, agency, and system levels to reduce burnout. For example, mindfulness-based practices, peer coaching, and resilience curricula have been shown to help mitigate burnout among health care professionals, especially when initiatives addressed multiple levels of systems simultaneously.22-24,25 Second, the findings emphasize the importance of workplace belonging in improving retention. A growing evidence base demonstrates that fostering an organizational culture of belongingness—such as by cultivating psychological safety—can reduce turnover in medical settings.25-27 Strategies to cultivate a psychologically safe, and therefore inclusive, culture should prioritize open communication, strong leadership, and staff development, among other elements.28 Third, findings underscore that retention is not solely a compensation problem. Although improving pay in the public health field is critical, our results suggest that organizational culture is predictive of whether LPHPs choose to remain in their jobs. Lastly, it is important to acknowledge that LHDs need sustained technical, financial, and political support at both the state and federal levels to implement changes that prioritize workforce stability.

Limitations

Our study is not without limitations; data are self-reported and measured on subjective scales, and reported intention to leave an organization or the workforce may not result in actual workforce attrition. However, our analysis also only includes LPHPs who are still employed at an agency and chose to respond. Those who are experiencing severe burnout or MEH may choose not to take part in a survey given the toll they are already under. Next, while the survey does include a large national sample, and the analytical methods use weighting to provide nationally representative estimates, potential non-response bias should not be discounted. In addition, there may be unmeasured variables potentially contributing to poor MEH and intentions to leave such as preexisting mental-health status as well as external economic pressures such as inflation and job-market churn, and other unmeasured personal factors. Results were collected between September 2024 and January 2025, slightly before and after the election, but prior to the beginning of the current presidential administration. Finally, this analysis is based on 1-item measures preventing estimation of item reliability, and given the correlational nature of this study, causality cannot be inferred from the relationships in this analysis.

Future research should build on these findings by examining longitudinal outcomes, such as whether those expressing intentions to leave actually exit. It would also be valuable to disaggregate findings by size of the LHD, geographic region, rurality, and LPHP characteristics (eg, sociodemographic identity and occupation).

Conclusion

In conclusion, our study affirms that burnout, perceived belonging, and MEH are not merely individual challenges: they are organizational and systemic concerns with profound implications for the future of LHD practice. Public health systems that fail to mitigate burnout, foster a sense of belonging, and address poor MEH among its workers risk loss of institutional knowledge and diminished service capacity. Addressing these issues is not optional if the local public health workforce is to be resilient, responsive, and adequately staffed to meet current and future public health needs. Strengthening the LHD workforce ultimately serves the health of the communities they protect.

Implications for Policy & Practice

• Burnout and low perceived belonging within an agency are related to poorer mental and/or emotional health, and these are predictive of intentions to leave an organization or the workforce.

• Burnout and low perceived belonging within an agency may be early warning signals of a deteriorating workforce and strain on the broader public health system.

• Addressing burnout and fostering workplace belonging may be protective factors against poor mental well-being, as well as prevent workplace departures, among LPHPs.

• Retention initiatives should consider both individual stressors and organizational culture as interconnected, rather than isolated, components of workforce sustainability.