Abstract
Objective:
The purpose of this study is to examine whether differences in self-reported core competency skill gaps among U.S. governmental public health workers with and without a formal degree in public health have changed since the last assessment in 2017.
Design:
This cross-sectional study utilizes data from the 2021 Public Health Workforce Interests and Needs Survey (PH WINS). Bivariate relationships were analyzed by conducting chi-square tests of respondents’ supervisory level and reported skill gaps. Multivariate logistic regressions of reported skill gaps were performed holding gender, age, race/ethnicity, public health certificate attainment, role type, current employer, and tenure in public health practice constant.
Setting:
A nationally representative sample of U.S. government public health employees.
Participants:
36,752 U.S. governmental public health employees across local and state health agencies representing 47 states.
Main Outcome Measures:
Self-reported competency skills gaps.
Results:
In 2021, among both nonsupervisors and supervisors, having a formal public health degree (bachelors, masters, or doctorate) was significantly associated with reduced odds of reporting a skill gap across more than half of the competency skills assessed (14 of 23 skills and 17 of 24 skills, respectively). Nonsupervisors and supervisors with a formal public health degree had fewer skill gaps in 2021 than in 2017. Furthermore, whereas in 2017, when having a public health degree had no effect on executives reporting a skill gap, in 2021, having a public health degree was significantly associated with reduced odds of reporting 2 skill gaps.
Conclusions:
Overall, across all position levels (ie, nonsupervisory, supervisor, executive), public health workers with a public health degree experienced fewer competency skill gaps in 2021 than in 2017. These findings from PHWINS 2021 illustrate that formal public health education generally decreases competency gaps across numerous competency domains. However, the variability in reported gaps across supervisory levels shows the need for ongoing evaluation and adaptation of formal public health degree programs.
Keywords: government public health workforce, PH WINS, public health competencies, public health education, workforce development
A competent public health workforce, defined as having the ability to proficiently perform various job-related tasks, is an essential part of the public health infrastructure.1 The demands of public health are diverse and require competencies that allow the public health workforce to effectively carry out the wide array of tasks and meet changing demands.1–3 The COVID-19 pandemic underscored the importance of a public health workforce with the skills essential to their work.4 A 2022 study using qualitative data from local health department staff to examine public health workforce gaps in Minnesota found that capacity and capability gaps increased following the pandemic.5 Minnesota local health departments reported receiving applicants who lacked certifications, licenses, or qualifications and who were generally unskilled, untrained, or inexperienced.5 Given the challenges faced by the workforce during the COVID-19 public health crisis, the diverse needs of populations, and the growing demands of the profession, it is important to periodically assess whether public health workers are competent in the skillsets required of the profession and to work to fill competency gaps for workforce strengthening.
One mechanism to address competency gaps is to increase access to and uptake of formal public health education, something that has been promoted over the last 2 decades.6,7 As a result, the number of schools and programs for public health have increased nationally and the number of graduates of these programs has grown an average of 13% over the past 2 decades.8 However, the percentage of the public health workforce with any formal public health training (eg, a bachelor, master, or related public health degree) has remained fairly constant with only 18% of the public health workforce having any type of degree in public health in 2021 (compared to 15% in 2017).9–11 According to 2017 data, having a degree in public health was associated with lower odds of reporting skill gaps in all core competency areas except effective communication, budgeting and financial management, and change management domains.12 Due to the changes in the demands of public health since 2017, it is imperative to examine whether or not public health workforce competency gaps have changed. As agencies plan for future public health emergencies and the evolving role of public health, understanding the value of a formal public health degree as it relates to changing workforce competencies is of particular interest.
The purpose of this study is to examine whether differences in self-reported core competency gaps among U.S. governmental public health workers with and without a formal degree in public health (bachelors, masters, or doctorate) have changed since the last assessment in 2017. This study utilizes Public Health Workforce Interests and Needs (PH WINS) data collected in 2021 compared to the 2017 data. Findings summarize whether skill gaps have improved, remained the same, or worsened. Insights from this work will be valuable to institutions that train and employ public health workers, including state and local health departments, educational institutions that offer public health degrees, and policy-makers who wish to support and expand the public health workforce.
Methods
Data
PH WINS is a nationally representative survey of governmental public health workers in the US. Administered and supported by the de Beaumont Foundation and the Association of State and Territorial Health Officials (ASTHO), PH WINS is conducted every 3 to 4 years providing longitudinal information about the public health workforce since 2014. Detailed survey design and sampling methods have been previously described by Robins et al.13 The current study focuses on survey questions related to self-reported training needs among public health workers. Respondents were asked to rate the day-to-day importance of, and their proficiency with 23 to 24 public health skill items, designed for their supervisory level (eg, nonsupervisor, supervisor/manager, or executive). These skills cover 9 strategic skill domains that are considered critical to public health: effective communication; data-based decision-making; justice, equity, diversity, and inclusion (JEDI); budget and financial management; change management, systems and strategic thinking; community engagement; cross-sectoral partnerships; and policy engagement.
Inclusion/exclusion criteria
This study concentrated on full-time governmental public health workers whose job roles would require the use of public health core skills/competencies (eg, epidemiologist, community health worker, health educator, etc). Respondents who were part-time employees (n = 3464, 7.7%) and those who reported their job roles as “other” (n = 778, 1.7%), “custodial” (n = 49, 0.1%), “clerical” (n = 3564, 8.0%), or undefined (n = 125, 0.3%) were excluded from analyses.
Dependent variables
For each of the 23 to 24 public health skill items, respondents were asked to use a Likert scale to rate both their perception of the importance of the skill to their current position (“not important,” “somewhat unimportant,” “somewhat important,” or “very important”) and their perceived proficiency in that particular skill (“unable to perform,” “beginner,” “proficient,” “expert,” or “not applicable”). If the respondent perceived a skill to be “somewhat important” or “very important” to their current job and also reported they were “unable to perform” the skill or were at a “beginner” level of proficiency for that skill, this was considered a “skill gap” or competency gap. We created a binary indicator to identify public health worker’s skill gaps, similar to previously published methodology.12
Independent variables
The main explanatory variable of interest in this study was a binary indicator of whether or not the respondent had a formal public health degree (yes or no). Other independent variables of interest included supervisory status (nonsupervisory, supervisor/manager, or executive), a binary indicator of whether or not the individual had ever obtained a certificate in public health (yes or no), role classification (administrative, public health sciences, clinical and laboratory, and social sciences/other), current employer (local or state government), tenure in public health practice (0–5, 6–15, 16 or more years), female (yes or no), race/ethnicity (white, black/African American, Hispanic/Latino, or other), and age (35 years and younger, 36–45 years, 46–55 years, 56 years or older).
Analysis
Unweighted and weighted descriptive statistics were calculated for all respondents included in this study. Bivariate relationships were analyzed by conducting χ2 tests of public health workers’ self-reported skill gaps by respondents’ supervisory level. Next, we used multivariate logistic regression models to examine self-reported skill gaps controlling for public health certificate attainment, role type, current employer, tenure in public health practice, which have historically been controlled for when examining skill gaps.12 Additionally, we include gender, race/ethnicity, and age as control variables. We accounted for the complex sampling design of PHWINS by using the survey and balanced repeated replication weights provided by de Beaumont (see Robins et al PHWINS 2021 Methodology Report).13 Because of our study’s large number of comparisons, our α value of significance was adjusted according to the Bonferroni correction and set at .0167 for all bivariate and multivariate analyses. Findings were considered marginally significant if P values were between .05 and .0167. All data were analyzed using Stata, Version 18 (College Station, Texas). Finally, we present skill gaps reported in 2021 to those reported in 2017 in tabular format and compare statistically significant findings across survey waves.12
Results
Demographics
In 2021, 36,752 individuals responded to the 2021 iteration of PHWINS, representing approximately 155,361 public health government workers. Demographic characteristics of this sample are displayed in Table 1. Approximately 15% (n = 5,585) of respondents had a formal degree in public health. The majority of respondents were non-supervisors (n = 25,696; 69.9%), females (n = 27,875; 76.9%), white (n = 21,110; 59.0%), and did not hold a certificate in public health (n = 28,957; 96.7%). All age categories and tenure categories were represented equally. Table 2 displays bivariate analyses of demographic characteristics by supervisory status. An estimated 14% of nonsupervisors, 21% of supervisors/managers, and 30% of executives have formal public health degrees.
TABLE 1.
Unweighted and Weighted Descriptive Statistics Among Respondents to PHWINS
| 2017 | 2021 | |||
|---|---|---|---|---|
| Characteristic | N (%) | Weighted N (%) | N (%) | Weighted N (%) |
| Total | 30,276 | 122,813 | 36,752 | 155,361 |
| PH degree | ||||
| Yes | 24,799 (81.9) | 101,324 (82.5) | 5,585 (15.2) | 25,044 (16.1) |
| No | 5,477 (18.1) | 21,489 (17.5) | 31,167 (84.8) | 130,317 (83.9) |
| PH certificate | ||||
| Yes | 920 (4.0) | 3,660 (96.0) | 986 (3.3) | 986 (3.3) |
| No | 21,927 (96.0) | 90,865 (96.1) | 28,957 (96.7) | 121,939 (96.6) |
| Supervisory level | ||||
| Non-supervisor | 20,464 (67.9) | 82,215 (67.3) | 25,696 (69.9) | 107,852 (69.4) |
| Supervisory/manager | 8,754 (29.0) | 36,138 (29.6) | 10,074 (27.4) | 43,392 (27.9) |
| Executive | 924 (3.1) | 3,781 (3.1) | 982 (2.7) | 4,117 (2.7) |
| Role | ||||
| Administrative | 5,824 (19.2) | 21,626 (17.6) | 7,147 (19.6) | 30,226 (19.6) |
| Clinical and laboratory | 9,127 (30.1) | 38,057 (31.0) | 10,543 (29.0) | 44,008 (28.6) |
| Public health services | 12,888 (42.6) | 52,975 (43.1) | 17,748 (48.7) | 75,390 (49.0) |
| Social services | 2,437 (8.1) | 10,156 (8.3) | 986 (2.7) | 4,373 (2.8) |
| Current employer | ||||
| Local government | 7,811 (26.6) | 42,762 (36.6) | 13,086 (37.0) | 64,999 (43.6) |
| State government | 21,575 (73.4) | 74,209 (63.4) | 22,262 (63.0) | 84,081 (56.4) |
| Tenure in public health practice | ||||
| 0–5 years | 18,361 (43.6) | 73,053 (42.3) | 12,499 (35.6) | 52,143 (35.2) |
| 6–15 years | 13,144 (31.2) | 54,766 (31.7) | 11,522 (32.9) | 49,311 (33.3) |
| ≥16 years | 10, 580 (25.1) | 44,897 (26.0) | 11,051 (31.5) | 46,806 (31.6) |
| Gender | ||||
| Female | 33,547 (77.8) | 138,902 (78.4) | 27,875 (76.9) | 117,967 (76.9) |
| Male/other | 9,571 (22.2) | 38,349 (21.6) | 8,383 (23.1) | 35,436 (23.1) |
| Race/ethnicity | ||||
| White | 24,418 (57.4) | 102,672 (58.6) | 21,110 (59.0) | 82,631 (54.6) |
| Black/African American | 6,547 (15.4) | 27,762 (15.8) | 4,572 (12.8) | 22,109 (14.6) |
| Hispanic or LatinX | 6,345 (14.9) | 22,721 (13.0) | 5,843 (16.3) | 26,480 (17.5) |
| Other | 5,251 (12.3) | 22,103 (12.6) | 4,236 (11.9) | 20,007 (13.2) |
| Age | ||||
| ≤35 years | 6,157 (21.1) | 23,727 (20.1) | 8,618 (25.9) | 35,941 (25.5) |
| 36–45 years | 6,597 (23.7) | 26,761 (22.7) | 8,295 (24.9) | 35,857 (25.5) |
| 46–55 years | 8,086 (27.8) | 34,471 (29.2) | 8,435 (25.3) | 35,744 (25.4) |
| ≥56 years | 8,279 (28.4) | 32,955 (27.9) | 7,944 (23.9) | 33,224 (23.6) |
Source: Public Workforce Interests and Needs Survey, 2021.
Notes: Weighted using national survey weights provided by de Beaumont.
TABLE 2.
| Characteristic | Nonsupervisor (n = 87,315; 69.4%) N (%) | Supervisor/Manager (n = 35,479; 27.9%) N (%) | Executive (n = 3,426; 2.7%) N (%) | P |
|---|---|---|---|---|
| PH Degree | <.001* | |||
| Yes | 14,672 (13.6) | 9,151 (21.1) | 1,224 (29.7) | |
| No | 93,184 (87.2) | 34,238 (78.9) | 2,896 (70.3) | |
| PH certificate | .01* | |||
| Yes | 2,828 (3.2) | 1,243 (3.5) | 202 (5.9) | |
| No | 84,487 (96.8) | 34,236 (96.5) | 3,224 (94.1) | |
| Role | <.001* | |||
| Administrative | 21,282 (19.9) | 7,462 (17.3) | 1,483 (36.3) | |
| Clinical and laboratory | 33,574 (31.4) | 10,072 (23.4) | 360 (8.8) | |
| Public health services | 48,365 (45.3) | 24,787 (57.5) | 2,235 (54.8) | |
| Social services and other | 3,569 (3.3) | 796 (1.8) | 3 (0.1) | |
| Current employer | <.001* | |||
| Local government | 44,192 (42.9) | 18,633 (44.4) | 65,003 (43.0) | |
| State government | 58,857 (57.1) | 23,365 (55.6) | 84,079 (56.0) | |
| Tenure in public health practice | <.001* | |||
| 0–5 years | 43,232 (42.3) | 8,326 (19.8) | 590 (14.6) | |
| 6–15 years | 32,878 (32.2) | 15,278 (36.3) | 1,155 (28.6) | |
| ≥16 years | 25,997 (25.5) | 18,516 (44.0) | 2,292 (56.8) | |
| Gender | < .001* | |||
| Female | 82,786 (77.8) | 32,487 (75.6) | 2,695 (66.1) | |
| Male/other | 23,594 (22.2) | 10,460 (24.4) | 1,384 (33.9) | |
| Race/ethnicity | <.001* | |||
| White | 54,528 (52.0) | 25,432 (60.2) | 2,671 (66.5) | |
| Black/African American | 15,697 (15.0) | 6,018 (14.2) | 399 (9.9) | |
| Hispanic/Latino | 19,981 (19.0) | 5,985 (14.2) | 516 (12.8) | |
| Other | 14,743 (14.0) | 4,836 (11.4) | 430 (10.7) | |
| Age | <.001* | |||
| ≤35 years | 29,411 (30.2) | 6,295 (15.9) | 242 (6.4) | |
| 36–45 years | 23,586 (24.2) | 11,305 (28.6) | 966 (25.7) | |
| 46–55 years | 22,410 (23.0) | 12,011 (30.4) | 1,331 (35.5) | |
| ≥56 years | 22,086 (22.7) | 9,929 (25.1) | 1,214 (32.4) |
Differences by supervisory level were calculated using χ2 tests.
Public Health Workforce Interests and Needs Survey, 2021.
National survey and replication weights provided by de Beaumont.
Significance P ≤ .05.
Nonsupervisor multivariate analysis
Examining nonsupervisor respondents to PH WINS 2021, those with a formal degree in public health had significantly lower odds of reporting a competency gap for 14 of the 23 skills assessed (see Table 3). Specifically, nonsupervisors with a formal public health degree were significantly less likely to report any skill gap within the domains of data for decision making (P ≤ .001), community engagement (P ≤ .004), and policy engagement (P ≤ .01) than nonsupervisors without a public health degree. Nonsupervisors were also significantly less likely to report a gap within 4 other domains: justice, equity, diversity, and inclusion (JEDI) (n = 1 skill gap), budgeting and financial management (n = 2 skill gaps), systems and systems thinking (n = 2 skill gaps), and cross-sectoral partnerships (n = 1 skill gap). See Table 3 for skill-level details. Possessing a formal public health degree was found to significantly increase the odds of nonsupervisors reporting a gap in their ability to: “Communicate in a way that persuades others to act” (P < .001; Domain: effective communication) compared to nonsupervisors without a public health degree.
TABLE 3.
Multivariate Analysis of Reported Skill Gaps Among Nonsupervisor Level Respondents With/Without a PH Degree in 2017 and 2021a,b
| 2017 PHWins | 2021 PHWins | ||||||
|---|---|---|---|---|---|---|---|
| Focus Area—Skill Gap | AOR | CI | P Valuec | AOR | CI | P Valuec | Changef |
| Effective communication | |||||||
| Communicate in a way that different audiences can understand | 1.142 | 0.919–1.418 | .22 | 1.008 | 0.877–1.158 | .91 | |
| Communicate in a way that persuades others to act | 1.215 | 0.945–1.562 | .19 | 1.300 | 1.144–1.478 | <.001d | Newly significant |
| Data-based decision-making | |||||||
| Identify appropriate sources of data and information to assess the health of a community | 0.650 | 0.509–0.831 | .01d | 0.572 | 0.471–0.696 | <.001d | |
| Collect valid data for use in decision-making | 0.649 | 0.467–0.902 | .01d | 0.726 | 0.611–0.862 | <.001d | |
| Identify evidence-based approaches to address public health issues | 0.616 | 0.490–0.774 | <.001d | 0.482 | 0.427–0.544 | <.001d | |
| Justice, equity, diversity, and inclusion (JEDI) | |||||||
| Describe the value of a diverse public health workforce | 0.664 | 0.506–0.871 | <.01d | 0.768 | 0.685–0.861 | <.001d | |
| Support inclusion of health equity and social justice principles into planning for program and service delivery | 1.076 | 0.717–1.614 | .72 | 0.928 | 0.813–1.046 | .20 | |
| Deliver socially, culturally, and linguistically appropriate programs and customer service | 1.096 | 0.918–1.310 | .30 | 1.027 | 0.885–1.190 | .72 | |
| Budgeting and financial management | |||||||
| Describe financial analysis methods applicable to program and service delivery | 0.993 | 0.696–1.418 | .97 | 0.988 | 0.856–1.139 | .86 | |
| Describe how public health funding mechanisms support agency programs and services | 0.890 | 0.635–1.247 | .49 | 0.862 | 0.778–0.955 | <.01d | Newly significant |
| Describe the value of an agency business plan | 0.881 | 0.650–1.195 | .41 | 0.850 | 0.726–0.996 | .04e | Newly significant |
| Change management | |||||||
| Describe the influence of internal changes on organizational practices | 0.863 | 0.694–1.073 | .18 | 0.939 | 0.846–1.042 | .23 | |
| Assess the external drivers in your environment that may influence your work | 0.984 | 0.806–1.201 | .87 | 0.886 | 0.775–1.013 | .08 | |
| Systems and strategic thinking | |||||||
| Describe how social determinants of health impact the health of individuals, families, and the overall community | 0.555 | 0.437–0.704 | <.001d | 0.486 | 0.407–0.579 | <.001d | |
| Participate in quality improvement processes | 0.976 | 0.736–1.294 | .86 | 0.963 | 0.848–1.095 | .56 | |
| Describe your agency’s strategic priorities, mission, and vision | 0.786 | 0.574–1.076 | .13 | 0.834 | 0.732–0.950 | <.01d | Newly significant |
| Community engagement | |||||||
| Describe the value of community strategic planning that results in a community health assessment or community health improvement plan | 0.917 | 0.621–1.355 | .66 | 0.696 | 0.595–0.814 | <.001d | Newly significant |
| Describe the importance of engaging community members in the design and implementation of programs to improve health in a community | 0.709 | 0.547–0.920 | .011d | 0.730 | 0.648–0.822 | <.001d | |
| Describe your role in improving the health of the community served by the agency | 0.842 | 0.645–1.101 | .2 | 0.788 | 0.676–0.918 | <.01d | Newly significant |
| Cross-sectoral partnerships | |||||||
| Engage community assets and resources to improve health in a community | 0.708 | 0.565–0.888 | <.01d | 0.928 | 0.817–1.053 | .24 | No longer significant |
| Collaborate with public health personnel across the agency to improve the health of the community | 0.595 | 0.439–0.807 | .001d | 0.678 | 0.581–0.790 | <.001d | |
| Policy engagement | |||||||
| Describe the relationship between a policy and many types of public health problems | N/A | N/A | N/A | 0.717 | 0.640–0.802 | <.001d | |
| Collect and summarize information to inform the development of policies external to the organization that affect the health of the community | N/A | N/A | N/A | 0.786 | 0.679–0.910 | <.01d | |
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
Data source: Public Workforce Interests and Needs Survey, 2021. National survey and replication weights provided by de Beaumont.
Results are individual logistic regressions for each skill gap, holding constant gender, race/ethnicity, age, education level, employer, role type, tenure in public health practice, and public health certificate attainment.
Bonferroni correction adjustment (significance level set at P ≤ .0167).
Significance P ≤ .0167.
Marginal Significance P ≤ .05.
Change in significance results between 2017 and 2021 PHWins Surveys.
Comparing respondents from 2021 to 2017, nonsupervisors with a formal public health degree in 2021 were less likely to report gaps in 6 skill areas that were not reported by those in 2017. More specifically, nonsupervisors with a formal public health degree in 2021 were significantly less likely to report skill gaps in the budgeting and financial management domain (n = 2 skill gaps), the community engagement domain (n = 2 skill gaps), the effective communication domain (n = 1 skill gap), and the systems and strategic thinking domain (n = 1 skill gap). See Table 3 for skill-level details. In 1 of the 23 skills assessed, nonsupervisors with a formal public health degree in 2021 were no longer less likely to report a skill gap in being able to engage: “community assets and resources to improve health in a community” (Domain: cross-sectoral partnerships) as was the case for respondents in 2017 when compared to their counterparts without a formal public health degree.
Supervisor/manager multivariate analysis
Examining supervisor/manager respondents to PH WINS 2021, those with a formal degree in public health had significantly lower odds of reporting a competency gap for 17 of the 24 skills assessed (see Table 4). Specifically, supervisors/managers with a formal public health degree were significantly less likely to report any skill gap within the domains of data for decision making (P ≤ .001), change management (P ≤ .01), community engagement (P ≤ .01), cross-sectoral partnerships (P ≤ .01), and policy engagement (P ≤ .3) than supervisors/managers without a public health degree. Supervisors/managers were also significantly less likely to report a gap within 3 other domains: justice, equity, diversity, and inclusion (JEDI) (n = 1 skill gap), budgeting and financial management (n = 1 skill gap), and systems and systems thinking (n = 3 skill gaps). Possessing a formal public health degree was not found to increase the odds of reporting any skill gap at the supervisor/manager level. See Table 4 for skill-level details.
TABLE 4.
Multivariate Analysis of Reported Skill Gaps Among Supervisor/Manager Level Respondents With/Without a PH Degreea,b
| 2017 PHWins | 2021 PHWins | ||||||
|---|---|---|---|---|---|---|---|
| Focus Area—Skill Gap | AOR | CI | P Valuec | AOR | CI | P Valuec | Changef |
| Effective communication | |||||||
| Communicate in a way that different audiences can understand | 0.954 | 0.725–1.254 | .73 | 0.989 | 0.743–1.316 | .94 | |
| Communicate in a way that persuades others to act | 1.144 | 0.769–1.700 | .50 | 0.868 | 0.703–1.071 | .18 | |
| Data-based decision-making | |||||||
| Identify appropriate sources of data and information to assess the health of a community | 0.582 | 0.408–0.830 | <.01d | 0.333 | 0.247–0.449 | <.001d | |
| Use valid data to drive decision making | 0.571 | 0.375–0.869 | .01d | 0.421 | 0.279–0.636 | .001d | |
| Apply evidence-based approaches to address public health issues | 0.632 | 0.409–0.978 | .04e | 0.398 | 0.281–0.556 | <.001d | |
| Justice, equity, diversity, and inclusion (JEDI) | |||||||
| Support development of a diverse public health workforce | 0.912 | 0.692–1.203 | .51 | 1.009 | 0.873–1.167 | .90 | |
| Incorporate health equity and social justice principles into planning for programs and services | 0.938 | 0.734–1.198 | .60 | 0.784 | 0.667–0.920 | <.01d | Newly significant |
| Implement socially, culturally, and linguistically appropriate policies, programs, and services that reflect the diversity of individuals and populations in a community | 0.851 | 0.679–1.068 | .16 | 0.884 | 0.724–1.079 | .20 | |
| Budgeting and financial management | |||||||
| Use financial analysis methods in managing programs and services | 1.038 | 0.831–1.296 | .74 | 0.990 | 0.875–1.120 | .88 | |
| Identify funding mechanisms and procedures to develop sustainable funding models for programs and services | 0.834 | 0.689–1.010 | .06 | 0.813 | 0.695–0.953 | .01d | Newly significant |
| Implement a business plan for agency programs and services | 1.031 | 0.788–1.348 | .82 | 0.897 | 0.773–1.041 | .15 | |
| Change management | |||||||
| Modify programmatic practices in consideration of internal and external changes | 0.884 | 0.617–1.266 | .49 | 0.587 | 0.473–0.728 | <.001d | Newly significant |
| Assess the drivers of your environment that may influence public health programs and services | 0.906 | 0.734–1.118 | .35 | 0.729 | 0.608–0.875 | <.01d | Newly significant |
| Systems and strategic thinking | |||||||
| Integrate current and projected trends into strategic planning for programs and services | 0.756 | 0.605–0.944 | .015d | 0.772 | 0.608–0.979 | .03e | |
| Build cross-sector partnerships to address social determinants of health | 0.749 | 0.591–0.948 | .018e | 0.619 | 0.529–0.725 | <.001d | |
| Apply quality improvement processes to improve agency programs and services | 0.915 | 0.730–1.147 | .43 | 0.870 | 0.714–1.062 | .17 | |
| Implement an organizational strategic plan | 0.671 | 0.476–0.948 | .03e | 0.673 | 0.565–0.800 | <.001d | |
| Community engagement | |||||||
| Apply findings from a community health assessment or community health improvement plan to agency programs and services | 0.808 | 0.611–1.070 | .13 | 0.404 | 0.320–0.509 | <.001d | Newly significant |
| Engage community members in the design and implementation of programs to improve health in a community | 0.740 | 0.562–0.975 | .03e | 0.746 | 0.606–0.918 | <.01d | |
| Assess how agency policies, programs, and services advance population health | 0.946 | 0.763–1.173 | .6 | 0.533 | 0.439–0.647 | <.001d | Newly significant |
| Cross-sectoral partnerships | |||||||
| Identify and engage assets and resources that can be used to improve health in a community | 0.746 | 0.586–0.951 | .019 | 0.710 | 0.580–0.869 | <.01d | |
| Engage in collaboration within the public health system, including traditional and nontraditional partners to improve the health of a community | 0.926 | 0.775–1.106 | .39 | 0.613 | 0.514–0.732 | <.001d | Newly significant |
| Policy engagement | |||||||
| Examine the feasibility of a policy and its relationship to many types of public health problems | N/A | N/A | N/A | 0.723 | 0.599–0.872 | <.01d | |
| Identify and assess options for policies external to the organization that affect the health of the community | N/A | N/A | N/A | 0.794 | 0.650–0.971 | .03e | |
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
Data source: Public Workforce Interests and Needs Survey, 2021. National survey and replication weights provided by de Beaumont.
Results are individual logistic regressions for each skill gap, holding constant gender, race/ethnicity, age, education level, employer, role type, tenure in public health practice, and public health certificate attainment.
Bonferroni correction adjustment (significance level set at P ≤ .0167).
Significance P ≤ .0167.
Marginal Significance P ≤ .05.
Change in significance results between 2017 and 2021 PHWins Surveys.
Comparing respondents from 2021 to 2017, supervisors/managers with a formal public health degree in 2021 were less likely to report gaps in 7 skill areas than those in 2017. As of 2021, supervisors/managers with a formal public health degree were significantly less likely to report skill gaps in the justice, equity, diversity, and inclusion (JEDI) domain (n = 1 skill gap), the budgeting and financial management domain (n = 1 skill gap), the change management domain (n = 2 skill gaps), the community engagement domain (n = 2 skill gaps), and the cross-sectoral partnerships domain (n = 1 skill gap). See Table 4 for skill-level details.
Executive multivariate analysis
Among executive respondents to PH WINS 2021, the vast majority of skills assessed did not have significant differences in competency gaps between those with and without a formal public health degree. More specifically, executives with a formal degree in public health only had significantly lower odds of reporting a competency gap for 2 of the 24 skills assessed (see Table 5). Specifically, executives with a formal public health degree were significantly less likely to report a gap in incorporating: “Health equity and social justice principles into across the agency” (P = .04; Domain: justice, equity, diversity, and inclusion (JEDI)); and using: “Financial analysis methods in making decisions about programs and services across the agency” (P < .01; Domain: budgeting and financial management) than executives without a public health degree. Possessing a formal public health degree was found to significantly increase the odds of executives reporting a skill gap in their ability to: “Communicate in a way that persuades others to act” (P = .02; Domain: effective communication) than executives without a public health degree.
TABLE 5.
Multivariate Analysis of Reported Skill Gaps Among Executive Level Respondents With/Without a PH Degreea,b
| Focus Area—Skill Gap | 2017 PHWins | 2021 PHWins | Changef | ||||
|---|---|---|---|---|---|---|---|
| AOR | CI | P Valuec | AOR | CI | P Valuec | ||
| Effective communication | |||||||
| Communicate in a way that different audiences can understand | 0.995 | 0.265–3.740 | .99 | 1.186 | 0.398–3.531 | .74 | |
| Communicate in a way that persuades others to act | 3.962 | 1.039–15.106 | .04e | 2.615 | 1.202–5.688 | .02e | |
| Data-based decision-making | |||||||
| Ensure the use of appropriate sources of data and information to assess the health of a community | 1.087 | 0.404–2.927 | .87 | 0.388 | 0.080–1.880 | .23 | |
| Use valid data to drive decision making | 1.087 | 0.404–2.927 | .87 | 0.597 | 0.120–2.971 | .51 | |
| Ensure the application of evidence-based approaches to address public health issues | 0.696 | 0.214–2.267 | .54 | 0.304 | 0.076–1.208 | .09 | |
| Justice, equity, diversity, and inclusion (JEDI) | |||||||
| Develop a diverse public health workforce | 0.780 | 0.364–1.711 | .54 | 1.015 | 0.505–2.042 | .96 | |
| Incorporate health equity and social justice principles into across the agency | 1.243 | 0.715–2.161 | .43 | 0.612 | 0.383–0.977 | .04e | Newly significant |
| Ensure the implementation of socially, culturally, and linguistically appropriate policies, programs, and services that reflect the diversity of individuals and populations in a community | 0.893 | 0.380–2.100 | .79 | 1.341 | 0.675–2.663 | .39 | |
| Budgeting and financial management | |||||||
| Use financial analysis methods in making decisions about programs and services across the agency | 1.593 | 0.951–2.667 | .08 | 1.858 | 1.158–2.980 | <.01d | Newly significant |
| Leverage funding mechanisms and procedures to develop sustainable funding models for the agency | 0.639 | 0.351–1.163 | .14 | 1.248 | 0.527–2.956 | .61 | |
| Design a business plan for the agency | 1.046 | 0.546–2.003 | .89 | 1.286 | 0.818–2.021 | .27 | |
| Change management | |||||||
| Manage organizational change in response to evolving internal and external circumstances | 1.018 | 0.471–2.204 | .96 | 1.545 | 0.917–2.602 | .10 | |
| Assess the drivers of your environment that may influence public health programs and services across the agency | 0.742 | 0.389–1.415 | .36 | 0.828 | 0.487–1.410 | .48 | |
| Systems and strategic thinking | |||||||
| Integrate current and projected trends into organizational strategic planning | 0.717 | 0.351–1.463 | .35 | 1.166 | 0.663–2.050 | .59 | |
| Influence policies external to the organization that address social determinants of health | 1.177 | 0.618–2.240 | .61 | 0.714 | 0.412–1.237 | .22 | |
| Create a culture of quality improvement at the agency or division level | 1.721 | 0.886–3.345 | .11 | 0.874 | 0.559–1.366 | .54 | |
| Ensure the successful implementation of an organizational strategic plan | 0.610 | 0.386–0.965 | .04e | 0.972 | 0.556–1.701 | .92 | No longer significant |
| Community engagement | |||||||
| Ensure health department representation in a collaboration process resulting in a community health assessment or community health improvement plan | 0.722 | 0.343–1.520 | .38 | 0.596 | 0.244–1.456 | .25 | |
| Ensure community member engagement in the design and implementation of programs to improve health in a community | 0.907 | 0.451–1.822 | .78 | 0.785 | 0.364–1.691 | .53 | |
| Advocate for needed population health services and programs | 1.316 | 0.659–2.629 | .43 | 0.640 | 0.320–1.279 | .20 | |
| Cross-sectoral partnerships | |||||||
| Negotiate with multiple partners for the use of assets and resources to improve health in a community | 1.456 | 0.598–3.546 | .40 | 1.432 | 0.898–2.283 | .13 | |
| Build collaborations within the public health system among traditional and nontraditional partners to improve the health of a community | 1.614 | 0.538–4.840 | .38 | 0.721 | 0.367–1.412 | .33 | |
| Policy engagement | |||||||
| Determine the feasibility of a policy and its relationship to many types of public health problems | N/A | N/A | N/A | 1.231 | 0.798–1.898 | .34 | |
| Prioritize and influence policies external to the organization that affect the health of the community | N/A | N/A | N/A | 0.954 | 0.566–1.606 | .86 | |
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
Data source: Public Workforce Interests and Needs Survey, 2021. National survey and replication weights provided by de Beaumont.
Results are individual logistic regressions for each skill gap, holding constant gender, race/ethnicity, age, education level, employer, role type, tenure in public health practice, and public health certificate attainment.
Bonferroni correction adjustment (significance level set at P ≤ .0167).
Significance P ≤ .0167.
Marginal Significance P ≤ .05.
Change in significance results between 2017 and 2021 PHWins Surveys.
Comparing respondents from 2021 to 2017, there were 2 significant changes in the likelihood of executives with a formal public health degree in 2021 to report gaps than those in 2017. Executives with a formal public health degree were significantly less likely to report skill gaps in the justice, equity, diversity, and inclusion (JEDI) domain (n = 1 skill gap) and significantly more likely to report skill gaps in the budgeting and financial management domain (n = 1 skill gap) than executives without a public health degree. Neither of these relationships were identified in 2017. While executives with a formal public health degree in 2017 were less likely to report a skill gap in being able to ensure: “the successful implementation of an organizational strategic plan” (Domain: systems and strategic thinking) when compared to executives without a formal public, this relationship did not continue in 2021.
Discussion
A competent public health workforce is critical to maintaining a robust public health infrastructure, especially as the demands of the field continuously evolve.1–3 The COVID-19 pandemic highlighted the need for public health professionals with essential skills and revealed workforce capacity gaps.4,5 It is crucial to regularly assess public health workers’ competencies and address skill gaps to strengthen our workforce. Increasing access to formal public health education has been one strategy, leading to a rise in the number of public health programs and graduates.10,14 Previous data from 2017 suggested that holding a public health degree reduced the likelihood of skill gaps in most competency areas, but changes in these gaps remain unclear.12 This study examined whether self-reported skill gaps among U.S. governmental public health workers have shifted since 2017 by analyzing PHWINS 2021 data.
Overall, across all position levels (ie, nonsupervisory, supervisor, executive), public health workers with a public health degree experienced fewer skill gaps in 2021 than in 2017. In 2021, having a public health degree was significantly associated with reduced odds of reporting a skill gap in over half of the competency skills assessed among both nonsupervisors and supervisors (14 of 23 skills and 17 of 24 skills, respectively). This was an improvement from 2017 where nonsupervisors and supervisors had reduced skill gaps in 8 of 21–22 skills assessed.12 Furthermore, whereas in 2017, when having a public health degree had no effect on executives reporting a skill gap, in 2021, having a public health degree was significantly associated with reduced odds of reporting 2 skill gaps.12
Among supervisors and executives, skill gaps were significantly less likely among individuals with public health degrees compared to those without for the skill of “Incorporate health equity and social justice principles into planning for programs and services” within the justice, equity, diversity, and inclusion (JEDI)) domain. This change is likely associated with the expanded emphasis on justice, equity, diversity, and inclusion (JEDI)) training within academic programs.14–16 The downstream effect of education that supports JEDI within formal public health programs may be that workforce members are better equipped to manage aspects of their job that require JEDI skillsets.
Regarding the domain of budgeting and finance, an area of historical skill gaps, there were fewer skills gaps reported among nonsupervisors and supervisors in 2021. In particular, the skill gap “Identify funding mechanisms and procedures to develop sustainable funding models for programs and services” decreased for both nonsupervisors and supervisors, suggesting that individuals with formal public health degrees are more prepared to ensure sustained funding for programs and services. However, within this same budgeting and financial management domain, improvement was not consistent for executives who, as of 2021, reported a significant increase in the skill gap “Use financial analysis methods in making decisions about programs and services across the agency.” This could be due to a more complex financial environment or executives being more aware of the complexities of financial decision-making.17
A consistent finding between 2017 and 2021, is the presence of skill gaps in the effective communication domain within all 3 supervisory levels. Specifically, nonsupervisors and executives with a public health degree are both more likely to report a gap in the skill “Communicate in a way that persuades others to act.” The Council on Education for Public Health (CEPH) requires several communication competencies for formal public health degrees.16,18 However, these requirements might not fully address the practical communication skills when it comes to persuasion, which are often developed through experience and hands-on practice.19 Awareness of this gap could have been heightened during the COVID-19 pandemic. During COVID-19, there was a lack of trust between the public and public health officials leading to increased harassment and mental distress within the public health workforce.20,21 This could relate to public health workers feeling less adept at communicating in a way that persuades others to act because fewer people were listening to public health guidance during the pandemic. Enhancing training programs to focus on more persuasive communication techniques and providing practical experience opportunities can help bridge these gaps.
In 2021, PHWINS added a new skill gap domain titled “Policy Engagement” with 2 new skills for all supervisory levels. This reflects a growing recognition of the importance of policy skills in public health practice and the CEPH competency requirement.22 Both nonsupervisors and supervisors/managers with a public health degree were less likely to report a skill gap within this newly identified competency domain. However, there was no difference between executives with and without a formal degree. The policy competency skills that are required to be taught in public health programs might not involve the strategic oversight and high-level decision-making that is required of executives. Executives might benefit from specialized training that focuses on high-level policy strategy and advocacy to close this gap.
The findings from PHWINS 2021 illustrate that formal public health education generally decreases skill gaps across numerous competency domains. However, the variability in reported gaps across supervisory levels shows the need for ongoing evaluation and adaptation of formal public health degree programs. It is essential to address the evolving needs of the public health field and ensure that the workforce is well-equipped to meet the challenges of their roles.
Strengths and limitations
This study has several strengths and weaknesses worth noting. First, this study is the first of its kind to longitudinally compare competencies among governmental public health employees with and without a formal education in public health. Additionally, this study utilized a representative national sample of public health employees from large and mid-sized governmental agencies at both state and local levels. It provides new insights that will be useful to the Association of Schools and Programs of Public Health (ASPPH) and university programs in planning for supporting the developing workforce. However, a number of limitations should be noted. Given all data was self-reported, respondents could have over-reported “good behavior” (eg, skills) or under-reported “bad behavior” (eg, skill gaps) due to social desirability bias. Also, we were unable to account for any additional professional or public health training outside of a formal public health degree and certificate attainment. This could potentially confound the results presented. Although this cross-sectional study offers valuable new findings, we are unable to establish causal relationships between formal public health degrees and self-reported skill gaps among workers. Furthermore, given the amount of comparisons in our analysis, we may have identified spurious relationships between having a formal public health degree and reporting skill gaps. To mitigate this risk, we applied a more conservative significance level using the Bonferroni correction.
Conclusion
This study provides fresh insights into the relationship between having a formal degree in public health and skill gaps among the US governmental public health workforce. Using 2021 data, we found that having a public health degree was associated with reporting fewer skill gaps than previously identified in 2017, further highlighting the value of formal public health education programs. As more data is collected, longitudinal analysis should continue to evaluate these skill gaps. Future research should focus on the effective communication domain and the lack of difference in skill gaps among executives with and without a formal degree in public health.
Implications for Policy & Practice.
Enhancing formal and informal training programs to focus on more persuasive communication techniques and providing practical experience opportunities can help bridge persistent communication gaps.
The emphasis on justice, equity, diversity, and inclusion (JEDI)) training within academic programs should be sustained as it is correlated to reduced skill gaps over time. However, the historically optional nature of JEDI committees in public health agencies does not appear to relate to reduced skill gaps among workers without public health degrees.
Both nonsupervisors and supervisors/managers with a public health degree were less likely to report a skill gap within the newly identified competency domain of Policy Engagement. However, executives with and without a formal public health degree would benefit from specialized training that focuses on high-level policy strategy and advocacy.
Acknowledgments
The lead author of this work was supported by the National Library of Medicine of the National Institutes of Health under award number T15LM012502. The content of this article is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or the National Library of Medicine.
The project did not receive any external funding.
Footnotes
The authors declare that they have no conflicts of interest.
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 and local governmental public health workforce in the United States, and was fielded in 2014, 2017, and 2021. For more information, visit phwins.org.
Ethical approval for this research was obtained from Indiana University on January 17, 2024 (Decision No 21927).
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