Rural–Urban Differences in the Public Health Workforce: Local Health Departments in 3 Rural Western States

Most local health departments or districts are small and rural; two thirds of the nation's 2832 local health departments serve populations smaller than 50 000 people.1 Rural local health departments have small staffs and slender budgets, yet they are expected to provide a wide array of services2 during a period when the health care system of which they are a part is undergoing change.3

This study provided quantitative, population-based data on the supply and composition of the rural public health workforce in 3 extremely rural states: Alaska, Montana, and Wyoming. The study focused on the relative supply of personnel in the principal public health occupational categories, differences across states in staffing levels, and difficulties experienced in recruiting and retaining personnel.

METHODS

We identified all local health departments in the 3 states with assistance from the state health departments—52 in Montana and 23 in Wyoming. In Alaska, each of the 22 local offices of the state public health department was treated as a separate local health department.

The survey instrument was based on work performed by the American Public Health Association,4,5 as modified by the Center for Health Policy Study of the University of Texas.6 The survey was mailed directly to the administrator of every local health department in 1999 and 2000. We used follow-up contacts until every local health department had responded, for a 100% response.

We defined a local health department as rural if it was within a county with fewer than 50 000 people. In Alaska, which does not have county governments, we designated the Anchorage and Fairbanks local health departments as urban.

In every state, some local services are also provided by state or regional public health personnel. We specifically excluded those personnel from the calculations that follow. We also excluded environmental health personnel from the analyses that follow.

RESULTS

The 3 study states had 99 local health departments, serving a population of almost 2 000 000, about half of which lives in rural areas. The average local health department had fewer than 10 in-house employees.

The supply of professional public health personnel, excluding environmental health workers, was virtually identical across states on a per capita basis. Despite different organizational formats across states, local health departments had approximately 31 full-time equivalents for every 100 000 residents, or approximately 1 local health department professional for every 3225 residents. This remarkable uniformity in workforce supply represents the product of convergent evolution, because no joint planning is done across any of these states' boundaries.

Alaska and Wyoming actually had a greater relative supply of public health professionals in the rural compared with the urban areas, as can be seen in Table 1 ▶. Rural local health departments tend to have fewer support staff. The major rural–urban differences lie in the size of the populations served and the number of people who work in the local health departments. Rural local health departments in these 3 states are very small, serving on average slightly more than 10 000 people, with about 5 working public health professionals in a typical office. Virtually all local health department professional personnel in rural Alaska are full-time; by contrast, most rural public health personnel in Montana work part-time, with Wyoming between these 2 extremes.

TABLE 1.

—Rural–Urban Differences in Local Health Department (LHD) Staffing: Alaska, Montana, and Wyoming, 1999–2000

	Alaska		Montana		Wyoming		Total
	Rural (n = 22)	Urban (n = 2)	Rural (n = 46)	Urban (n = 6)	Rural (n = 21)	Urban (n = 2)	Rural (n = 89)	Urban (n = 10)
Demographics
Population served	279 106	342 710	369 155	446 140	326 703	138 033	974 965	926 882
Average district population	12 687	171 355	8025	74 357	15 447	69 016	10 483	92 688
Staffing (excludes sanitarians)
Total professional staff	121	104	213	175	150	40	484	319
Total professional FTEs	116.6	96.7	97.8	139.5	99.9	34.9	314.3	271.1
Professional FTEs/100 000	41.8	28.2	26.5	31.3	30.6	25.3	32.2	29.2
Total support FTEs	63.8	82.0	34.3	37.7	45.5	17.8	143.6	137.5
Support FTEs/100 000	22.9	23.9	9.3	8.5	13.9	12.9	14.7	14.8
Mean total FTEs/100 000	64.6	52.1	35.8	39.7	44.5	38.2	47.0	44.1

Note. FTE = full-time equivalent.

As shown in Table 2 ▶, the core of all the local health departments—urban or rural—is the public health nurse. These nurses constitute the majority of the professional workforce in the rural local health departments, largely because few other professionals work in these remote settings. Urban areas also rely heavily on nurses, but other types of professional personnel—from epidemiologists to nutritionists—play a greater role. Managers are also slightly more abundant in rural areas, primarily because Alaska uses more management personnel in these settings. By contrast, every other occupational category within public health is more plentiful in urban as opposed to rural local health departments.

TABLE 2.

—Composition and Per Capita Supply of Professional Public Health Workforce in Local Health Departments (LHDs): Alaska, Montana, and Wyoming, 1999–2000

	Mean FTEs per 100 000 Population
	Alaska		Montana		Wyoming		Total		Percentage of LHDs With Staff in This Category
Professional Categories	Rural	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural LHDs	Urban LHDs
Management	5.0	1.8	5.7	6.1	6.3	6.1	5.7	4.5	59	100
Clinical personnel
Physicians	0.0	0.1	0.4	0.1	0.3	0.3	0.2	0.1	62	80
Nurses	28.5	11.8	15.4	10.3	20.6	12.6	20.8	11.2	96	100
Physician assistants	0.0	0.0	0.03	0.0	0.0	0.7	0.1	0.1	3	10
Nurse practitioners	3.2	1.5	0.9	0.4	1.2	2.5	1.7	1.1	23	60
Nutritionists	0.4	2.6	0.4	2.2	0.3	0.6	0.4	2.1	11	70
Health educators	0.0	0.9	0.7	2.8	0.0	0.7	0.3	1.8	3	70
Social workers	0.0	0.0	1.0	2.2	0.2	0.0	0.5	1.1	8	50
Other direct care providers	4.3	0.9	1.9	3.4	1.3	1.1	2.4	2.1	26	80
Subtotal	36.4	17.7	20.7	21.4	24.0	18.5	26.3	19.6	NA	NA
Other public healtha	0.4	8.8	0.0	3.9	0.3	0.7	0.2	5.2	1	50
Total	41.8	28.2	26.4	31.4	30.6	25.3	32.2	29.3	NA	NA

Note. FTE = full-time equivalent; NA = not applicable.

^aIncludes epidemiologists, disease investigators, laboratory scientists, communications specialists, planners, and others.

Both state-to-state and rural–urban differences are seen in the extent to which individual local health departments are successful in recruiting professionals with a public health background. Alaska, with its predominantly full-time staff, has a highly professionalized workforce. Montana, with its predominantly part-time workforce, recruits public health professionals from other delivery settings, often individuals without previous public health experience or training. Wyoming again falls somewhere in between.

In the 3 states we studied, rural local health departments had relatively few vacancies. Whereas 70% of the urban local health departments were recruiting for public health nurses, only 21% of the rural local health departments had a similar vacancy. Nurse practitioners were the most difficult professionals to recruit. Rural–urban differences showed no clear pattern. Where recruitment was difficult, low salaries, difficulty finding qualified local professionals, and problems attracting personnel were reported to be common.

DISCUSSION

The Rural Local Health District

This study found that the core of the rural public health system is the public health nurse. There is approximately 1 full-time equivalent public health nurse for every 6000 people. In many cases, these nurses learn on the job. Many have no specific public health training and no experience in public health, and many of them work part-time.

Rural–Urban Differences

This study showed that the per capita supply of public health personnel was similar in the rural and urban places we studied. The differences were more subtle. Rural public health personnel were less likely to have formal public health training and experience and more likely to be employed part-time. Perhaps more important, rural public health personnel had a much smaller team of people with whom to interact and a much narrower range of public health skills represented in the local office.

Personnel shortages are relatively infrequent, even in the most remote rural areas. Many of the rural public health workers have been in these positions for long periods. The challenges of continuing education and further training can be immense, but rural public health workers tend to stay in their local communities.

Formal input to the rural local health department team from physicians and dentists is virtually nonexistent. Most rural local health departments have a volunteer physician who can sign death certificates or attend an occasional meeting. Our results conform almost exactly with those of the 1 other comprehensive national study that examined small local health departments.7 These authors concluded that there is a weakness in the “front lines” of public health; our results would certainly support that conclusion.

The rural public health system is small and isolated, but so are many other public functions located in rural communities. For these professionals to be effective—and to survive their often-stressful jobs—they must be connected with other professionals at the local, regional, and state levels. Our impression is that where the state plays a large role in organizing and running the system, local public health workers feel much more to be a part of something larger than themselves. Where state involvement is less pervasive, local health department staff feel much more uncertain and alone.