Public Health Workforce Enumeration

Abstract

Comprehensive data on the public health workforce are fundamental to workforce development throughout the public health system. Such information is also a critical data element in public health systems research, a growing area of study that can inform the practice of public health at all levels. However, methodologic and institutional issues challenge the development of comparable indicators for the federal, state, and local public health workforce.

A 2006–2007 Association of State and Territorial Health Officials workforce enumeration pilot project demonstrated the issues involved in collecting workforce data. This project illustrated key elements of an institutionalized national system of workforce enumeration, which would be needed for a robust, recurring count that provides a national picture of the public health workforce.

A NATIONAL WORKFORCE enumeration system is important for the assessment, advocacy, and accountability of the national public health workforce. Only by assessing the size and composition of the national workforce can agencies and organizations ensure that the workforce is large enough and skilled enough to deliver essential public health services to the US population. Descriptive data are critical to advocating increased resources for workforce development, such as the demonstration project and student loan repayment program of the Pandemic Flu and All Hazards Preparedness Act. The project and program, which seek to attract workers to the field of public health by offering student loan repayment, are currently unfunded. Advocacy for funding the project and program is hampered by a lack of national data on the current gaps that exist for qualified members of the workforce or vacant positions. Making the case for funding these types of activities requires compelling national data that show the urgent need for public health workers and the critical role they play in protecting the nation's health. Data are also needed to monitor the impact of these and other investments in the public health system toward achieving national public health goals. These data also would become an important basis for the growing body of public health systems research, yielding findings that can be used to strengthen all of public health practice.

A 2003 Association of State and Territorial Health Officials (ASTHO) survey showed a trend toward shortages in the state-level public health workforce; the 2007 update showed that state governmental public health systems still face a workforce crisis.^1,2 This trend has spurred interest in workforce data at the local and state level. In at least 5 states since 2000, state health agencies, universities, and public health institutes, in collaboration with local public health jurisdictions, have conducted enumerations of local public health workforces. Efforts to collect local public health workforce data are also occurring at the national level. The National Association of City and County Health Officials (NACCHO) collected the number of full-time equivalent workers in 13 occupational categories from NACCHO members.³ Merging data from across public health sectors and jurisdictions would result in an even more complete picture of workforce needs and strengths.

The most recent national public health enumeration counted approximately 450 000 workers in 2000.⁴ This effort and the critiques of the reported findings illustrate the need for a system that produces national data on a regular basis, thereby allowing the monitoring trends and the measuring longitudinally of the impact of activities on the workforce, rather than the current intermittent efforts using diverse approaches. Institutionalizing enumeration would result in a process that is repeatable, affordable, and consistent.

The 2006–2007 ASTHO workforce enumeration pilot project was a small step toward the goal of institutionalized workforce enumeration. The project tested strategies for enumerating nursing and environmental health sectors in 8 state health agencies. In developing the pilot, the guiding committee engaged in extensive discussions about the differences in professional standards across typical public health fields, such as the contrasts between nursing, for which there are fairly uniform education and state licensing definitions, and environmental health, which is practiced by persons with widely differing educational backgrounds and (often) no specific license.

A related challenge was that of deciding the degree of specificity essential to a universal enumeration (number or full-time equivalent, job title or educational credential or both, title of assigned program or content of work or both, and degree of demographic detail, such as age, gender, race/ethnicity, and work history). With a good universal enumeration, some variables (career trajectory, educational history) could be studied by using representative rather than convenience samples. Less expensive convenience samples can be used, but interpretation of the results is difficult.

The ASTHO effort showed that a national approach would depend entirely on agreement about standard definitions that can be translated into the existing, disparate information systems and job classifications. A national enumeration system would need to rely as well on establishing a method of counting the workers who perform public health functions in settings outside governmental health agencies, such as environmental and agriculture agencies, academia, and the private and nonprofit sectors.

As has also been encountered by NACCHO, the pilot project showed that a national enumeration system would have to include methods that minimize duplicative counting of workers who are employed by state government but work in local and regional governmental public health settings. The project also highlighted a need for a streamlined, targeted data collection system for information; reaching out to individual workers is very labor intensive and impractical.

Advancing the field of public health requires aligning fragmented efforts to collect workforce data and updating much needed statistics on the size and composition of the workforce. The results of this alignment and updating will inform national and nationwide activities to recruit and retain a strong public health workforce.