Identifying Needs for Advancing the Profession and Workforce in Environmental Health

Abstract

An ever-changing landscape for environmental health (EH) requires in-depth assessment and analysis of the current challenges and emerging issues faced by EH professionals. The Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health initiative addressed this need.

After receiving responses from more than 1700 practitioners, during an in-person workshop, focus groups identified and described priority problems and supplied context on addressing the significant challenges facing EH professionals with state health agencies and local health departments. The focus groups developed specific problem statements detailing the EH profession and workforce’s prevailing challenges and needs according to 6 themes, including effective leadership, workforce development, equipment and technology, information systems and data, garnering support, and partnerships and collaboration.

We describe the identified priority problems and needs and provide recommendations for ensuring a strong and robust EH profession and workforce ready to address tomorrow’s challenges.

Public health is evolving with a focus on enhancing leadership capabilities and data-driven decision-making, demonstrating improvements in community health outcomes, and preparing a workforce that is equipped to tackle current and future challenges.^1,2 Environmental health (EH) is a foundational area of state health agencies and local health departments³ and is in the midst of this transformation with rapidly increasing and expanding responsibilities for responding to emerging issues and emergencies to protect the public from exposures to environmental hazards. Extreme weather events and natural disasters, Legionnaires’ disease outbreaks, and establishing new regulatory processes for cottage foods and food additives are examples of complex challenges stressing the EH profession. Although charged with critical responsibilities for addressing these challenges, the EH workforce struggles with needs for increased resources in areas such as information technology and workforce development.

In 1942, Kroeze noted that the role of sanitarians, now commonly classified as EH professionals:

is being further expanded through the broader program of local sanitation work resulting from better coverage of previously recognized problems and also the appearance of new modern problems.^4(p613)

This perspective has been consistently echoed within the EH profession in response to an ever-changing technological, societal, and political landscape.^5,6 Considering these changing landscapes, it is paramount to develop a comprehensive understanding of needs and implications to ensure that the EH profession and workforce can respond to emerging issues. In fact, a need remains to define what resources and tools EH professionals in health departments will need to effectively deliver the “10 essential environmental public health services,” which describe the necessary actions for protecting and improving EH.⁷

In response to this need, the Centers for Disease Control and Prevention (CDC), the National Environmental Health Association, and Baylor University conducted an assessment of the EH workforce of US state, tribal, local, and territorial public health departments. This unique initiative, Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health (UNCOVER EH), consisted of a Web-based assessment and 2 in-person workshops.⁸ The first in-person workshop was held in June 2018 during the National Environmental Health Association (NEHA), Annual Educational Conference in Anaheim, California. This initial workshop focused on EH programmatic and technical areas (e.g., drinking water quality, food safety, vector control) and identified timely EH practice and research needs.⁹ The second in-person workshop, held in August 2018 at the NEHA headquarters in Denver, Colorado, examined topics affecting EH professionals in state health agencies and local health departments (e.g., leadership, partnerships, workforce development). We present and analyze the priority problems and needs determined during the second in-person workshop and provide recommendations for strengthening the EH profession and workforce.

PRIORITY ISSUES AND NEEDS

The focus groups produced 29 problem statements organized by 6 preidentified themes, including effective leadership, workforce development, equipment and technology, information systems and data, garnering support, and partnerships and collaboration. A focus group methods description is provided in the appendix (available as a supplement to the online version of this article at http://www.ajph.org). The problem statements identify and provide context on the priority issues and challenges facing the EH profession and workforce. We present the key issues represented in the problem statements, discuss their implications, and provide recommendations, which are summarized in the box on page 290.

BOX 1— Summary of Recommendations for Strengthening the Environmental Health Profession and Workforce.

Effective leadership Explore options for designing and implementing state- or local-level leadership development and training programs. Establish and encourage the development of formal mentorship programs as a key component of building EH professional leadership competencies. This will require a concerted effort among governmental and nongovernmental stakeholders to establish the frameworks, develop curriculum, and provide resources and tools for jurisdictions across the nation.

Workforce development Develop a consolidated strategy for standardizing EH professional qualifications, educational requirements, and credentialing. A standardized identity is needed for describing the EH professional workforce and efforts to demonstrate EH impact and value, which is necessary for ensuring accurate and effective workforce development efforts.

Equipment and technology Establish a collaborative effort, facilitated at the national level, for sharing information pertaining to advances in equipment and technology. This should include development of a repository for housing information and resources such as best practices, success stories, training descriptions, and other materials demonstrating the effective application and utility of various EH inspection and investigating equipment and technologies.

Information systems and data Form comprehensive guidance and tools, through engagement of EH programs and professionals with informatics experience and expertise, for determining necessary and appropriate EH information system functionalities to meet jurisdictional needs for collecting, managing, and analyzing data. This includes promoting resources and training to increase informatics-related workforce competencies. Additionally, conduct an evaluation of EH-related surveillance systems and possibilities for integrating data, monitoring EH issues, and examining the impact of EH services.

Garnering support Conduct studies to determine the impact of EH services or interventions on improving health outcomes. To support this research, an initiative is needed for identifying appropriate and reliable health and environmental outcome indicators for measuring impact and to support ongoing EH surveillance. Resulting data about the impact of the EH profession can be incorporated into messaging intended to build awareness and advocacy for the profession.

Partnerships and collaboration Produce a comprehensive framework to assist EH programs and professionals with identifying potential partners and fostering strong, collaborative relationships with governmental and nongovernmental agencies, organizations, and other stakeholders.

Note. EH = environmental health.

Effective Leadership

Across the related problem statements, key challenges are characterized by leaders’ needs to increase knowledge, skills, and competencies for effectively leading EH programs and their professionals. These needs are compounded by limited availability of leadership training and development opportunities and by not institutionalizing aspects of leadership into workforce development and planning efforts (see the box on page 291). This situation is further complicated by politics that influence leaders’ decision-making processes. The upcoming cadre of EH professionals must have opportunities to build strong leadership capabilities and be empowered to lead their organizations.

BOX 2— Environmental Health Leadership and Workforce Development Problem Statements.

Effective leadership

1. EH leaders do not always use data or evidence or consider day-to-day realities in the field for determining necessary staff competencies, skills, and training needs.

2. Politics influence leadership decisions and can result in appointment and hiring of leaders who lack a thorough understanding of EH practice.

3. Mentoring or coaching is essential for building staff leadership competencies, yet there is limited support, encouragement, and ability to mentor.

4. All EH professionals can be leaders; however, there are limited opportunities to develop leadership skills and competencies, along with staff empowerment to engage in leadership.

5. Leadership capacity and capability needs to be a consideration in workforce development, succession planning, and credentialing.

Workforce development

6. Data and evidence for the impact of the EH profession and its work (i.e., reduction of illness) and description of workforce challenges (supply and demand) does not exist, but it is essential for promoting and maintaining a robust workforce.

7. Defining and standardizing national-level EH professional job qualifications, educational requirements, and necessary credentials are needed to strengthen recognition as a profession.

8. A unified strategy is needed for ensuring EH professionals and prospective professionals (i.e., college graduates) are prepared and ready to enter the workforce with the necessary soft skills, technical and scientific knowledge, and practice-based experience (i.e., completed internships).

9. The EH profession must evolve according to generational and workforce trends, changing demographics, and innovative work models to attract and retain highly qualified graduates and skilled professionals.

10. There is a lack of common definition or identity for the EH profession, which leads to limited public recognition of its value and importance.

Note. EH = environmental health.

Needs for strengthening EH professional leadership competencies have been previously identified and recognized as a significant challenge.¹⁰ Although the EH workforce continues to face longstanding challenges in this area, Public Health 3.0, a recent initiative to advance public health, reinforces a strategic perspective while encouraging leaders to enhance capabilities to address public health challenges that include systematic and data-driven approaches.¹ Although leadership training is recognized as an important need for the EH workforce,⁸ there are limited opportunities for training and development opportunities.

Establishing formal training programs can address gaps in leadership development and aid in building related competencies. For example, the Environmental Public Health Leadership Institute, funded by the CDC for 8 years (2004–2011) provided classroom and practice-based education and experience in areas such as partnership building, conflict resolution, problem solving, and systems thinking for more than 200 EH professionals.¹¹ Participation in this leadership institute was intended to build and strengthen a range of leadership abilities and empowered graduates to bring about organizational change.¹² However, programs such as these are resource intensive and difficult to sustain.

Considering the resource-intensive nature of national-level leadership institutes, exploring possible frameworks for implementing state- or local-level programs is a viable approach for facilitating comprehensive EH professional leadership training opportunities. Establishing and encouraging the development of formal mentorship programs is a key component of fostering EH leadership competency building. The National Association of County and City Health Official’s Retail Food Program Standards Mentorship Program is an example of a multifaceted mentorship program that facilitates mentor–mentee relationships and interaction.¹³ These efforts require a concerted effort among stakeholders, including governmental and nongovernmental organizations, to establish the frameworks, develop curricula, and provide resources and tools for jurisdictions across the nation to use.

Workforce Development

There is an overarching need to standardize EH professional qualifications, educational requirements, and credentialing to enhance the ability to generate evidence of the profession’s effectiveness and value to support and inform workforce development initiatives (see the box on page 291). Varied educational and credentialing requirements contribute to a poorly defined profession and hinder support for enhancing the EH workforce and increasing awareness of the services delivered by EH professionals. Developing a standard identity for the profession can lead to greater appreciation and recognition for the EH profession, which would ultimately attract more highly qualified candidates to the workforce.

The state health agency and local health department workforce, of which EH is one of the largest segments, has been subject to recent challenges affecting recruitment and retention of staff.^14–16 In recent years, local health department EH programs have experienced budget cuts and reductions in services along with a reduction of more than 2000 EH full-time equivalents over an 8-year period (2008–2016).^15,17 Additionally, the EH workforce appears to be aging with the highest percentages of EH professionals older than 45 years, whereas approximately a quarter of the workforce plans to retire within 5 years.⁸ In some local-level jurisdictions, finances and capacity are stabilizing, potentially presenting an opportunity to strengthen the EH workforce and services delivery system.^17,18 However, lack of a common identity for the EH professional is an area of concern and hinders workforce development efforts regardless of available resources.

Effective design and implementation of workforce development efforts depends heavily on the ability to accurately describe and identify the professionals of a particular discipline and its practice. Discrepancies in defining and describing professions and credentialing apply to the general public health workforce and specifically to EH.^19,20 This contributes to EH being an “invisible” profession whose efforts often go unnoticed because of the preventive nature of its work.^6,21

Nationally, EH professional and workforce characteristics such as educational background, credentials, and job titles appear to vary greatly, which presents challenges for describing the EH profession and professionals working in health departments.⁸ Describing the profession is further complicated at the organizational level by wide variation in health department EH program characteristics and differences in local-level EH services delivery, which is associated with governance type (e.g., state-governed local health departments vs home rule jurisdictions) among other organizational characteristics.²² Public health workforce taxonomy is an approach to describing public health workforce characteristics²³; however, a consolidated strategy is needed for standardizing such criteria specific to the EH profession for establishing a professional identity along with the educational and credential requirements necessary for ensuring accurate and effective workforce development efforts.

Equipment and Technology

EH professionals routinely conduct inspections and complex investigations that require sophisticated equipment and technological resources. However, resource limitations, specifically lack of advanced instrumentation and technologies, hinder abilities to consistently and effectively deliver essential services (see the box at the top of page 292). Additionally, the availability of current technologies, equipment maintenance, and replacement of aging equipment used for inspections and investigations is inconsistent among health departments and is highly dependent on the availability of financial resources.

BOX 3— Environmental Health Technology, Data, and Information Problem Statements.

Equipment and technology

1. Electronic inspection technologies and hardware (portable tools) provide return on investment (e.g., quality, consistency, reporting, financial) but are differentially available, understood, and communicated.

2. Equipment used for inspections is differentially available and supported (directly by leadership, technical support), of variable quality, not consistently maintained or upgraded, and often surpassing EH capacity by private industry (public image or perceptions of EH service delivery or competency).

3. Advanced equipment, processes (structure differences), and services (public partnerships with academia, businesses) for general EH issues and illness investigations are not consistently provided (resource access), shared (partnerships), and understood (training, maintenance).

4. EH is increasingly called on for emergency response, yet planning for and access to equipment and technologies must become a priority for health departments.

Information systems and data

5. Inconsistent and inaccessible EH data collection and analysis tools preclude effective and efficient intervention decisions and communication.

6. Failure of consistent, sustainable, and resilient data management systems adversely affects delivery of essential EH services.

7. Software and data automation tools used by EH professionals are not consistently adaptable, supported, nor understood.

8. National surveillance systems exist for select EH programs, but whether these operate effectively or could serve as models for other EH programs is not known.

9. Identifying health outcomes resulting from delivery of EH services is limited by integration of diverse data sets.

Note. EH = environmental health.

Increasing the availability of resources such as modern electronic inspection software can increase efficiencies and economic benefits. Otherwise, resource limitations limit the quality of routine services and responses to emergencies, potentially leaving local communities at risk. Demonstrating potential gains in productivity or return on investment for adopting new technologies, such as shifting from paper-based processes to electronic inspections, can provide important information for realizing economic benefits and encouraging resource allocation for acquiring new technologies. Implementing data management systems that seamlessly transfer information among software systems is another important consideration for EH professionals.

A collaborative effort, facilitated at the national level, needs to be established for sharing information pertaining to advances in equipment and technology. Promoting training and sharing information on new technologies can increase awareness and support for acquisition or adoption of new equipment and technologies. One result of the collaborative should be developing a repository that houses resources and information, including best practices, success stories, training descriptions, core laboratory service providers, and other materials demonstrating the effective application, return on investment, and utility of various EH inspection and investigation instrumentation and technologies.

Information Systems and Data

EH information and data management systems are commonly available, yet levels of their capacity, utility, and use of existing data vary across jurisdictions (see the box at the top of page 292). Additionally, diverse data sets from national surveillance systems along with local and state-level data sources are available; however, these inconsistently focus on particular EH topic areas and are difficult to integrate. These limitations affect the potential use of data to identify emerging EH issues and determine the effectiveness of EH services and their impact on health outcomes. Increased consistency and capacity of these systems can support the use of data to inform and drive improvements in essential EH services.

Public health informatics embraces the use of actionable data for advancing efforts to address community health concerns and other determinants of health leading to inequities.²⁴ Initiatives to promote the use of informatics to show the collective value of EH services and activities could spur the use of diverse data streams and analytics to advance EH practice. As the role for informatics increases, there are related training needs for the local health department workforce and identified gaps in EH professionals’ skills and abilities in data collection and analysis.^8,25 Incorporating related core competencies into workforce development efforts for the public health workforce in general and EH professionals in particular can build EH professionals’ abilities to gather, analyze, and interpret data.^26–28

To address the identified information system and data use challenges, the development of comprehensive guidance or frameworks, with engagement of EH programs and professionals with informatics experience and expertise, is needed for identifying appropriate information systems and functionality to meet jurisdictional needs for collecting, managing, and analyzing data. This guidance must also include resources and recommended training for increasing informatics-related workforce competencies. In terms of surveillance systems, conducting an evaluation of current and universally accessible EH-related surveillance systems and possibilities for data integration will increase the understanding of potential uses and application for monitoring EH issues in communities served and examining the impact of EH services.

Garnering Support

Support for the EH profession fluctuates with changing economic and political conditions and influences, which leads to inconsistent and unsustainable programs and services (see the box at the bottom of page 292). EH inclusion and strengthened contributions to initiatives, such as national voluntary accreditation for public health departments, could increase recognition and support. However, a persisting lack of awareness of the EH profession, its benefits, and its contributions to public health is a barrier to realizing its value and sustaining funding. Using data to generate this evidence coupled with effective messaging to build advocacy is crucial for increasing the awareness of the profession and its value.

BOX 4— Environmental Health Support and Partnership Problem Statements.

Garnering support

1. Lack of awareness and understanding of the impact of EH programs and professionals leads to a lack of support and funding.

2. EH concerns and issues need to be better represented in the health department accreditation process, which could lead to increased support of EH programs.

3. EH issues are perceived as partisan, which presents challenges for receiving consistent levels of support.

4. Data, metrics, and best practices are necessary for defining EH successes and increasing awareness of impacts.

5. Funding sources do not always promote sustainability (e.g., grants, out-of-date fee structures), which can lead to negative impacts on program capacity.

Partnerships and collaboration

6. Increased understanding of what EH is and how EH professionals protect the public’s health is needed for building stronger partnerships.

7. Expectations to do more with less creates a need for EH to establish effective partnerships and collaboration to address emerging and traditional issues.

8. Networking across jurisdictions is needed for addressing current and emerging EH threats that are cross-sector and regional in nature.

9. Current and emerging EH effects of climate change are not being addressed, which requires increased collaboration.

10. EH is not addressing health equity, and it needs to be a part of the conversation.

Note. EH = environmental health.

In the broader public health context, more research is needed on workforce effectiveness.²⁹ Generating data on the work of the EH profession and its impact on improving health outcomes is necessary for increasing awareness of the profession’s value and importance. The National Environmental Health Partnership Council’s exploratory study examining the value of EH services provided a key statement, “Environmental public health action saves lives, saves money and saves the future.”^30(p1) The council’s report revealed evidence of the economic value of EH services; however, it acknowledged critical gaps in evaluating the health impacts and benefits of EH interventions.³⁰

Undertaking a similar study is a necessary step forward for describing the impact of EH services or interventions on improving health outcomes. In addition, the study needs to identify appropriate and reliable health and environmental outcome indicators for measuring impact but also to support ongoing EH surveillance, which is necessary for the longitudinal monitoring of EH hazard trends and health effects.³¹ These results could catalyze jurisdictional approaches to establishing specific indicators to measure successes and inform decision-making about the effective delivery of EH services. This effort can produce invaluable information for marketing efforts for the EH profession, similar to a recent initiative that sought to understand effective ways to communicate with the public about the field of EH.³² Incorporating data about the impact of the EH profession will strengthen the messaging to build advocacy for the profession.

Partnerships and Collaboration

There is a need for strengthening relationships and networking between EH and partners or stakeholders across regions to address complex traditional and emerging public health issues (see the box at the bottom of page 292). As a form of partnership, state health agencies and local health departments engage in cross-state or jurisdictional sharing of resources to increase capacity for providing public health services.^15,16 Aside from sharing resources, networking and exchange of information are beneficial for facilitating coordinated responses to EH challenges at a regional level.

Broadening the intersections among public health and nongovernmental partners, including multisectoral partnerships, is encouraged for addressing topics such as population health and health equity.³³ EH needs to strengthen partnerships and engagement in collaborative efforts with other agencies, stakeholders, or community organizations to address emerging issues, such as the health impacts of climate change. Furthermore, EH engagement with other governmental agencies and nongovernmental organizations with EH roles and responsibilities can foster stronger relationships for forming comprehensive strategies to address public health challenges. Considering the many factors for identifying potential partners and establishing strong, collaborative relationships with stakeholders, a comprehensive framework needs to be developed to aid EH programs and professionals in forming effective partnerships.

CONCLUSIONS

EH professionals fulfill a vital role in protecting the nation’s health. UNCOVER EH revealed a range of priority challenges and needs for ensuring the EH workforce is enabled, capable, supported, and prepared to fulfill this critical role and respond to current and future public health threats. The magnitude and scope of EH practice and workforce challenges related to those we have described might change, but we see a consistency in the nature and context of the identified problems over time. For example, in 2003, the CDC convened a workgroup of stakeholders in an extensive process to develop A National Strategy to Revitalize Environmental Public Health Services.¹⁰ Participants focused on 6 overarching goals, including build capacity, support research, foster leadership, communicate and market, develop the workforce, and create strategic partnerships. Many of these challenges also apply to the broader public health workforce.³⁴ A multifaceted response is required for resolving persisting and underlying deficiencies to advance the EH profession and protect the health of local communities in the future.

This workshop and its focus groups included a relatively small sample of EH professionals with limited representation of the overall workforce. However, participant selection was informed by a purposive sampling strategy that resulted in participants from varied position levels (directors, managers, and filed staff), levels of government (state and local), and different states. The workshop focused on EH professionals and professionals in state health agencies and local health departments, yet there are other governmental agencies, particularly at the state level, with EH responsibilities.³⁵ Future efforts might address the EH professionals and their practice in these other agencies.

Focus group participants provided a well-informed consensus on a range of priority issues, many of which are consistent with the focus areas of past initiatives and current efforts to enhance the public health and EH workforces. Holistically, the identified problems show a need to use data and evidence to demonstrate the value and effectiveness of the EH profession and practice. Addressing these problems will project the EH profession toward a future with increased recognition, strengthened partnerships, and more support and resources for sustainably protecting the nation’s health.

UNCOVER EH is fulfilling a longstanding need to conduct an in-depth analysis of the EH profession, identifying prevailing challenges and priority issues, and supplying essential information for ensuring a strong and robust EH workforce consisting of professionals ready to meet the challenges of the 21st century. Leaders and decision-makers at all governmental and nongovernmental levels have an unprecedented opportunity to consider these findings, derived directly from practicing EH professionals, as they determine strategies, approaches, or allocation of resources to strengthen and enhance the EH profession and workforce.