National Information Center on Health Services Research and Health Care Technology (NICHSR)
Public Health Systems and Services Research Workforce Report:
Recent and Future Trends in Public Health Workforce Research, 2009
Prepared by The University of Kentucky Center for Public Health Systems and Services Research
for the National Library of Medicine.
Public health workforce research is a subset of a larger endeavor to investigate the public health system, referred to interchangeably as Public Health Systems and Services Research (PHSSR) or Public Health Systems Research (PHSR). Several definitions have been offered for PHSSR; however, a consensus definition has emerged. Scutchfield, in a special issue of the journal Health Services Research dedicated to PHSSR, put forth the following consensus definition of PHSSR, arrived at by the Academy Health PHSR Special Interest Group:
- Public Health Systems Research (PHSR) is a field of study that examines the organization, financing, and delivery of public health services within communities and the impact of these services on public health.
- PHSR is a multidisciplinary field of study that recognizes and investigates system level properties and outcomes that result from the dynamic interactions among various components of the public health system and how those interactions affect organizations, communities, environments, and population health status.
- The public health system includes governmental public health agencies engaged in providing the ten essential public health services, along with other public and private sector entities with missions that affect public health.
- The term “services” broadly includes programs, direct services, policies, laws, and regulations designed to protect and promote the public’s health and prevent disease and disability at the population level.”
PHSSR has traditionally been divided into four areas: organization and structure; finance; workforce, and technology, data, and methods. While identifying the appropriate entities to include in PHSSR has been difficult for all these areas, given the rather murky definition of PHSSR, it has been particularly difficult in the area of workforce research. This may be due, in large part, to the lack of an operationalized definition of the public health workforce.  Given the large number of entities outside of governmental public health agencies that can potentially impact public health, from private hospitals, to charities, to other governmental agencies such as first responders, it is difficult to determine which personnel are appropriate to include. Furthermore, there does not currently exist any national licensure program for public health workers, which compounds the difficulty associated with identifying and enumerating the public health workforce.
While there have been renewed efforts to collect public health workforce data, to date, there is a scarcity of published research on the both the characteristics and functions of the public health workforce in the United States. Efforts have been undertaken to enumerate the public health workforce; however, despite these attempts, first in 2000 and then in 2007, there is still not a consistent or clear idea of the makeup of the public health workforce in the U.S., or its functions. This is hampered, in part, by the lack of a standardized definitions, job classifications, or data gathering techniques.  The contents of a 2003 issue of The Journal of Public Health Management and Practice specifically dedicated to research involving the public health workforce reflect a broader trend in workforce research.  Areas addressed include enumeration as described above, workforce development, training and credentialing, the current state of the public health workforce, education at schools of public health, and the adequacy of the public health workforce in underserved populations. However, in spite of the scope and depth of these and other publications on the public health workforce, research as a whole remains fragmented and sparse. Important questions regarding the public health workforce remain.
This is particularly concerning in light of the aging public health workforce, and associated shortage of public health workers, reported by entities such as the Association of State and Territorial Health Officials (ASTHO) and the Association of Schools of Public Health (ASPH). The ASPH, in a 2008 policy brief, stated that “The current public health workforce is inadequate to meet the health needs of the U.S. and global population- and worsening worker shortages will reach crisis proportions in the coming years. Fewer workers, drawing on diminished resources to meet the needs of more people, mean Americans are likely to be at grave risk unless measures are taken immediately to rebuild the workforce.”  In the absence of an accurate enumeration of the public health workforce, it is impossible to clearly identify the magnitude of worker shortages or potential shortages, and their implications for the public's health. Attempts to quantify the public health workforce, such as those done by ASTHO from 1970-1995, were never fully supported.  As a result, no consistent, comprehensive source of data about this vital component of the public health system exists. This lack of clarity can adversely impact policy and planning decisions such as agency funding, effective emergency response resource allocation, and the production of appropriately trained public health workers. Policy and program decisions based on inadequate data may have profound negative effects on system performance. For example, a system lacking a sufficient number of trained epidemiologists may have difficulty accurately identifying an outbreak of acute disease. In addition, this system may not be able to accurately identify the scope, depth, and severity of chronic conditions that threaten the health of the community, such as diabetes. This, in turn, can hamper the ability of the system to identify the most effective way to allocate sufficient resources to effectively combat these problems.
Efforts are underway within the federal government to address the lingering questions regarding the characteristics and distribution of the public health workforce. The Centers for Disease Control and Prevention (CDC) currently fund, through a cooperative agreement with the Public Health Foundation, two Centers of Excellence dedicated to research about the public health workforce; one at the University of Kentucky and the other at the University of Michigan. The Health Resources and Services Administration (HRSA) Bureau of Health Professions is currently engaged in research focusing on public health nurses, dentists and doctors. The Bureau of Labor Statistics, which may be the largest common source of information about the workforce in the United States, is currently contemplating changing their standard occupational classifications to more effectively capture and define the makeup of the public health workforce. Data collected at the national level can be used to create policy that reflects a system wide view of the needs of the public health workforce in the United States.
Individual states, often in conjunction with academic partners, have also recently undertaken enumeration activities. Ohio, North Carolina, Washington, Wisconsin, and Iowa have all collected data on the state of their public health workforce. These data can help identify state specific trends and needs in the public health workforce, and can be used by state policy makers to make decisions to allocate resources to public health agencies based on identified workforce deficits and needs.
Public health practice organizations, including ASTHO, the National Association of City and County Health Officials (NACCHO) and the National Association of Local Boards of Health (NALBOH) are currently engaged in designing and implementing harmonious surveys that, in part, are intended to capture data regarding the public health workforce. This effort, done with support from the Robert Wood Johnson Foundation and coordinated by the University of Kentucky Center for Public Health Systems and Services Research, will ideally provide a clearer picture of the characteristics of the public health workforce at the state, local, and governing body levels. This can be used by the leadership of public health agencies to identify the staffing patterns, training levels, and credentialing most appropriate for their agencies.
In addition, discipline specific research is being conducted in a number of different areas of public health. For example, the Council of State and Territorial Epidemiologists, an ASTHO affiliate, is collecting and analyzing data on the specific makeup of the epidemiologic workforce at the state level. The Association of Maternal and Child Health Programs is also currently analyzing the results of a workforce development survey conducted in 2009. Discipline specific research has the potential to uncover trends, needs and capacities of the various professional fields involved in public health practice.
Future trends in workforce research may largely be influenced by efforts to encourage collaboration between stakeholders, and attempts to implement uniformity in the training, education and credentialing of the public health workforce. The CDC and HRSA are currently discussing ways they can collaborate on research involving workforce issues. The previously mentioned Centers of Excellence are collaborating to do joint research on the makeup of the public health workforce. In addition, the previously mentioned work on data harmonization reflects a renewed commitment to collaboration among the three levels of the public health practice community. Activities directed toward providing uniformity are primarily focused on accreditation, education, and credentialing. Two of the accreditation domains proposed by the Public Health Accreditation Board revolve around administrative capacity and maintaining a competent workforce. The ASPH has recently released core competencies for students in accredited Masters in Public Health (MPH) programs, and is currently creating core competencies for students attending accredited Doctor of Public Health (Dr.P.H.) programs. Significant progress toward credentialing the public health workforce has recently been made, with the National Board of Public Health Examiners offering the first nationwide certification in public health exam in 2008. Data from these efforts to create a more uniform public health system can provide valuable insight into how and which specific standards are necessary to improve public health.
Clearly, much progress has been made in public health workforce research, particularly recently. However, important work still remains to be done. If the field of PHSSR is to be successful in investigating the dynamics of the public health system, and how the system impacts communities, developing a greater understanding of the role and makeup of the public health workforce will be a cornerstone of these efforts. As Woltring and Novick state "The workforce is the most essential element in our collective efforts in assuring the public health."  Public health workers influences all parts of the public health system- they manipulate inputs, develop processes, deliver system outputs, and, as a result, impact the health of the communities that they serve.
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Funded by NLM under Contract HHSN276200800558P. Written by Rick Ingram, M.Ed.,
Robert M. Shapiro II, B.A., and Robin Pendley, MPH, CPH.