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AJPH201719234_Beck 1418..1424 State Health Agency and Local Health Department Workforce: Identifying Top Development Needs Angela J. Beck, PhD, MPH, Jonathon P. Leider, PhD, Fatima Coronado, MD, MPH, and Elizabeth Harper, DrPH Objectives.To identify occupationswith high-priorityworkforce development needs at public health departments in the United States. Methods. We surveyed 46 state health agencies (SHAs) and 112 local health de- partments (LHDs). We asked respondents to prioritize workforce needs for 29 occu- pations and identify whether more positions, more qualified candidates, more competitive salaries for recruitment or retention, or new or different staff skills were needed. Results. Forty-one SHAs (89%) and 36 LHDs (32%) participated. The SHAs reported having high-priority workforce needs for epidemiologists and laboratory workers; LHDs for disease intervention specialists, nurses, and administrative support, management, and leadership positions. Overall, the most frequently reported SHA workforce needs were more qualified candidates and more competitive salaries. The LHDs most fre- quently reported a need for more positions across occupations and more competitive salaries. Workforce priorities for respondents included strengthening epidemiology workforce capacity, adding administrative positions, and improving compensation to recruit and retain qualified employees. Conclusions. Strategies for addressing workforce development concerns of health agencies includeprovidingadditional trainingandworkforcedevelopmentresources,and identifyingbest practices for recruitment and retention of qualified candidates. (Am J Public Health. 2017;107: 1418–1424. doi:10.2105/AJPH.2017.303875) Public health workforce research is an areain which more evidence is needed to better understand how to organize, finance, and effectively deliver public health services.1 Public health workforce studies have pri- marily focused on enumerating governmental public health workers2–5; assessing worker characteristics and educational attainment6–8; identifying occupational trends9–11; de- veloping worker competencies12–15; analyz- ing factors associated with recruitment, retention, and retirement16,17; and identify- ing correlates of job satisfaction.18 Three national surveys periodically collect data on governmental public health work- force characteristics: the profile studies conducted by the Association of State and Territorial Health Officials (ASTHO)10 and the National Association of County and City Health Officials (NACCHO),11 and the Public HealthWorkforce Interests andNeeds Survey.19 Collectively, these studies have reported a reduction in workforce size since 2008, a shift in the types of occupations employed in state health departments, and limited formal public health training, with an estimated 17% holding a public health degree.8,10,11 However, the field continues to seek definitive answers con- cerning the number of workers required to deliver public health services and recog- nizes certain knowledge gaps, including the types of skills, educational backgrounds, and occupations needed for core tasks and functions required by public health de- partments.20 Ongoing national public health reform efforts, including the Foundational Public Health Services approach and Public Health 3.0, also have a strong workforce focus.21,22 To identify public health workforce needs and determine areas requiring workforce development, the University of Michigan Center of Excellence in Public Health Workforce Studies implemented the Public Health Workforce Gaps Study in collabo- ration with ASTHO and with support from the Centers for Disease Control and Pre- vention. The goals of this study were to (1) identify occupations with perceived work- force development needs, (2) determine the types of workforce development needs by occupation, and (3) gain knowledge re- garding workforce turnover and succession planning. This report focuses on state and local health department workforce develop- ment needs by occupation. METHODS We designed the Public Health Work- force Gaps Study as an explanatory mixed methods23 project that included an agency- level survey of state health agencies (SHAs) and local health departments (LHDs) in the United States, conducted in summer 2016. Although not included in this article, we also conducted follow-up interviews with select survey respondents. Survey ABOUT THE AUTHORS Angela J. Beck is with the Center of Excellence in Public Health Workforce Studies, University of Michigan School of Public Health, Ann Arbor. Jonathon P. Leider is with JP Leider Research and Consulting, Minneapolis, MN. Fatima Coronado is with Center for Surveillance Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA. Elizabeth Harper is with Association of State and Territorial Health Officials, Arlington, VA. Correspondence should be sent to Angela J. Beck, PhD, MPH, Clinical Assistant Professor of Health Behavior and Health Education, Associate Director, Center of Excellence in Public Health Workforce Studies, University of Michigan School of Public Health, 1420 Washington Heights, Ann Arbor, MI 48109 (e-mail: ajbeck@umich.edu). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This article was accepted April 18, 2017. doi: 10.2105/AJPH.2017.303875 1418 Research Peer Reviewed Beck et al. AJPH September 2017, Vol 107, No. 9 AJPH RESEARCH mailto:ajbeck@umich.edu http://www.ajph.org http://www.ajph.org development began during fall 2015 and included pretesting with ASTHO staff and 2 sets of cognitive interviews with 7 public health practitioners. We distributed the online survey to human resource personnel and senior deputies in 46 SHAs and senior leadership in a random sample of 112 LHDs across the US human resource staff, and we encouraged senior leadership to complete the organizational survey together. We considered the LHD study segment a pilot to test this methodology in local set- tings. The sample included a mix of geo- graphical, organizational, and governance status characteristics but was not designed to be nationally representative. Approximately two thirds of the LHDs sampled served communities with 100 000 or more persons and one third served fewer than 100 000 persons. Ninety-four sample LHDs were locally governed, 13 were governed by the state health agency, and 5were under a shared governance structure. The LHDs were sampled evenly geographically. We offered respondents a list of 29 oc- cupations selected from the Public Health Workforce Taxonomy24 and workforce needs were assessed (Table A, available as a supplement to the online version of this article at http://www.ajph.org, for occupa- tion definitions). Because we did not wish to constrain respondents to needs that were only within the agency’s current financial wherewithal to address, we asked the fol- lowing: “If your agency had sufficient funds to address workforce needs, which occupa- tions would you consider to have relatively higher priority and lower priority needs?” Respondents grouped the occupations into 3 categories, on the basis of their own set of criteria: higher priority, lower priority, or “not applicable” (i.e., occupations not employed by and not needed by the agency). For all occupations categorized as higher or lower priority, we asked respondents to identify whether the following workforce need categories were applicable: more posi- tions, more qualified candidates, more competitive salaries for recruitment or re- tention, new or different skills, “other” workforce development needs, or no workforce development needs. We collected additional information on training needs if “new or different skills” was selected and “other” needs if selected. To better characterize SHA responses, we added variables used in previous studies10,11 to the state data set: type of governance structure (i.e., decentralized, centralized, shared, or mixed); population size of the jurisdiction served (i.e., small: £ 2 750000; medium: 2 750001–6 250000; large: > 6250000); and geographical regions coded as follows: New England= states in US Department of Health and Human Services (HHS) Regions 1 and 2; Mid-Atlantic/Great Lakes=HHS regions 3 and 5; South =HHSRegions 4 and 6;Mountains/Midwest=HHSRegions 7 and 8; and West=HHS Regions 9 and 10. We did not include US territories in this study. We conducted analyses of LHD and SHA descriptive statistics in aggregate. We also analyzed SHA data by geographical region, population size, and governance structure emphasizing the occupations most fre- quently identified as having high work- force priority needs as a means for summarizing the occupations of highest priority. We managed quantitative data in Microsoft Excel 2016 (Microsoft Corpora- tion, Redmond, WA) and analyzed them in Stata 13.1 (StataCorp LP, College Station, TX). RESULTS Forty-one of 46 SHAs (89%) responded to the survey, as did 36 of 112 LHDs (32%). One SHA did not report workforce needs, leaving 40 SHA responses for these analyses. The SHA respondents collectively included 24 human resource personnel, 17 senior deputies, 2 health agency directors, and 8 other staff. The majority of respondents were from SHAs with decentralized governance structures (n = 23), followed by centralized (n = 9), and mixed or shared (n = 8), and served communities with small (n = 13), medium (n= 13), and large (n = 14) pop- ulation size. The SHA respondents most frequently represented the Mid-Atlantic/ Great Lakes region (n= 10), followed by the South and Mountains/Midwest regions (n = 9 each), New England (n= 7), and the West (n = 5). The LHD respondents included 19 local health officials, 15 senior deputies, 4 human resource personnel, and 9 others. Twenty-six LHDs served communities of 100 000 or more persons; 10 served com- munities of fewer than 100 000 persons. The SHA respondents most frequently identified the highest-priority workforce needs in the following occupations: epide- miologists (88%); laboratory workers (73%); public health informatics specialists (72%); licensure, regulatory, or enforcement staff (68%); program managers (65%); environ- mental health workers (65%); disease in- tervention specialists (63%); information systems specialists (63%); public health and community health nurses (63%); and department directors (60%; Table 1). Overall, the most frequently reported workforce need types were more qualified candidates and more competitive salaries; fewer respondents reported need for more TABLE 1—State Health Agency Workforce Development Needs by Top High-Priority Occupations: Public Health Workforce Gaps Study, United States, 2016 Workforce Need Priority, No. (%) Occupation No. Higher Priority Lower Priority Not Applicable Epidemiologist 40 35 (88) 5 (13) 0 (0) Laboratory worker 40 29 (73) 10 (25) 1 (3) Public health informatics specialist 39 28 (72) 11 (28) 0 (0) Licensure, regulatory, or enforcement worker 40 27 (68) 12 (30) 1 (3) Public health or program manager 40 26 (65) 14 (35) 0 (0) Environmental health worker 40 26 (65) 13 (33) 1 (3) Disease intervention specialist 40 25 (63) 13 (33) 2 (5) Information systems specialist 40 25 (63) 10 (25) 5 (13) Public health or community health nurse 40 25 (63) 12 (30) 3 (8) Program or department director 40 24 (60) 13 (33) 3 (8) AJPH RESEARCH September 2017, Vol 107, No. 9 AJPH Beck et al. Peer Reviewed Research 1419 http://www.ajph.org positions or need for workers to learn new or different skills. However, the specific workforce needs differed by occupations. At least 80% of SHA respondents reported a need for more com- petitive salaries to recruit and retain epide- miologists (89%), laboratory workers (86%), public health managers (85%), disease in- tervention specialist (85%), information sys- tems specialists (84%), and public health informatics specialists (81%). A need for more qualified candidates was reported for every occupation by at least half of SHAs, with public health informatics specialist (85%), information systems specialist (80%), and programor department director (74%) among themost frequently reported. Furthermore, at least half