Northern Nevada Public Health: Utilizing the Public Health Workforce Calculator and Workforce Capacity Self-assessment Tools to Develop a Framework for Workforce Investment.

CONTEXT: Health departments nationally are critically understaffed and lack infrastructure support. By examining current staffing and allocations through a Foundational Public Health Services (FPHS) lens at the Northern Nevada Public Health (NNPH), there is an opportunity to make a strong case for greater investment if current dedicated full-time equivalents are inadequate and to guide which investments in public health workforce are prioritized. OBJECTIVE: To assess the use of the Public Health Workforce Calculator (calculator) and other tools to identify and prioritize FPHS workforce needs in a field application. DESIGN: Field application of the calculator in conjunction with the use of FPHS workforce capacity self-assessment tools. SETTING: NNPH. PARTICIPANTS: NNPH and Public Health Foundation (PHF). INTERVENTION: From June 2022 through April 2023, PHF collaborated with NNPH, serving Washoe County, to provide expertise and assistance as NNPH undertook an assessment of its workforce needs based upon the FPHS model. MAIN OUTCOME MEASURES: Comparison of the calculator output with FPHS workforce capacity self-assessment tools. RESULTS: The calculator and the FPHS capacity self-assessment process yielded complementary FPHS workforce capacity gap data. The use of a structured and transparent process, coupled with additional tools that included prioritizing needs, provided a viable and sustainable process for public health workforce investment planning. NNPH successfully utilized the results to bolster a supplemental funding request and a state public health appropriation. CONCLUSIONS: The use of the calculator and an FPHS workforce capacity self-assessment in a facilitated and structured process such as that used by NNPH to identify staffing priorities may hold promise as an approach that could be used to support decision-making and justification for infrastructure resources when funding for public health increases in the future.

Estimating Public Health Workforce Efforts Toward Foundational Public Health Services.

CONTEXT: The Foundational Public Health Services (FPHS) include a core set of activities that every health department should be able to provide in order to ensure that each resident has access to foundational services that protect and preserve health. Estimates of the public health workforce necessary to provide the FPHS are needed. OBJECTIVE: This study assessed the potential use of an FPHS calculator to assess health department workforce needs. DESIGN AND SETTING: Qualitative interviews were conducted via Zoom in December 2020-January 2021. PARTICIPANTS: Seventeen state and local public health leaders. MAIN OUTCOME MEASURES: Qualitative insights into the potential use of an FPHS calculator. RESULTS: Almost all participants expressed that a reliable estimate would help them justify requests for new staff and that a calculator based on the FPHS would help organizations to critically assess whether they are meeting the needs of their communities and the core expectations of public health. Although participants expected that a tool to calculate full-time equivalent needs by the FPHS would be helpful, some participants expressed concerns in regard to using the tool, given ongoing workforce issues such as recruitment challenges, hiring freezes, and funding restrictions. An anticipated positive consequence of using this tool was that it may lead to cross-training the workforce and result in more diverse expertise and skills among existing workers. The other unintended consequences were that an FPHS calculator would require a substantial amount of time assessing the current FPHS efforts of existing staff and the results of the FPHS gap estimate could become the bar rather than the minimum needed. CONCLUSIONS: The current public and political focus on public health infrastructure as a result of the COVID-19 pandemic has created a window of opportunity to create change. An FPHS-based staffing tool may help transform public health and initiate a new era.

Public Health Graduates and Employment in Governmental Public Health: Factors That Facilitate and Deter Working in This Setting.

OBJECTIVES: Previous surveys of public health graduates examine where they work; however, little is known about public health graduates' employment decisions or the factors that facilitate interest or deter interest in working in governmental public health settings. The purpose of the current pilot study was to build on the information previously collected in graduate surveys by expanding questions to undergraduates and asking about decisions and factors that influence choices of employment. METHODS: A pilot survey of graduates of public health programs was conducted. Respondents provided information about their degree programs, year of graduation, and current employment. Questions asked where they applied for jobs, factors they considered, experiences with the application processes, and so forth. Descriptive statistics were calculated using frequencies and proportions. Open-ended responses were qualitatively reviewed and general themes were extracted. RESULTS: Employment preferences were ranked the highest for not-for-profit organizations (ranked first among 21 of 62, 33.9%), followed by governmental public health agencies (ranked first among 18 of 62, 29.0%). Among master of public health graduates, 54.7% sought employment within this setting, although only 17.0% of those employed full time at the time of the survey were employed within a governmental public health agency. Job security (84.7%), competitive benefits (82.2%), identifying with the mission of the organization (82.2%), and opportunities for training/continuing education (80.6%) were the most influential, positive factors garnering interest in working in governmental public health. Factors that were the biggest deterrents included the ability to innovate (19.2%), competitive salary (17.8%), and autonomy/employee empowerment (15.3%). CONCLUSIONS: Approximately half of the respondents applied for a job within governmental public health in anticipation of or since graduating. However, only a quarter of employed respondents are currently working within governmental public health, suggesting a missed opportunity for recruiting the other quarter who applied and were interested in governmental positions.

Needling Policy Makers and Sharpening the Debate: Do Syringe Exchange Programs Improve Health at the Population Level?

CONTEXT: In the midst of the current opioid epidemic, states have selected differing legislative routes implementing pathways to ensure access to clean needles and syringes. OBJECTIVE: To determine whether states that implemented laws supporting syringe exchange programs (SEPs) had reductions in transmission rates of hepatitis B, hepatitis C, and HIV infection compared with states without such laws. DESIGN AND SETTING: Utilizing a longitudinal panel design, we determined the legal status of SEPs in each state for years 1983-2016. Disease transmission rates for this period were estimated via a simple Poisson regression, with transmitted cases as the dependent variable, law categories as the predictor variables, and the log of state population as the exposure. The mean number of incident cases per state-year was also calculated. PARTICIPANTS: US states were utilized as the unit of analysis. RESULTS: Hepatitis B and hepatitis C mean transmission rate per 100 000 population declined in states with local ordinances/decriminalized statutes and legalized SEPs (hepatitis B: 71% and 81%, respectively, differences P < .001; hepatitis C: 8% and 38%, respectively, differences P < .001). Reductions in mean incident cases per state-year mirrored these findings. HIV infection among injection drug users yielded inconsistent results. CONCLUSIONS: Hepatitis B and hepatitis C transmission were reduced at the population level in states with SEP laws in a pattern reflecting the degree of legal intervention. HIV infection, based upon a smaller data set, showed a mixed impact. POLICY IMPLICATIONS: The results show promise that SEPs have population-level effects on disease transmission. States lacking SEPs should reconsider current policies.

Maintaining a Competent Public Health Workforce: Lessons Learned From Experiences With Public Health Accreditation Domain 8 Standards and Measures.

CONTEXT: Public health accreditation is an ongoing national movement to improve the quality of public health departments and the public health system in the United States; however, calls have been made for more evidence regarding best practices in the accreditation process. OBJECTIVE: The purpose of this work is to provide evidence about best practices in the accreditation process, specifically within the workforce development domain. It is the first in-depth investigation into workforce development using data collected by Public Health Accreditation Board (PHAB). DESIGN: Using deidentified accreditation application data from PHAB, this study employs a mixed-methods approach to examining practices, lessons learned, challenges, and strategies pertaining to workforce development planning for Domain 8. SETTING: United States. PARTICIPANTS: US state (n = 19) and local health departments (n = 115). MAIN OUTCOME MEASURES: Public Health Accreditation Board assessment scores for the workforce measures and the relationship between the health department's approach to meeting a PHAB measure criteria and the PHAB assessment score. RESULTS: Of the 9 different approaches identified as ways of encouraging the development of a sufficient number of qualified public health workers (version 1, measure 8.1.1), only 1 approach (local health department internship programs with schools of public health; B = 0.25, P < .03) was significantly related to higher scores. An opportunity for improvement identified for measure 8.2.1 was that plans missing a clear identification of the gap between current staff competencies and staff needs were associated with a 0.88-point decrease in the 4-point score (P < .001). CONCLUSIONS: Findings suggest that there are approaches adopted for meeting PHAB domain 8 measures that will impact the overall conformance assessment and score of a health department pursuing accreditation. There are several opportunities for improvement that health departments might consider when planning for accreditation or assessing their activities.

The State of the US Governmental Public Health Workforce, 2014-2017.

Public health workforce development efforts during the past 50 years have evolved from a focus on enumerating workers to comprehensive strategies that address workforce size and composition, training, recruitment and retention, effectiveness, and expected competencies in public health practice. We provide new perspectives on the public health workforce, using data from the Public Health Workforce Interests and Needs Survey, the largest nationally representative survey of the governmental public health workforce in the United States. Five major thematic areas are explored: workforce diversity in a changing demographic environment; challenges of an aging workforce, including impending retirements and the need for succession planning; workers' salaries and challenges of recruiting new staff; the growth of undergraduate public health education and what this means for the future public health workforce; and workers' awareness and perceptions of national trends in the field. We discussed implications for policy and practice.

Perceptions of Public Health 3.0: Concordance Between Public Health Agency Leaders and Employees.

CONTEXT AND BACKGROUND: The newest era of public health, deemed "Public Health 3.0," supports cross-sector collaborations to address social determinants of health. These activities often require collaborations with nontraditional public health entities. As this new era begins, it is important to understand perceptions of the public health workforce with regard to Public Health 3.0. OBJECTIVE: To assess perceptions of support toward Public Health 3.0 activities by the public health workforce, identify characteristics associated with support, and measure concordance in support between agency directors and the general workforce. DESIGN: This cross-sectional study utilizes the 2017 Public Health Workforce Interests and Needs Survey to understand support and concordance regarding Public Health 3.0 activities by a nationally representative sample of governmental public health employees. Logistic regression models are used to identify characteristics associated with support of each 3.0 activity and concordance. MAIN OUTCOME MEASURES: Governmental public health employees' opinions on how involved their agency should be in the K-12 education system, the economy, the built environment, transportation, housing, social connectedness, and health equity within their jurisdiction and concordance in support of involvement between agency directors and the general workforce. RESULTS: Overall, individual perceptions supporting involvement were highest for health equity and social connectedness and lowest for transportation. Supervisory status, education, and being at a local health department were associated with greater odds of supporting all 3.0 activities. Concordance with agency directors was greatest among other executives relative to nonsupervisors. CONCLUSIONS: There is overall generally high support of many 3.0 activities, but there are gaps in agreement by supervisory status, gender, race/ethnicity, education, role type, and jurisdiction. Findings may help support agency leaders in better communicating the role of their agencies in Public Health 3.0 activities, and workforce education regarding such activities may be necessary for the success of Public Health 3.0's success.

The Relationship Between Health Department Accreditation and Workforce Satisfaction, Retention, and Training Needs.

BACKGROUND: To improve quality and consistency of health departments, a voluntary accreditation process was developed by the Public Health Accreditation Board. Understanding accreditation's role as a mediator in workforce training needs, satisfaction, and awareness is important for continued improvement for governmental public health. OBJECTIVE: To compare differences in training needs, satisfaction/intent to leave, and awareness of public health concepts for state and local health department staff with regard to their agency's accreditation status. DESIGN: This cross-sectional study considered the association between agency accreditation status and individual perceptions of training needs, satisfaction, intent to leave, and awareness of public health concepts, using 2017 Public Health Workforce Interests and Needs Survey (PH WINS) data. Respondents were categorized on the basis of whether their agencies (at the time of survey) were (1) uninvolved in accreditation, (2) formally involved in accreditation, or (3) accredited. RESULTS: Multivariate logistic regression models found several significant differences, including the following: individuals from involved state agencies were less likely to report having had their training needs assessed; staff from accredited and involved agencies identified more gaps in selected skills; and employees of accredited agencies were more aware of quality improvement. While state employees in accredited and formally involved agencies reported less job satisfaction, there were no significant differences in intent to leave or burnout. Differences were identified concerning awareness of various public health concepts, especially among respondents in state agencies. CONCLUSIONS: While some findings were consistent with past research (eg, link between accreditation and quality improvement), others were not (eg, job satisfaction). Several self-reported skill gaps were unanticipated, given accreditation's emphasis on training. Potentially, as staff are exposed to accreditation topics, they gain more appreciation of skills development needs. Findings suggest opportunities to strengthen workforce development components when revising accreditation measures.

Has Voluntary Public Health Accreditation Impacted Health Department Perceptions and Activities in Quality Improvement and Performance Management?

CONTEXT: The Public Health Accreditation Board (PHAB) is now in its 10th year, making it an ideal time to study the impact of PHAB accreditation on local health departments (LHDs). OBJECTIVE: To examine whether applying for PHAB accreditation affects perceptions and activities regarding quality improvement (QI) and performance management (PM) within LHDs. DESIGN: Data from the National Association of County & City Health Officials' 2010, 2013, and 2016 National Profile of Local Health Departments and associated QI modules were linked to PHAB-applicant data collected in e-PHAB in a cross-sectional and longitudinal approach examining self-reported QI/PM activities. PARTICIPANTS: Local health departments responding to National Association of County & City Health Officials Profile questionnaires and QI modules in 2010, 2013, and 2016. MAIN OUTCOME MEASURES: Implementation of formal QI program within agency, numbers of formal QI projects in the past year, presence of elements indicating formal QI program implementation, and changes over time by accreditation status as of June 2017. RESULTS: Accredited and in-process LHDs showed greater gains over time in all of the outcome measures than LHDs not registered in e-PHAB. Results of logistic regression controlling for population served and governance type found accredited LHDs more likely to report formal QI programs agency-wide (odds ratio: [OR] = 27.0; P < .001) and have implemented 6 to 8 elements of formal QI (OR = 27.0; P < .001) in 2016, compared with nonaccreditation-seeking LHDs. Between 2013 and 2016, LHDs that responded to both survey waves that were registered in e-PHAB or accredited were significantly more likely than nonaccreditation-seeking LHDs to report any increase in overall level of QI implementation (OR = 4.89; P = .006) and increase in number of elements of formal QI (OR = 16.1; P < .001). CONCLUSIONS: Local health departments accredited by June 2017 and those in process reported more formal QI activities and showed greater improvements with QI/PM implementation over time than LHDs not undertaking accreditation. Public Health Accreditation Board accreditation appears to influence QI/PM uptake. As health departments are contemplating whether to apply for accreditation, the potential for developing a more robust QI/PM system should be taken into account.

National Voluntary Public Health Accreditation: Are More Local Health Departments Intending to Take Part?

OBJECTIVE: This article examines local health department (LHD) participation and intentions to participate in national voluntary accreditation and reasons for not seeking accreditation. Specifically, it compares the results of national surveys among LHDs in 2010, 2013, and 2014. DESIGN: Longitudinal cohort study. SETTING: United States. PARTICIPANTS: LHDs that responded to the 2014 Forces of Change Survey and the 2010 and 2013 National Association of County and City Health Officials Profile studies. MAIN OUTCOME MEASURES: LHD level of engagement in Public Health Accreditation Board (PHAB) accreditation. RESULTS: Data of 2014 indicated that 1% of LHDs achieved accreditation and 11% had submitted an application or a statement of intent, compared with 6% of LHDs that submitted an application or a statement of intent in 2013. The percent of LHDs that indicated they planned to apply for accreditation but had not submitted a statement of intent declined from 27% in 2013 to 22% in 2014. In multivariate models, controlling for governance category and jurisdiction population size, LHDs in states where the state health department (SHD) participated in e-PHAB had higher odds of being favorably inclined toward accreditation than those located in states where the SHD was not in the e-PHAB system (odds ratio = 2.82, 95% confidence interval: 1.81-4.41). Across 2013 and 2014, and across small and large LHDs, the top 2 reasons for deciding not to apply for accreditation were the time/effort required exceeded the benefits (67%) and fees were too high (46%). CONCLUSIONS: SHDs are powerful mediators of LHDs' perceptions of the PHAB accreditation program. Health department governance structure and jurisdiction population size are associated with LHD accreditation participation decisions. With the launch of PHAB's program, fewer LHDs are undecided about accreditation participation and many have taken affirmative steps to become accredited. The top 2 reasons LHDs indicated for not proceeding with accreditation were time/effort exceed benefit and fees perceived as too high.

Deciphering the imperative: translating public health quality improvement into organizational performance management gains.

With the launching of the national public health accreditation program under the auspices of the Public Health Accreditation Board (PHAB), health department momentum around quality improvement adoption has accelerated. Domain 9 of the PHAB standards (one of 12 domains) focuses on evaluation and improvement of performance and is acting as a strong driver for quality improvement and performance management implementation within health departments. Widespread adoption of quality improvement activities in public health trails that in other US sectors. Several performance management models have received broad acceptance, including models among government and nonprofits. A model specifically for public health has been developed and is presented herein. All models in current use reinforce customer focus; streamlined, value-added processes; and strategic alignment. All are structured to steer quality improvement efforts toward organizational priorities, ensuring that quality improvement complements performance management. High-performing health departments harness the synergy of quality improvement and performance management, providing powerful tools to achieve public health strategic imperatives.

Marshaling the evidence: the prioritized public health accreditation research agenda.

A national public health department accreditation program was recently developed and implemented by the Public Health Accreditation Board (PHAB) to improve the quality and performance of public health departments. Because of its potential to transform public health, it is critical that the evidence base around accreditation be strong. With input from public health practitioners and researchers, PHAB developed a research agenda that highlights priority questions related to barriers and facilitators to seeking and obtaining accreditation, the PHAB standards and review process, metrics to determine the impact of accreditation, and benefits and outcomes associated with accreditation for the departments that undergo the process. We present that agenda, discuss the potential challenges of conducting accreditation research, and call on researchers to build a greater base of evidence related to accreditation.

Local Public Health Department Characteristics Associated With Likelihood to Participate in National Accreditation.

OBJECTIVES: We examined factors associated with completing, initiating, or intending to pursue voluntary national accreditation among local health departments (LHDs). METHODS: We examined National Association of County and City Health Officials 2010 and 2013 profile data in a pooled cross-sectional design with bivariate and multivariable regression analyses. We conducted individual multivariable models with interest in accreditation and likely to accredit as outcome variables, comparing changes between 2010 and 2013. RESULTS: LHDs with formal quality improvement programs are significantly more likely to have initiated or completed the accreditation process (odds ratio [OR] = 7.99; confidence interval [CI] = 1.79, 35.60), to be likely to accredit (OR = 2.41; CI = 1.65, 3.50), or to report an interest in accreditation (OR = 2.32; CI = 1.67, 3.20). Interest was lower among LHDs in 2013 than in 2010 (OR = 0.56; CI = 0.41, 0.77); however, there was no difference regarding being likely to accredit. LHDs with a high number of full-time equivalent employees were more likely to indicate being likely to accredit or interest in accreditation. CONCLUSIONS: Quality improvement may facilitate the accreditation process or be a proxy measure for an unmeasurable LHD attribute that predicts accreditation.

Defining the functions of public health governance.

We conducted a literature review in 2011 to determine if accepted governance functions continue to reflect the role of public health governing entities. Reviewing literature and other source documents, as well as consulting with practitioners, resulted in an iterative process that identified 6 functions of public health governance and established definitions for each of these: policy development; resource stewardship; continuous improvement; partner engagement; legal authority; and oversight of a health department. These functions provided context for the role of governing entities in public health practice and aligned well with existing public health accreditation standards. Public health systems research can build from this work in future explorations of the contributions of governance to health department performance.

Measuring public health practice and outcomes in chronic disease: a call for coordination.

A strategic opportunity exists to coordinate public health systems and services researchers' efforts to develop local health department service delivery measures and the efforts of divisions within the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to establish outcome indicators for public health practice in chronic disease. Several sets of outcome indicators developed by divisions within NCCDPHP and intended for use by state programs can be tailored to assess outcomes of interventions within smaller geographic areas or intervention settings. Coordination of measurement efforts could potentially allow information to flow from the local to the state to the federal level, enhancing program planning, accountability, and even subsequent funding for public health practice.

From patchwork to package: implementing foundational capabilities for state and local health departments.

Daily public health responses are threatened by the inadequate capacity of public health agencies. A 2012 Institute of Medicine report defined a package of foundational capabilities that support all programs and services within a health department. Standardizing foundational capabilities may help address the increasing disparity in health department performance nationally. During the Fall of 2013, we collected information on how much state and local health departments knew about foundational capabilities. To our knowledge, this was the first study to assess current health department infrastructure as it relates to foundational capabilities.

Practitioner perspectives on foundational capabilities.

CONTEXT: National efforts are underway to classify a minimum set of public health services that all jurisdictions throughout the United States should provide regardless of location. Such a set of basic programs would be supported by crosscutting services, known as the "foundational capabilities" (FCs). These FCs are assessment services, preparedness and disaster response, policy development, communications, community partnership, and organizational support activities. OBJECTIVE: To ascertain familiarity with the term and concept of FCs and gather related perspectives from state and local public health practitioners. DESIGN: In fall 2013, we interviewed 50 leaders from state and local health departments. We asked about familiarity with the term "foundational capabilities," as well as the broader concept of FCs. We attempted to triangulate the utility of the FC concept by asking respondents about priority programs and services, about perceived unique contributions made by public health, and about prevalence and funding for the FCs. SETTING: Telephone-based interviews. PARTICIPANTS: Fifty leaders of state and local health departments. MAIN OUTCOME MEASURES: Practitioner familiarity with and perspectives on the FCs, information about current funding streams for public health, and the likelihood of creating nationwide FCs that would be recognized and accepted by all jurisdictions. RESULTS: Slightly more than half of the leaders interviewed said that they were familiar with the concept of FCs. In most cases, health departments had all of the capabilities to some degree, although operationalization varied. Few indicated that current funding levels were sufficient to support implementing a minimum level of FCs nationally. CONCLUSIONS: Respondents were not able to articulate the current or optimal levels of services for the various capabilities, nor the costs associated with them. Further research is needed to understand the role of FCs as part of the foundational public health services.