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local public health agency, nursing shortage, rural public health, rural safety net, workforce



  1. Hajat, Anjum
  2. Stewart, Karen
  3. Hayes, Kathy L.


This work describes the public health workforce and training needs of rural local public health agencies (LPHAs) in comparison with suburban and metropolitan LPHA jurisdictions. A survey was sent to 1,100 LPHAs nationwide. The rural urban commuting area codes (RUCAs) defined LPHAs as rural or urban, and the Standard Occupational Classification system enumerated the workforce. Most occupational classifications had significantly fewer staff in rural LPHAs. Public health nurses ranked as the most needed staff and serve in various important capacities in rural LPHAs. In terms of training, job-specific or programmatic continuing education was identified as the most important training need. Developing leadership and public health workforce capacity within rural public health is an essential agenda item for rural America. Decision makers may need to consider different organizational structures while balancing the need for local input and control. Regionalization and collaborative approaches to difficult workforce issues may present potential solutions to workforce challenges.


In its recent publication, The Future of the Public's Health in the 21st Century, the Institute of Medicine noted, "Under the glare of a national crisis, policy makers and the public became aware of vulnerable and outdated health information systems and technologies; an insufficient and inadequately trained public health workforce; antiquated laboratory capacity; lack of real-time surveillance and epidemiological systems; ineffective and fragmented communications networks; incomplete domestic preparedness and emergency response capabilities; and communities without access to essential public health services. These problems leave the nation's health vulnerable [horizontal ellipsis]."


These issues, however timely, are not news to the public health community. In 1988, the Institute of Medicine Committee for the Study of the Future of Public Health stated, "[horizontal ellipsis] no citizen from any community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection [horizontal ellipsis]."2(p.9) There has been a general consensus that the fabric of the public health infrastructure is badly frayed.


A well-trained public health workforce is an essential component to an effective public health system. Descriptions of the public health workforce paint a picture of a multidisciplinary group of professionals with disparate educational backgrounds in various health care and related fields. Leaders have frequently worked their way through the ranks, and may or may not have formal training in public health.2-5 One analysis noted that 78 percent of local public health agency (LPHA) executives had no formal public health training and the likelihood that an LPHA executive would have such training decreased in jurisdictions with smaller populations. 6


The issue of public health training has become critically important. A number of competencies for public health professionals have been identified and curricula for training have been developed to ensure a capable and well-rounded workforce able to perform the essential services of public health. Measures proposed to strengthen the public health workforce have included distance-learning technologies; improving linkages between academics and practice; and creating incentives and certification programs. 2-4,7-9


Despite the attention to the public health workforce over the past several years, there is surprisingly little documentation of the rural public health workforce. A February 2000 report 10 to the Secretary of the Department of Health and Human Services on rural public health issues identified workforce preparedness as one of six areas of concern, and stated that, "Rural health departments face a continuing problem attracting and retaining the proper mix of public health professionals. Further, there is a growing need to improve continuing education opportunities [horizontal ellipsis]."(p.10) The report went on to urge an immediate broad-based strategy for improving the skills of the current rural public health workforce. 10


Elsewhere, discussions of the rural public health workforce were limited to single-state or regional analysis. A report on the professional public health workforce in Texas stated that the geographic distribution of the state's public health workforce was concentrated in population centers, suggesting a possible urban-rural maldistribution. 11 Similarly, a comparison of public health infrastructure in four frontier states noted a relationship between low population density/community isolation and the reduction or even absence of public health services. 12 Two studies of LPHAs in predominantly rural western states noted fairly profound differences in organizational structure among the states, yet similar public health workforce composition and supply, with nurses filling the vast majority of positions. The authors also noted that a major component of LPHA activities in the states studied is direct medical services, and that many LPHA administrators identified the lack of staff with previous public health training or experience as a major problem in reaching their agency's public health goals. 13,14


The purpose of this article is to describe the public health workforce and training needs of rural LPHAs in comparison with suburban and metropolitan LPHA jurisdictions.