Beck, Angela J.

Erwin, Paul Campbell

Leider, Jonathon P.

Yeager, Valerie A.

English

IUPUIScholarWorks

Public Health Undergraduates in the Workforce: A Trickle, Soon a Wave?

providers. For instance, PHWINSdata show that approximately 40%of the employees with a nursingdegree at the state health agencylevel work outside clinical settings,and at the local level, 21% of nurseshold roles that are nonclinical.Deﬁning these roles appropriately iscritical, especially for public healthnursing, as Bekemeier et al.7(p50)note, “the inefﬁcient or improperdeployment of the limited publichealth nursing workforce can ad-versely undermine the health ofwhole populations.”Consideration of the differentlevels of analytic and trainingrequirements is necessary to ﬁlldifferent kinds of roles and pro-grams. Although many consider amaster of public health (MPH)degree a standard for entry intothe ﬁeld, some lower-level posi-tions could be staffed by trainedpublic health workers withbachelor’s degrees. Doing sowould allow public healthagencies to concentrate scarcesalary dollars into a smaller num-ber of MPH-required positionsand have those positions conductthe more sophisticated tasks thattruly require the higher level offormal training that comes with amaster’s degree. This could be aﬁnancially viable alternative forcash-strapped agencies to attractqualiﬁed MPH graduates intogovernmental public health byraising job requirements andsalary levels for these roles.Although salaries are not theonly barrier to public health hir-ing, state and local health de-partments should engage indiscussions regarding how thepublic health workforce perceivesalary and beneﬁts.7 Even thoughbeneﬁts packages in public sectorjobs have been considerablyweakened in recent years, they arestill viewed as a competitive ad-vantage comparedwithbeneﬁts inprivate sector jobs.3 In addition,exploring strategies to implementin states where the funding andauthority exist to maneuver salarybands should be considered. Asthe ﬁeld of governmental publichealth remains poised for gener-ational change, state and localgovernmental public health canand should domore to recruit andretain the best and the brightest.Salary discussions are only oneimportant part of these efforts, butthe likelihood exists that onlybetter ﬁnancial compensation andincentives will help recruitmentand retention, especially for keypublic health occupations.Valerie A. Yeager, DrPH,MPhilJonathon P. Leider, PhDCONTRIBUTORSBoth authors contributed equally to thedraft of and revisions to this editorial. J. P.Leider conducted empirical analyses re-lated to this work.ACKNOWLEDGMENTSThe authors would like to thank FátimaCoronado, MD, MPH, for her contri-butions to and support of this work.The 2017 Public Health Workforce In-terests and Needs Survey was conducted asa collaboration between the Association ofState and Territorial Health Ofﬁcials andthe de Beaumont Foundation. JonathonP. Leider was a consultant to the project.CONFLICTS OF INTERESTThe authors have no conﬂicts of interestto disclose.REFERENCES1. Leider JP, Harper E, Bharthapudi K,Castrucci BC. Educational attainment ofthe public health workforce and its im-plications for workforce development.J Public Health Manag Pract. 2015;21(suppl 6):S56–S68.2. BeckAJ, Leider JP,Coronado F,HarperE. State health agency and local healthdepartment workforce: identifying topdevelopment needs. Am J Public Health.2017;107(9):1418–1424.3. Sellers K, Leider JP, Bogaert K, AllenJD, Castrucci BC. Making a living in gov-ernmental public health: variation in earn-ings by employee characteristics and worksetting. J Public Health Manag Pract. 2019;25(suppl 2, Public Health Workforce Interestsand Needs Survey 2017):S87–S95.4. Liss-LevinsonR, Bharthapudi K, LeiderJP, Sellers K. Loving and leaving publichealth: predictors of intentions to quitamong state health agency workers.J Public Health Manag Pract. 2015;21(suppl 6):S91–S101.5. Monster Worldwide. Despite beingunhappywith their pay, nearly 8 in 10 ﬁndgreat satisfaction with the people theywork with, according toMonster’s GlobalWage Index Report. December 11, 2014.Available at: https://www.monster.com/about/a/workers-unhappy-with-pay-happy-with-coworkers-survey-says-1211. Accessed September 24, 2017.6. Sellers K, Leider JP, Harper E, et al. ThePublic Health Workforce Interests andNeeds Survey: the ﬁrst national survey ofstate agency employees. J Public HealthManag Pract. 2015;21(suppl 6):S13–S27.7. Bekemeier B, Walker Linderman T,Kneipp S, Zahner SJ. Updating the deﬁ-nition and role of public health nursing toadvance and guide the specialty. PublicHealth Nurs. 2015;32(1):50–57.Public Health Undergraduates in theWorkforce: A Trickle, Soon a Wave?See also Sellers et al., p. 674.The recent growth in publichealth undergraduate degreeprograms has been remarkable,with the number of degreeconferrals increasing from 750 in1992 to 6500 in 2012 and 13 000in 2016.1 This growth is in part areﬂection of the attention toundergraduate public health ed-ucation by the Association ofSchools and Programs of PublicHealth (ASPPH) in its Framingthe Futures Initaitive2 and theinclusion of “stand-alone” un-dergraduate degree programs inaccreditation standards of theCouncil on Education for PublicHealth (CEPH).3 These un-dergraduate degree programsspan a wide variety of in-stitutional settings, from thosewith both accredited under-graduate and graduate degreeprograms (e.g., Johns HopkinsUniversity) to those with onlyan undergraduate program (e.g.,Clemson University). Discussionson the purpose and focus ofundergraduate degree programsrange from “the educated citizenand public health model”4 to amore intentional workforcepreparation focus.5The degree to which suchgrowth has affected the publichealth workforce has not beenpreviously documented to ourknowledge.What we do know isthat only a small portion of theABOUT THE AUTHORSPaul Campbell Erwin is an AJPH associate editor and is with the School of Public Health,University of Alabama at Birmingham. Angela J. Beck is with the University of MichiganSchool of Public Health, Ann Arbor. Valerie A. Yeager is with the Richard M. FairbanksSchool of Public Health, Indiana University–Purdue University, Indianapolis. Jonathon P.Leider is with the Division of Health Policy and Management, School of Public Health,University of Minnesota, Minneapolis.Correspondence should be sent to Paul Campbell Erwin, MD, DrPH, School of PublicHealth, University of Alabama at Birmingham, 1665 University Blvd, RPHB 140B, Bir-mingham, AL 35294-0022 (e-mail: perwin@uab.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.This editorial was accepted January 23, 2019.doi: 10.2105/AJPH.2019.305004AJPH PH WINSMay 2019, Vol 109, No. 5 AJPH Erwin et al. Editorial 685public health workforce (14%)has had any formal education inpublic health.6 This promptedour exploration of public healthundergraduate degrees amongemployees who responded to the2014 and 2017 Public HealthWorkforce Interests and NeedsSurvey (PHWINS), as describedin the analytic essay by Sellerset al. (p. 674) in this issue ofAJPH. The essay focuses on ﬁvemajor themes: workforce di-versity, the aging workforce,workers’ salaries and recruitingnew staff, the growth of un-dergraduate public health edu-cation, and workers’ awarenessand perceptions of nationaltrends in the ﬁeld.We provide further perspec-tives on one of the ﬁve themes—the growth of undergraduatepublic health education—andits impact on the public healthworkforce. Overall, in 2014, 505of 22 288 (2.3%) state and localhealth department employeeshad an undergraduate publichealth degree. In 2017, that in-creased to 1851 of 43 701 (4.2%).Those with versus those withoutan undergraduate public healthdegree tended to be younger (asshown in Figure 1 and Figure A,available as a supplement to theonline version of this article athttp://www.ajph.org) and weremore likely to have had a pre-vious job in public health, be acontract or intern employee, beemployed in public health sci-ences (e.g., epidemiologist, en-vironmentalist, or sanitarian),have a higher salary, and have afurther higher public health de-gree. What can we glean fromthese ﬁndings to better un-derstand and prepare for how thegrowth of undergraduate publichealth academic programs mightshape the public health work-force of the future? We renderour opinions on this question,which we raise for purposes offurther debate and discussionacross public health academia andpractice.CONSEQUENCESWe surmise that there areseveral potential consequencesof the growth in undergraduatepublic health degree programs,with a mixture of what we deemto be positive and negative.These perspectives arise from ourcollective experiences in bothacademia and public healthpractice.The Upside1. The growth in undergraduateeducation expands the po-tential for having more publichealth employees with at leastsome level of formal trainingin public health comparedwith earlier yearswhen formaltraining was limited to thosewith an MPH, DrPH, orPhD. This is already shownby the increase in the per-centage of health departmentemployees with an under-graduate public health degreeidentiﬁed in the two PHWINS—from 2.3% in 2014to 4.2% in 2017.2. If we consider the publichealth system writ large—which includes all individuals,organizations, and agenciesthat contribute to the healthof the public—then even ifthe graduate with a bachelor’sdegree in public health doesnot work for a governmentalhealth agency but rathersome other entity within thelarger public health system,we will have a more publichealth–informed workforceoverall. In other words, if thegraduate with a bachelor’sdegree in public health goes tomedical school or gets a job atthe YMCA or with Susan G.Komen, she or he can applyknowledge of populationhealth and community healthprograms (i.e., development,implementation, evaluation)to clinical practice or to thoseorganizations’ initiatives. Thelimited data available onwhere students are goingafter graduation indicate thatsuch penetration may al-ready be taking place. From2014 to 2015 data on 1300graduates, ASPPH reportedthat more than 75% wereemployed and 12% werepursuing further education;of those employed, 34%worked at for-proﬁt in-stitutions, nearly 20% athealth care organizations,and only 11% at govern-mental organizations.1,73. For the graduate with abachelor’s degree in publichealth, creating a bachelor’s toMPHpath that is a 3+2 or 4+1 degree pathway shortens thetime and lessens the ﬁnancialburden of graduate school.This may attract more stu-dents to public health aca-demic programs overall andmore advanced public healthdegree holders to the jobmarket.051015202521–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60% With Public Health Bachelor’s DegreeAge of Staff, YearsSHA CO LHDFIGURE 1—Percentage of State Health Agency Central Ofﬁce (SHA CO) Staff and Local HealthDepartment (LHD) Staff With a Public Health Bachelor’s Degree, by Age and Setting: Public HealthWorkforce Interests and Needs Survey, United States, 2017AJPH PH WINS686 Editorial Erwin et al. AJPH May 2019, Vol 109, No. 5The Downside1. The growth in undergraduatepublic health education mayﬂood the job market anddisplace those with an MPHfrom entry-level positions ingovernmental public healthagencies. With the ongoingchallenges of providingcompetitive salaries in gov-ernmental health agenciescompared with nonproﬁtorganizations and the privatesector, it may simply be easierto hire a person with a publichealth bachelor’s degree and“train them up” to an MPH-equivalent knowledge levelthrough years of experienceon the job.2. Undergraduate public healthstudents may overwhelmgovernmental public healthpractice, nonproﬁt agencies,and other community orga-nizations with the experien-tial activities (e.g., unofﬁcialinternships or work experi-ence) requirement of publichealth bachelor’s degrees.The 2016 revised CEPHaccreditation standardsrequire baccalaureate pro-grams to provide students“opportunities to integrate,synthesize and apply knowl-edge through cumulativeand experiential activities,”and “schools and programs[should] encourage exposureto local-level public healthprofessionals and/or agenciesthat engage in public healthpractice.”3 The governmentalpublic health agency may nothave the capacity to attendto this student body and atthe same time provide ﬁeldplacement sites (e.g., practi-cums, internships) for MPH,DrPH, andmany other healthprofessional students.3. Academic programswill growfaster than CEPH has thecapacity to accredit, threat-ening a reduction in quality tothe lowest possible denomi-nator, whichmay subsequentlyhave negative repercussions forthe workforce. Consideringthe expansion of accreditedschools and programs, thegrowth of all academic degreeprograms—undergraduate,MPH, and doctoral—has beenphenomenal over the past20 years.THE NEED FORADDITIONAL DATAPOINTSThe Sellers et al. article de-scribes major workforce themesidentiﬁedwith both the 2014 and2017 PH WINS data; the twodata points provide a startingplace for identifying trends. Butjust as any good public healthsurveillance requires regularrepetition, we will need regular,consistent ﬁelding of surveys suchas PH WINS to create a publichealth workforce surveillancesystem that informs both practiceand academia. Such data will becritical to examining the poten-tial upsides and downsides ofexpanding undergraduate pub-lic health degree programs. Allof the speculations included inthis editorial should be put tothe test, but in the meantimewe encourage debate and dis-cussion about the changingacademic landscape for publichealth and how that can bestshape the future public healthworkforce.Paul Campbell Erwin, MD,DrPHAngela J. Beck, PhD, MPHValerie A. Yeager, DrPHJonathon P. Leider, PhDCONTRIBUTORSP.C. Erwin conceptualized the editorialand prepared the initial draft. A. J. Beck,V. A. Yeager, and J. P. Leider made sub-stantive contributions to the initial draft.J. P. Leider provided data from the PublicHealth Workforce Interests and NeedsSurvey. All authors participated in theresponse to reviewers and the editorialrevisions and approved the ﬁnal submittedversion.ACKNOWLEDGMENTSThe authors wish to acknowledge thehelpful reviews and comments providedbyAJPH editor-in-chief AlfredoMorabia,MD, PhD, and associate editor Luisa N.Borrell, DDS, PhD.CONFLICTS OF INTERESTThe authors have no conﬂicts of interestto declare.REFERENCES1. Resnick B, Leider JP, Riegelman R.The landscape of US undergraduatepublic health education. Public Health Rep.2018;133(5):619–628.2. Association of Schools and Programs ofPublic Health. Recommended criticalcomponent elements of an undergraduatemajor in public health. 2012. Available at:https://www.aspph.org/teach-research/models/undergraduate-baccalaureate-cce-report. Accessed September 26, 2017.3. Council on Education for PublicHealth. 2016 revised criteria. 2016.Available at: https://media.ceph.org/wp_assets/2016.Criteria.pdf. Accessed De-cember 12, 2016.4. Riegelman RK, Albertine S. Un-dergraduate public health at 4-year in-stitutions: it’s here to stay. Am J Prev Med.2011;40(2):226–231.5. Wykoff R, Khoury A, Stoots JM, PackR. Undergraduate training in publichealth should prepare graduates for theworkforce. Front Public Health. 2015;2:285.6. Sellers K, Leider JP, Harper E, et al. ThePublic Health Workforce Interests andNeeds Survey: the ﬁrst national survey ofstate health agency employees. J PublicHealth Manag Pract. 2015;21(suppl 6):S13–S27.7. Association of Schools and Programs ofPublic Health. ASPPH presents charac-terizing undergraduate public health ed-ucation within the academic public healthcontinuum. 2017. Available at: https://www.aspph.org/event/aspph-presents-characterizing-undergraduate-public-health-education-within-the-academic-public-health-continuum. AccessedJanuary 7, 2019.AJPH PH WINSMay 2019, Vol 109, No. 5 AJPH Erwin et al. Editorial 687

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Public Health Undergraduates in the Workforce: A Trickle, Soon a Wave?

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