Over the last two decades, a series of national reports have expressed concern with the readiness of the public health workforce to adequately address the scientific, technological, social, political and economic challenges facing the field. The 1988 report from the Institute of Medicine's (IOM) Committee for the Study of the Future of Public Health served as a catalyst for the re-examination of the public health infrastructure and the workforce in particular. The Committee's call to increase the relevance of public health education and training for public health practice prompted a renewed effort to identify the scientific, technical, managerial and leadership competences needed by public health personnel in the field and the organizations that employ them . In 2003, the IOM reiterated its call for action to train public health workers in core competences, specifically those working in public health departments .
Despite impressive gains over the past decades, many public health challenges remain. Changes in communicable disease control (HIV/AIDS, tuberculosis) and the evolution of social and behavioural problems (violence, addiction, obesity) have precipitated a renewed focus on population-based approaches to solving these problems [3–5]. Beaglehole and Dal Poz found that, in spite of the best efforts of academicians and policy-makers since the 1998 IOM report, little has been done and the "current organization and delivery of public health services are inadequate for these new challenges" . These sentiments are shared by other experts as well, with Rowitz noting that the curriculum taught in many public health programmes may no longer be sufficient or effective in meeting future demands . To meet the challenges of current public health problems, national leaders in the United States have encouraged local health departments (LHDs) to reduce direct-care, personal health services and focus more intentionally on population-based approaches to protect and promote health and to prevent disease and injury [1, 4].
Since the 1988 IOM report, a number of researchers have sought to assess the education needs of the public health workforce. Several recent studies have addressed these concerns. One report addressed current deficits in the training of health educators. Allegrante et al. posed the question: "What are the skills that currently employed personnel need that they do not have?" and identified eight areas of competence and skill that were lacking .
A second study, conducted by researchers from the Pennsylvania and Northeast Public Health Workforce Training Project, identified universal competences and training priorities for the public health workforce in Maine, New Jersey, Pennsylvania, Rhode Island and Vermont . A third study – of public health workers in Alabama, Arkansas, Louisiana and Mississippi-suggested a strong need for training in essential public health services .
More recently, public health workforce preparedness has taken on new urgency in response to the 2001 terrorist attacks, anthrax being sent through the United States postal system, the SARS outbreak and the spread of bird flu. An assessment of the public health workforce in North Carolina included an evaluation of core public health competences and emergency preparedness . A study in Georgia focused exclusively on understanding the learning needs of the public health workforce as related to bioterrorism and emerging health threats, establishing baseline data for evaluating future training programmes .
At the national level, an assessment of the training needs of LHD executive administrators provided a direct measure of the backgrounds of key administrators at formal local public health agencies across the country. In general, they found that nearly 80% of the respondents had no formal public health training .
Prior to this study, a group of Texas researchers examined characteristics of the public health workforce in Texas . Kennedy et al. developed a two-stage sample survey to estimate the size of the workforce in the state and to describe settings as well as job and personnel characteristics. They concluded by raising concerns about the adequacy of the formal education of the public health workforce in Texas, providing the catalyst for the research described here.
Despite the flurry of research in the area over the past years, a number of important questions have been insufficiently explored: First, which types of public health workers need additional training in public competences? For example, do nurses and health educators have the same training needs? Second, do training needs vary by public health setting? For example, do public health workers employed by the state health department have the same training needs as those employed in LHDs?
Defining the public health workforce
Effective training and education for a continuously evolving workforce and field, such as public health, require a clear understanding of the composition, nature and services of the workforce. However, there is little consistency among public health worker job definitions at the national or local level. The public health workforce has been defined as "those individuals employed by local, state, and federal government health agencies" . Still others contend that the public health workforce should include a wider array of workers to include those in academia, private sector employees who provide community-based services and education and economic development professionals .
The difficulties of defining the public health workforce are further compounded by a lack of standardization among job categories. The Bureau of Labor Statistics at the United States Department of Labor tracks the nation's workforce and classifies job categories through a scheme called the Standard Occupational Classifications system. The system classifies workers in a four-tiered pyramid fashion, starting with broad major groups and ending with a detailed description of the occupation . Gerzoff and Gebbie note that despite the millions currently employed in public health, none of the detailed categories in the Standard Occupational Classifications system are specific to public health; they recommend more rigorous definitions . Although the Standard Occupational Classifications system provides some direction in classifying job categories, the diversity and ambiguity among the public health workforce both nationally and in Texas defies simple aggregation.
Employment settings are critically important in assessing the public health workforce because of the interaction with the public. Health departments in Texas vary widely in their size, functionality and services offered. This variability often dictates the level and kind of interaction with the public. Employees of LHDs are typically the visible presence of the public health workforce. LHD workers typically provide public health services such as immunizations, STD treatment and restaurant inspections, and are viewed as the first-line responders to health emergencies.
Texas has two types of LHDs. Currently, there are 67 LHDs in Texas that receive state funding . Because of this state funding, these health departments are referred to as "participating" health departments. The state funds comprise two sources: approximately 25% from the Preventive Health and Human Services (PHHS) block grant from the Centers for Disease Control and the remaining 75% from state general revenue . By receiving state funds, participating LHDs have certain requirements and services they must provide as a condition of receiving that funding. As a result, participating LHDs most often provide a wide array of public health services, such as immunizations, restaurant and septic tank inspections, maternal and child health care services, public health education, dental services and HIV and STD counseling.
There are 78 LHDs that receive no state funding and are called "non-participating" LHDs . Several of these non-participating LHDs are large, full-service health departments, but most are small and provide mainly environmental services such as animal control and septic tank and restaurant inspections. Non-participating health departments do not receive state funds or assistance, but are still eligible for certain federal funds.
In addition to LHDs, the State of Texas operates two types of state-level health departments because of the rural nature and sparse population in many of Texas' counties. While the state-level health departments do provide some direct services to the public, they are typically more engaged in broad policy-setting and administrative functions. In addition, the state-level health departments also provide support services for LHDs.
The State of Texas is divided into 11 public health regions. The public health regions were established in 1970 as the legislature recognized the necessity for complete public health services to be made available to all the people in all Texas counties. Prior to that time, only 67 of Texas' 254 counties had organized public health services. The intent of the legislative agenda behind the creation of regional public health offices was to concentrate a collection of public health professionals and special consultants in a central location where their expertise could be used efficiently by counties with and without organized health units.
The regional departments support all health programmes, provide comprehensive public health services and provide assistance to the other organized health units within the region. The public health regions are extensions of the Texas Department of Health, now known as the Texas Department of State Health Services (TDSHS) and operate under the Commissioner of Health . Today there are eight regional public health headquarters around the state, as some regions share administration of more than one public health region These regional health departments often act as the sole public health presence in many of Texas' most rural counties . In addition to the regional health departments, the state's primary health department has its headquarters in Austin, serving as the lead agency for administering and setting policy for the state's public health programmes.
The Texas Public Health Training Center
In 2000, the School of Rural Public Health at the Texas A&M University System Health Science Center, the School of Public Health at the University of North Texas Health Science Center and the School of Public Health at the University of Texas-Houston established the Texas Public Health Training Center (TPHTC). The mission of the TPHTC is to ensure that the Texas public health workforce has access to high quality learning programmes as a means of strengthening technical, scientific, managerial and leadership competences and capabilities of current and future public health workers.
Funding for the TPHTC was established under P.L. 105–392, the Health Professions Education Partnerships Act of 1998, to assess the learning needs of the public health workforce and provide training to meet them. Currently, 44 states and the District of Columbia are covered by similar Public Health Training Centers. Core funding comes from the United States Department of Health and Human Services through the Health Resources and Services Administration – Bureau of Health Professions, which seeks to improve the nation's public health system by strengthening the technical, scientific, managerial and leadership skills and abilities of current and future public health professionals .
The development of the TPHTC was projected in a four-phase plan, scheduled to be completed over a five-year project period. The results reported in this article reflect Phase I objectives. One of the primary objectives of Phase I was to conduct a needs assessment of the Texas public health workforce. This objective was directly influenced by House Bill 1444, passed in the 76th Texas Legislature in 1999.
The Bill was the culmination of two years of study conducted by the TDSHS, the School of Public Health at the University of Texas-Houston, the LBJ School of Public Affairs at the University of Texas and the School of Rural Public Health at the Texas A&M University System Health Science Center. As a result of that work, Texas became the first state in the United States to have the 10 essential public health services specifically written into the state statute, Local Public Health Services Act – Health and Safety Code 121.0021. The 10 essential public health services are as follows:
monitor health status to identify community health problems;
diagnose and investigate health problems and health hazards in the community;
inform, educate and empower people about health issues;
mobilize community partnerships to identify and solve health problems;
develop policies and plans that support individual and community health efforts;
enforce laws and regulations that protect health and ensure safety;
link people to needed personal health services;
assure a competent public health and personal health care workforce;
evaluate effectiveness, accessibility, and quality of personal and population-based health services;
research new insights and innovative solutions to health problems.