Initiatives and strategies for strengthening the governmental public health sector in the United States emphasize the need for a robust, skilled, and diverse workforce. Recent literature on the public health workforce has called for improving its diversity,1,2 but little evidence has been published to describe the benefits of workforce diversity on population health or on health departments' functional capacities. This gap in the literature may be due in part to a lack of reliable agency-level data on workforce demographic composition. Most contemporary analyses of public health workforce demographics rely on data from the Public Health Workforce Interests and Needs Survey (PH-WINS), administered every 3 years since 2014 to employees of a nationally representative sample of state and local public health departments. The 2021 iteration of PH-WINS included responses from approximately 42 000 individual employees of 47 state health departments and 439 local health departments (LHDs). Notably, only LHDs with more than 25 employees and serving populations over 25 000 were included.3 Of these participants, 54% self-identified as non-Hispanic White and 79% as female, and the mean self-reported age was 46.4 These data indicate that workforce participation by younger age groups and racially minoritized populations has increased since 2014, but that the workforce remains less diverse than the general U.S. population. Although the employee-level data from PH-WINS provide valuable information about the workforce as a whole, the survey is prone to non-response bias and does not capture a majority of the LHDs in the United States. In addition, there remains a need to characterize the demographic diversity of the agencies charged with delivering population health services to their communities. The National Association of County and City Health Officials (NACCHO) most recently attempted to describe the racial and ethnic composition of LHDs nationwide in its 2010 National Profile of Local Health Departments Study (Profile). This study indicated that 31% of LHD staff identified as a race other than White and 12% as Hispanic/Latino. Gender data were not collected in this assessment.5 While studies from clinical medicine,6 nursing,7 and public administration8 have demonstrated positive associations between staff diversity and agency-level effectiveness, such associations might not be currently measurable in the governmental public health setting. Moreover, a lack of recent, reliable, and representative estimates of agency-level demographics hinders the ability to assess change in these indicators over time. Therefore, the objective of this paper is to provide agency-level staff demographics – race, gender, and ethnicity – at LHDs, fulfilling this need for baseline data moving forward since COVID-19 to allow tracking of demographic changes over time in the local governmental public health workforce. Methods This analysis uses data from the 2022 NACCHO Profile, a triennial survey conducted to gain a national landscape of activities, services, workforce, and infrastructure at LHDs across the United States. Profile data were collected between June and September 2022 with a study population of 2512 LHDs, yielding a 38% response rate. Data in these analyses are weighted using post-stratification weighting based on jurisdiction size to provide national estimates. These analyses focused on three items that asked LHD officials about the percent of their staff identified with different race, ethnicity, and gender categories, as well as a single item that asked about the source of these demographics data. The mean percentages of LHD staff breakdowns by race, ethnicity, and gender categories were calculated, along with percentages of LHDs that fall into four categories (0-25.9%; 26-50.9%; 51-75.9%; 75-100%) for White, Non-Hispanic, and female. Cross-tabulations of means of LHD demographic data by jurisdiction size (small <50 000; medium 50 000-499 999; large 500 000+ population) and location (urban and rural) were also run. Results The mean percentages of staff that identify for each race, ethnicity, and gender category are presented in Table 1. Overall, most staff at LHDs are White (77%), not Hispanic/Latino (78%), and female (79%). Approximately, 6% of LHD staff identify as Black, 7% as Hispanic/Latino, and close to none identify as gender non-conforming, non-binary, or transgender. Of note, Profile has a range of 8-15% missing data across these demographics. TABLE 1 - Mean Percentages of Staff across LHDs for Race, Ethnicity, and Gender Overall % Small % Medium % Large % Urban % Rural % Race White 77.2 84.5 69.8 41.0 72.4 81.2 Black/African American 6.2 3.9 8.6 17.3 7.9 4.8 Asian 1.0 0.5 1.4 5.3 2.0 0.2 Native Hawaiian/Other Pacific Islander 0.0 0.0 0.1 0.3 0.1 0.0 American Indian/Alaska Native 0.5 0.6 0.5 0.7 0.3 0.7 Other Race 3.5 2.4 4.5 9.7 5.4 1.8 2 Or More Races 1.0 0.8 1.1 2.1 1.3 0.7 Missing Data on Race 10.5 7.4 14.1 23.7 10.5 10.5 Ethnicity Hispanic/Latino 7.2 4.6 9.9 18.5 10.9 4.0 Not Hispanic/Latino 77.7 83.4 71.0 54.8 73.6 81.2 Missing Data on Ethnicity 15.1 12.0 19.1 26.6 15.5 14.9 Gender Female 79.4 83.8 74.1 61.9 73.1 84.7 Male 13.1 11.4 15.5 17.4 17.3 9.5 Non-Binary/Non-Conforming 0.0 0.0 0.1 0.0 0.0 0.0 Transgender 0.0 0.0 0.0 0.1 0.0 0.0 Missing Data on Gender 7.5 4.8 10.3 20.6 9.5 5.8 Note: Unweighted n = 916; data presented are weighted. When disaggregating demographics by jurisdiction size and urbanization, large LHDs tend to appear more diverse with greater percentages of staff that are Black, Asian, or two or more races. In addition, large LHDs tend to have more staff that identify as Hispanic/Latino compared to small or medium sized LHDs, though they also had higher percentages of missing data comparatively. LHDs serving a majority urban population tend to feature greater demographic variation, with higher mean percentages of staff identifying as Black, Asian, other, or two or more races; as Hispanic/Latino; or as male. The percent of LHDs with different staff breakdowns for White, Non-Hispanic, and female are presented in Table 2. Approximately, 8 in 10 LHDs have over half of their staff identifying as White. Similarly, 8 in 10 LHDs have over half of their staff identifying as Non-Hispanic/Latino, while almost 90% of LHDs have a majority of their staff identifying as female. About one in 10 LHDs have 0-26% of their staff who identify as White or identify as female. TABLE 2 - Percentages of LHDs with Different Demographic Breakdowns 0-25.9% of staff 26-50.9% of staff 51-75.9% of staff 76-100% of staff White 13% 5% 12% 70% Not Hispanic 16% 2% 6% 75% Female 8% 3% 16% 73% Note: Unweighted n = 916; data presented are weighted. When asked about how demographic data were collected for their LHDs, almost half of survey respondents (48%) reported that estimates were based on their perception. Approximately, 18% of LHDs used data reported by their human resources teams, while 26% of LHDs used aggregates from employee self-identified sources. More data were missing for this item (N = 860) than for the demographic questions. Discussion This paper provides a timely overview of agency-level staff demographics at LHDs nationwide, especially moving forward from the COVID-19 pandemic. Findings suggest that a majority of LHDs report that their staff identify as predominately White, non-Hispanic/Latino, and female. Percentages of staff at LHDs identifying as races other than White, Hispanic/Latino, and gender non-conforming, non-binary, or transgender are low. In addition, disparities in race and ethnicity are evident across LHDs, with larger and urban departments displaying slightly greater variation. Overall, these results align somewhat with PHWINS, which also indicated 79% of the national workforce in the public health sector identified as female.4 But there are some variations to note. For example, results from this study suggests that the local governmental public health workforce has a slightly higher percentage of staff identifying as White (77%) compared to approximately half in PHWINS (54% non-Hispanic White).4 Also, results from the demographic staff-level data suggest alignment with demographics of LHD top executives, which has been captured by the Profile study for many iterations. For example, the percentage of LHD top executives that identify as female rose from 56% in 2008 to 66% in 2019, while percentages of top executives identifying as a race other than White and Hispanic/Latino have remained below 10% since 2008.9 Limitations The 2022 Profile study data were self-reported by LHDs and not independently verified. Therefore, the findings should be approached with an acknowledgment of the related limitations around reliability and validity of information. LHDs might have offered incomplete or inconsistent information for various reasons, especially given that data were collected in a time of volatility during the COVID-19 pandemic. Additionally, aggregate reporting of demographics may obscure uneven distributions across LHDs, while the level of missing data could potentially affect findings despite weighting techniques attempting to adjust for non-response. In addition, demographic data were often provided by the main respondent via perception, thereby highlighting potential gaps in demographic reporting practices across LHDs. It is recommended that data collection for workforce demographics be more systematic and intentional at the organizational level for reporting beyond perceptions, to ensure greater reliability of the data. Even so, Profile is one of the main sources of comprehensive data on LHDs across the United States, and adding agency-level demographics fulfills the need to better understand the local governmental public health workforce. Conclusion This paper describes one of the most recent attempts at capturing agency-level staff demographics at LHDs nationwide through the 2022 National Profile study conducted by NACCHO. Although the study has limitations, it provides essential baseline data moving from the COVID-19 pandemic to help track changes in national estimates of diversity in local governmental workforce over time. Moving forward, it will be essential to understand how workforce diversity trends connect with local community-level health and functional capacities of LHDs in the United States.
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