How to characterize the public health workforce based on essential public health operations? environmental public health workers in the Netherlands as an example

A national cross-sectional survey was conducted using an online questionnaire.

To assess the services provided by the workforce we used the recently defined essential public health operations (EPHOs) by the World Health Organisation in Europe (WHO Eur) [20]. The EPHOs describe the main tasks of public health and can be used as a unifying and guiding basis to monitor and evaluate policies, strategies and actions for reforms and improvement in public health.

The environmental public health workforce was defined as all workers who contribute to the delivery of environmental public health. We made this definition operational as: all those who consider environmental public health as part of their job and who are responsible for providing any of the EPHOs for (on average) ≥ 0.5 h/week. This small number of hours per week was chosen to capture all disciplines and services provided. For example, the work of the health care inspectorate includes promotion of public health and responsible care through effective enforcement of the quality of health services. For environmental public health these services are delivered only 2–3 weeks per year.

As the EPHOs are not yet implemented in public health practice in the Netherlands, we operationalized the EPHOs to environmental public health using existing policy documents, e.g. from the professional organisation of environmental public health physicians, guidelines on the size of the environmental public health workforce and the most recent advice of the Advisory Committee on Medical Manpower planning [Capaciteitsorgaan] on the training inflow of environmental public health physicians [21]. We also involved a group of 5 national environmental public health experts who agreed on the resulting specifications. Based on the documents and the expert opinions, we made some changes to the EPHOs: EPHO ‘advocacy communication and mobilisation for health’ was combined with EPHO ‘health promotion’. We decided to combine these two EPHOs as ‘advocacy communication and mobilisation for health’ according to WHO eur contains improving health literacy and enhancing population’s capacity to access, understand and use information to reduce risk or prevent disease [22]. These kind of activities are part of health promotion in the Netherlands. ‘Regional consultation and support’ was added as EPHO as some local public health services fulfil this specific role for other local public health services. A description of environmental public health and the EPHOs is presented in Table 2.

According to Dutch law, formal ethical approval was not required, but we took every effort to effectively inform the respondents and protect their privacy.

The questionnaire was developed based on a review of literature, interviews with public health experts and consultation with other researchers and contained 20 items divided into three parts:

Testing of the practicality of the questionnaire among all employees of a local public health service (n = 217) resulted in some modification of the wording and the order of some items For the present study the adapted version was used. After some adaptations based on a pre-test of this questionnaire among 5 environmental public health workers, the questionnaire took about 10 min to complete.

Potential respondents were selected in a two-layered recruitment strategy. First we identified all organisations likely to conduct environmental public health tasks and second, within these, we invited all workers considered to be performing environmental public health.

To enhance recruitment across organisations and of as many employees and disciplines substantially involved in environmental public health, we composed two complementary mailing lists. In the first mailing list (core group; n = 182), we included all workers of the departments of environmental public health of the local public health services. Then, we explored who might also be likely performing environmental public health EPHOs outside the department of environmental public health of the local public health services, and included those addresses in the second mailing list (peripheral group; n = 290). For example, in order to recruit respondents involved in EPHOs ‘surveillance’ and ‘health promotion’ we approached all workers from the divisions of epidemiology and health promotion of the local public health services. Similarly, we approached direct network contacts, like employees of the Ministry of Health, Welfare and Sport, environmental public health workers from the National Institute for Public Health and the Environment and departments of public health of two universities in order to recruit workers involved in EPHO ‘advancing public health research’ and EPHO ‘governance for health’.

Both mailing lists were composed in collaboration with environmental public health experts and the national association organisation of all local public health services (GGDGHOR-Netherlands, Table 1). This organisation supports environmental public health practice, policy and research from a national perspective and maintains a good overview of the national environmental public health network.

The survey was performed in March 2013. The invitation to participate in the survey was distributed by e-mail to 472 workers. The invitation emphasized voluntary participation and responses would be confidential. The e-mail contained a link to a secured website where they could complete the electronic questionnaire [23]. In the week after the invitation, two reminders were sent to the non-responders. After two weeks the database was closed, data were downloaded, and the analyses were performed with SPSS 14.0.

The response rate among the local public health services was 100 %. Within the organisations, the response rate of individual workers was 70 % (127/182) in the core group and 28 % (81/290) in the peripheral group. After exclusion of respondents who reported not to be involved in environmental public health or who reported spending ≤ 0.5 h/week (n = 59), and double (n = 26) and partial respondents (n = 14), 129 questionnaires were available for analysis: 112 from the core and 17 from the peripheral group. As the characteristics of both respondent groups were similar for educational background, job titles and involvement on EPHOs, we combined the data from these two groups.

Of all respondents, 26 added remarks to the questionnaire. Of these, 6 indicated that the number of hours spent per EPHO was difficult to estimate and 3 reported not to recognize the EPHOs as a reflection of their daily practice. The other comments were personal additions to the answers.

Existing benchmark data:

National experts in the field of environmental public health indicated that the data were recognizable as a reasonable reflection of the actual situation with regard to educational background, employment setting, task differentiation and the provision of EPHOs.

Of all respondents, the mean age was 46 years (SD 10.2), 64 % was female, 71 % had special training for environmental public health, 59 % had ≥ 5 years working experience in their current job, and 80 % was educated at university level (or higher) with various disciplinary backgrounds (e.g. medicine, nursing, toxicology, biology, and environmental hygiene) (Table 3). Respondents had multiple different job titles. Of the primary job titles 79 % could be classified in 5 main categories (policy advisor, environmental public health physician, environmental public health nurse, environmental public health advisor, and environmental public health emergency expert); the remaining 21 % consisted of 22 different job titles.

Twenty eight Respondents were physician, 10 were trained as environmental public health physician, 10 were trained as public health physician and 8 were physicians ‘other’, of which 6 were in training for environmental public health physician.

Of all respondents, 92 % were working in local public health services, 13 % worked outside the local public health services (e.g. university, Ministry, or research institute), some had multiple work settings, and 45 % were working in environmental public health and in other domains (e.g. infectious disease control).

Figure 1 shows the distribution of the capacity across the 10 EPHOs. All EPHOs were provided; most FTEs were spent on the essential operations ‘Surveillances of (the determinants of) population (environmental) health and wellbeing’ and ‘assuring governance for health’ and the least FTEs were spent on the EPHOs ‘health protection’ and ‘assuring sustainable organisational structures’. See Table 4 for the specific percentages and the average hours per week spent per EPHO.

Compared to environmental public health physicians, environmental public health nurses were less often involved in performing the EPHOs, ‘Advancing research’ and ‘regional consultation and support’ (Table 4).

The total capacity of the environmental public health workforce was estimated at 110 FTEs (range 79–152 FTEs) or 0.66 FTE per 100,000 inhabitants. Of the total FTEs, 97 % (96 FTEs) was provided through the local public health services and 13 FTEs through other organizations.