Recruitment begins with attracting potential applicants to employment. We observed two main barriers that public health departments experienced in terms of recruitment: perceptions of an unsatisfying work environment and low salaries. Public health employment is perceived as an unsatisfying environment for diverse employees while being most friendly toward white employees (13).

Salaries that are not competitive with other employment sectors was cited as a potential reason why public health students and new graduates did not find governmental public health employment to be appealing (14, 15). One small pilot survey (n = 83) found that 17.8% of recent public health graduates from six schools of public health across the United States cited pay as a major deterrent to seeking employment in governmental public health (15). A qualitative study that engaged public health students and recent graduates in focus groups identified fair pay as a key component of fulfilling and meaningful work (14). Additionally, an assessment of public health job postings before and after the onset of the COVID-19 pandemic found that competition from the insurance sector has increased (16).

Actively creating a “welcoming and satisfying” work environment for employees of all racial and ethnic groups can help foster a more diverse workforce (13). Black public health students also reported important barriers to public health employment: family financial situations creating difficulty completing degrees and accessing internships; lack of personal and family experience navigating the higher education system, and racism and stereotyping (17). Focus groups with Black public health students and graduates suggests early exposure to public health as a field for Black students to increase awareness of the field and its potential as a career path. Additionally, emphasizing how public health can help communities by addressing social determinants of health can bolster a positive impression of public health (17).

No specific opportunities were offered in the literature specifically related to improving salaries. However, there are other ways to work to offset this barrier. While LHD’s often cannot offer salaries as high as their competitors, LHDs have the unique benefit of being viewed as employers who do meaningful work (14, 15). The service-oriented mission of LHDs is a very salient factor relative to private-sector employers. In one survey, 90% of federal, state, and local public health workers reported feeling that their work was important (18). Leaning into this mission and emphasizing it in marketing efforts to potential employees can help LHDs stand out. Job-related factors like job security, competitive salaries, and benefits are also attractive to potential employees (14, 15, 18–20). Loan forgiveness also offers an excellent incentive to attract suitable applicants (14), particularly since a majority of public health graduates have $55,000 or more in debt (21).

In addition to positive marketing to attract public health talent, LHDs can also partner with academic institutions–either formally or informally–to become an Academic Health Department (AHD) (22, 23). AHDs create an exchange of skills and talent between health departments and the academic institution that benefits both parties. This can create pathways to recruit public health students to LHDs and offer opportunities for continuing education for health department staff (23). AHDs also create an environment in which LHDs can collaborate with academic institutions on public health curricula, development of certificate programs, and building pathways to public health degrees (23, 24). Health departments should also actively market toward potential applicants from disciplines other than public health, as non-public health degree holders do commonly work in health departments (25).

Student internship experiences are often a requirement in public health degree programs and thus are a common component of the public health workforce pathway. Internships can benefit the LHD by attracting future employees either directly or by supporting word-of-mouth referrals (22, 26–29). One internship program aimed specifically to undergraduate students from groups underrepresented in public health found that the program was successful in increasing their interest in pursuing public health employment (30, 31). Interns add to the workforce capacity of LHDs by contributing tasks related to data collection and analysis; program planning and evaluation; and development of reports, manuscripts, posters, and presentations (22, 26, 32). Internships also provide an opportunity for the professional development of preceptors by allowing them to exercise mentorship and management skills (26).

There are many potential benefits to providing compensation as part of internships. Compensation would help increase the pool of quality applicants (28), reduce inequity in opportunity for participation (17, 28), and make the internship more competitive with other opportunities (33). Health departments can address this by seeking potential funding sources for internship stipends. There are also existing internship programs that place interns with host sites and cover the cost of intern pay (34). Virtual internships can offer the additional benefit of internship flexibility (35).

Going beyond attracting applicants, the hiring process itself poses more barriers for those who do decide to apply. Unclear job descriptions, rigid interview procedures, and a lack of transparency around work locations, hiring processes, and timelines contribute to recruitment barriers (14, 15, 36). Potential employees cite the lack of communication that they often experience with LHD’s as a deterrent for applying for LHD positions (15). These barriers create frustration for both applicants and hiring managers, and can deter applicants from continuing with the process (14, 15, 36).

Streamlining application platforms where possible and increasing transparency around the roles and benefits can improve the application process for potential employees (14). Characteristics of more efficient application platforms include being easily searchable, and require “minimal work on the part of applicants.” For example, using an uploaded resume to populate application fields rather than requiring applications to duplicate effort by uploading a resume and still manually filling out all application fields. Additionally, these positions should be posted to popular job sites, particularly those that allow applicants to apply directly through the platform. To make the application process more transparent, job descriptions and qualifications should be easy to understand, pay rates should be clearly posted, and a contact person should be provided (14). Additionally, to widen the applicant pool, LHDs should consider experience level should when determining minimum qualifications for a role, as practical experience can make up for less formal education (37).

Once new employees have been hired, a new set of barriers emerges related to getting them to stay at their specific LHD or within the field of governmental public health in general. These barriers center around the organizational work environment and offering satisfactory pay. Several parts of the organizational work environment are cited as reasons why current public health employees may consider leaving their jobs. Dynamics between supervisors and their staff is an important component of organizational culture. Satisfaction with supervisors and organizational support had a positive effect on employees no longer intending to leave their organizations (38). Such satisfaction included creativity being rewarded, being treated respectfully, feeling like the agency valued their professional development, and effective communication within the agency (38).

Unsatisfactory pay, in addition to being a barrier in attracting applicants, is also a barrier in retaining existing employees. Current public health employees who are satisfied with their pay are more likely to be satisfied with their job and less likely to consider leaving their current position (18, 19, 39–42). Among younger staff in particular, pay has been reported as the top reason for considering leaving their job (19, 20).

There are several ways that LHDs can improve the organizational work environment to improve employee retention. This can include encouraging and rewarding creativity, implementing effective workplace communication, treating employees with respect, being supportive of employees, and fostering workplace flexibility (38, 43, 44). Engaging staff in accreditation activities is associated with an increased perception of leadership support (45). However, while public health managers may be highly trained in their areas of expertise, they are often not formally trained in the development of employees and organizations. Supporting this training for leadership can empower them to improve the work environment (19).

Providing mentoring opportunities can act as a workplace benefit to improve employees’ workplace satisfaction. LHDs nationwide have experimented with a variety of mentoring methods including one-to-one, peer mentoring, mentoring circles, speed mentoring, mentoring partnerships, online mentoring, and apprenticeship mentoring (46–48). Notably, mentorship holds exceptional value for employees from underrepresented or minoritized groups (49). To support equity in mentorship programs, LHDs have been encouraged to ensure that mentorship programs are accessible to all employees, minority employees are encouraged to participate in these programs, and that the responsibility of equitable participation rests on senior management (49). This consideration is particularly important if programs allow managers to select mentees through informal channels.

Although existing employees commonly report being unsatisfied with their pay, studies on both state and local public health employees found that they also report being happy with the benefits and job stability that comes with public health employment (20, 39). Continuing and even augmenting benefits where possible could improve both recruitment and retention efforts.

A lack of professional development and advancement opportunities within the agency are a major factor for current public health employees. Availability of professional development is a prime factor in public health professionals considering leaving their position but ultimately deciding to stay (38). Younger employees in particular cited a lack of advancement opportunities as a prime reason for considering leaving (19, 20). This points to a “greener pastures phenomenon” where younger workers are more willing to change jobs for better opportunities (19, 20).

Investing in training and development of existing employees has the benefit of helping to retain employees and encourage them to advance within the organization, with both formal and informal training opportunities forming an important role in professional development (48). Employees with a long tenure at the agency have invaluable institutional knowledge. Some evaluations demonstrated the success of posting certain vacancies for internal candidates only or creating new high-level and lateral positions for internal candidates to broaden employee experience in retaining mid-career and senior-level employees (50). Additionally, studies focused on both state and local health departments suggest that creating internal growth opportunities for employees will assist in preserving this institutional knowledge and will support organizational succession planning (48, 51–53).

Younger generations in particular report that opportunities for advancement hold great value when considering whether to stay with a current public health employer (19). Offering those individuals growth and development opportunities within the agency can help retain internal talent and experience (19, 20). To support this initiative, some agencies have experimented with leadership development programs for high-potential employees. Once high-potential candidates are identified, a systematic approach is adopted for their focused development by recognizing areas of competency enhancements, setting goals, creating individualized development plans, planning strategic job assignments, providing mentoring, and evaluating developmental progress (50, 54). These candidates have also been offered targeted training for advanced roles, provided opportunities to practice new techniques, and offered mentorships to nurture these skills.