State Health Official Career Advancement and Sustainability Evaluation—Description of the Methods Used in the SHO-CASE Study State health officials (SHOs) lead state governmental public health agencies, playing an important role in their states. However, little comprehensive research has examined SHOs or characteristics of these leaders, limiting evidence about ways to improve SHO selection and subsequent performance. This brief describes the methods of the SHO-CASE study focused on current and former SHOs in state public health agencies. Methods used include qualitative components that informed the development of survey questions, survey administration, and survey response. A total of 147 SHOs responded to the SHO survey representing every state and Washington, District of Columbia. The SHO-CASE study survey database represents the most comprehensive database of its kind regarding a range of attributes of current and former SHOs. These data can be used to explore factors contributing to SHO success including valuable insights into effectively working with the states' elected officials.

State Health Officials: Backgrounds and Qualifications Context: State health officials (SHOs), the executive and administrative leaders of state public health, play a key role in policy development, must be versed in the relevant/current evidence, and provide expertise about health issues to the legislature and the governor. Objective: To provide an empirical examination of SHO backgrounds and qualifications over time. Design, Setting, and Participants: Cross-sectional survey of current/former SHOs. Main Outcome Measures: State health official educational backgrounds; public health experience; previous employment setting. Results: Two-thirds of respondents (64.6%) reported having a medical degree, approximately half (48.3%) a formal public health degree, and almost one-quarter (21.8%) a management degree. The majority had governmental public health experience at some prior point in their career (70.0%). Almost two-thirds worked in governmental public health immediately before becoming an SHO. The proportion that was female increased significantly by decade from 5.6% in the 1970s/80s to 46.4% in the 2010s (P = .02). Conclusions: The main finding from this study shows that more than two-thirds of SHOs have had governmental public health experience at some point in their career. This is not a new trend as there were no statistical differences in public health experience by decade. More than half of the SHOs were appointed to the role directly from governmental public health, indicating that their public health experience is timely and likely germane to their appointment as SHO. Findings also indicate improvements in gender diversity among one of the most influential leadership roles in governmental public health whereas significant changes in racial and ethnic diversity were not identified. Women are increasingly being appointed as SHOs, indicating increasing gender diversity in this influential position. Given that governmental public health employees are predominantly women, there is still room for gender equity improvements in executive leadership roles. This is coupled with the need for further racial and ethnic diversity improvements as well.

Public Health Senior Deputy's Perceptions of State Health Officials' Success Factors: Professional Characteristics, Personal Attributes, and Signs of Derailment Context: Senior deputies work closely with state health officials (SHOs) in state public health agencies and are a valuable resource for understanding their roles, responsibilities, and characteristics. Objective: Examine senior deputies' perceptions of SHO success factors. Design: Qualitative study including nominal group technique focus groups, a small expert focus group, and interviews. Setting: US state public health agencies. Participants: Senior deputies in state public health agencies 2016/2017. Main Outcome Measures: Perceptions of SHO success factors. Results: The most commonly perceived professional characteristics of a successful SHO included the following: credible trusted voice with internal respect/external credibility; improves public health prominence/visibility with an evidence-based agenda; and grows the agency/leaves it stronger. Perceptions of the most common personal attributes for success included excellent listening skills; credibility/honesty/trustworthiness; and public health experience/knowledge. The most commonly perceived signs of SHO derailment included when SHOs have a visible lack of support of elected officials (eg, governor/legislators) and when the SHO is “bypassed” by elected officials. Conclusions: A key finding of this study centers on the relationship between the SHO and the governor; meeting the expectations of the governor was identified as a significant professional characteristic of success. Findings highlight the expectation that SHOs have a clear understanding of the governor's priorities and how to relate to the governor's office early in their tenure. This goal should be a priority for transition teams that aid new SHOs as they begin in their new roles. Study insights can help better prepare for orientation/onboarding of new SHOs. Development of key transition documents and tools for rapid onboarding should be considered. Transition teams should assist new SHOs in establishing an understanding of the governor's priorities and how to best communicate with to the governor's office early in their tenure. Strong senior management teams should be prioritized and fostered.

Tenure and Turnover Among State Health Officials From the SHO-CASE Survey: Correlates and Consequences of Changing Leadership Objective: To examine characteristics associated with tenure length of State Health Officials (SHOs) and examine reasons and consequences for SHO turnover. Design: Surveys of current and former SHOs linked with secondary data from the United Health Foundation. Setting: Original survey responses from SHOs in the United States. Participants: Respondents included SHOs who served between 1973 and 2017. Main Outcome Measures: Tenure length and consequences of SHO turnover. Results: Average completed tenure among SHOs was 5.3 years (median = 4) and was shorter in recent time periods compared with decades prior. Older age at appointment (β = −0.109, P = .005) and those holding a management degree (β = −1.835, P = .017) and/or a law degree (β = −3.553, P < .001) were each associated with shorter SHO tenures. State Health Officials from states in the top quartile for health rankings had significantly longer average tenures (β = 1.717, P = .036). Many former SHOs believed that their tenure was too short and reported that their departure had either a significant or very large effect on their agency's ability to fulfill its mission. Conclusions: State Health Official tenures have become shorter over time and continue to be shorter than industry chief executive officers and best practice recommendations from organizational researchers. States have an opportunity to consider and address how factors within their control influence the stability of the SHO position.

The National Epidemic of Gun Violence: The Vermont Department of Health Response This case study details a 2018 “near miss” school mass-shooting event in Vermont that involved a former student and occurred contemporaneously with the Parkland, Florida, tragedy. The situation “jolted” this rural state's governor, lending urgency to the need to enact sensible gun control laws. He comes to support a series of proactive bills already in the legislature and advocate for further preventive strategies. The state's commissioner of health plays public health's traditional role within state government as trusted health promotion and education resource to frame the issue in public health and public safety terms. He portrayed health data on firearm injuries and deaths and formed a public health strategy including surveillance, identification of risk factors, and resources for school- and community-based prevention. On April 11, 2018, Governor Phil Scott signed a package of gun-related legislation that included increasing the legal age for gun purchases, expanding background checks for private gun sales, banning high-capacity magazines and rapid-fire bump stocks, and extreme risk protection orders. The final results were examined from an evidence-based public health standpoint, acknowledging the lack of gun research by federal agencies since the 1996 enactment of the Dickey Amendment that prohibits the Centers for Disease Control and Prevention from conducting firearms-related research. The case study illustrates the paradox of moving forward on gun safety, where more research is needed, but research does not necessarily influence political leaders or policy. It also demonstrates how prevention of gun violence can be portrayed in a public health framework, drawing upon data and strategies used in upstream preventive efforts in areas such as early childhood development, mental health, and substance misuse.

A Public Health Performance Excellence Improvement Strategy: Diffusion and Adoption of the Baldrige Framework Within Tennessee Department of Health In 2011, Tennessee was faced with poor state health rankings with newly elected officials promoting customer-focused government. To refocus, the Tennessee Department of Health chose a multiyear plan to adopt, diffuse, and integrate the Malcolm Baldrige Performance Excellence framework. Senior leaders changed the organizational culture using participatory strategic planning coupled with introduction of performance improvement initially led by departmental staff who volunteered for training by the state Baldrige affiliate. New tools and processes were diffused across the department's central and regional offices and county health departments. Departmental units documented performance improvement through hundreds of internal projects and more than 100 innovation-driven Baldrige achievement awards. Over time, performance improvement approaches were integrated into existing departmental programs and new initiatives, leading to additional successful process changes and population health improvements. The department's approach included multiple steps: adopt Baldrige Performance Excellence as means to promote culture change with a goal of improved organizational and population health performance; use the visual Baldrige framework and its categories to underscore inclusiveness, comprehensiveness, and synergies of desired change; choose, invest in, and implement multiple evidence-based management strategies to support culture change toward improvement; and continuously evaluate outcomes, linked to required reports to suppliers (governor and legislators) and customers (public, patients, and partners). The Baldrige Performance Excellence framework was found to be an effective approach to promote culture change through emphasizing improvement in a public health organization.

Leadership Disparities in State Governmental Public Health Workforce: Examining the Influence of Gender Objective: To determine the extent to which gender disparities exist in either obtaining a leadership position or pay equity among those with leadership positions in state governmental public health agencies. Design: Utilizing the 2014 Public Health Workforce Interests and Needs Survey, a nationally representative cross-sectional study of state governmental public health agency employees, the characteristics of the state governmental public health agency leadership were described. We estimated the odds of being a manager or an executive leader and the odds of leaders earning greater than $95 000 annually for women compared with men using polytomous multinomial regression and logistic regression models, respectively. Setting and Participants: The Public Health Workforce Interests and Needs Survey was conducted via electronic survey at 37 state health departments. This study utilized only those respondents who listed their current position as a supervisory position (n = 3237). Main Outcome Measures: Leadership position and high-earning leadership were the 2 main outcome measures explored. Leadership position was defined as a 3-level ordinal variable: supervisor, manager, or executive leader. High-earning leadership was defined as a member of leadership earning $95 000 or greater. Results: Women accounted for 72.0% of the overall state governmental public health agency workforce and 67.1% of leadership positions. Women experienced lower odds (odds ratio = 0.55, 95% confidence interval: 0.39-0.78) of holding executive leadership positions than men and lower odds (odds ratio = 0.64, 95% confidence interval: 0.50-0.81) of earning an annual salary greater than $95 000. Conclusion: While women were represented in similar proportions in the general workforce as in leadership positions, gender disparities still existed within leadership positions. Increased effort is needed to ensure that opportunities exist for women in executive leadership positions and in pay equity. With public health's commitment to social justice and the benefits of diversity to an agency's policies and programs, it is important to ensure that women's voices are equally represented at all levels of leadership.

Local Health Departments' Spending on the Foundational Capabilities Improving our nation's public health system requires a detailed understanding of public health expenditures and related revenue sources, yet no comprehensive data source exists that contains such information for governmental health agencies at all levels. Using pilot study data of a standardized financial accounting framework for public health agencies—in the form of a uniform chart of accounts crosswalk—this article presents local health departments' (LHDs') expenditures on the foundational capabilities, that is, crosscutting skills and capacities needed to support all of an LHD's programs and activities. Among 16 sample LHDs from 4 states, per capita foundational capabilities spending ranged from $1.10 to $26.19, with a median of $7.67. Larger LHDs and LHDs with greater financial resources spent more per capita, as did accredited LHDs. Future work using data from a larger sample of LHDs is needed to examine agency and community-level characteristics associated with adequate funding for the foundational capabilities.