Employment outcomes and job satisfaction of international public health professionals: What lessons for public health and COVID‐19 pandemic preparedness? Employment outcomes of public health graduates

Abstract The profile of public health professionals (PHPs) and COVID‐19 preparedness is assessed against the employment outcomes (EO), precarious employment (PE), and job satisfaction (JS) of the European Public Health Master programme alumni. The study is descriptive, cross‐sectional, conducted from May‐October 2020. A survey was developed to assess the EO, PE and JS. Participants were recruited by email. SPSS statistics 26 version was used to perform descriptive analysis. A total of 189 PHPs participated (65% response) with majority women (66%), the mean age was 36 years. Participants were employed (80%), in non‐governmental organisations (20%), and academia (19%). Common employment positions were managerial (37%) and consultancy (18%). Majority of PHPs were exposed to PE (81%), the most frequent elements were ‘temporary employment’ (54%), and ‘the lack of labour union’ (53%). The JS of PHPs was ‘satisfied’. A blend of scientific public health knowledge and interpersonal competencies, reforms in current employment conditions, development of professional entities to safeguard PHPs' rights, and continuous investment in public health is necessary for PHPs to strengthen COVID‐19 pandemic preparedness. Furthermore, monitoring and evaluation of EO and JS are crucial to prepare PHPs according to the needs of the employment market and to be aware of PHPs' needs.


| Study population
The whole Europubhealth alumni cohorts covering the years from 2006 (first generation) to 2019, were invited to participate in the online survey. The open-access Europubhealth alumni directory was used to contact the potential participants. 30 Further details about the Europubhealth programme are provided in Appendix 3.

| Data collection and analysis
A general invitation was posted on the social media groups of Europubhealth alumni to raise awareness about the survey. Using Qualtrics software, an invitation to participate in the self-administered survey was sent by e-mail. The objectives of the research and planned data management were explained in the invitation letter, all participants were assured of confidentiality and anonymity when they gave consent to participate. To recruit as many participants as possible e-mail surveys and reminders were sent in weekdays and weekends, on the morning and afternoon trying to capture different participants' time zones and schedules. Reminders to participate were sent at weekly intervals to non-respondents. When e-mails were not successful, the researcher tried to contact participants through social media and/or peers.
Given the social science scope, 50% is deemed to be an average response rate. 31 Four participants opted-out and 23 did not complete the survey, thus, their answers were eliminated from the analysis. Available data on the numbers of alumni by generation was compared with the results with mean generational participation rate of 66%. 32 A thematic analysis of the employment sectors and job titles based on frequency was conducted by Microsoft Excel. The Statistical Package for Social Sciences (SPSS) version 26 was used to perform descriptive statistics. 33

| Ethical approval
This study was reviewed and approved by two members of the sub-board panel of the Ethics Review Committee Health, Medicine and Life Sciences (FHML-REC) of Maastricht University, The Netherlands.

| RESULTS
The results of this study present the profile of PHPs, who graduated from the Europubhealth programme. The main findings encircle the following themes: general findings (participation and demographics), EOs, PE, JS, and training and participation of PHPs in the COVID-19 response.

| General findings
A total of 189 PHPs completed the survey. The response rate was 65%. The mean number of years since graduation was 6 ± 3.81 SD (minimum 1, maximum 12). On average, 66% of each cohort participated. Detailed information can be found in Appendix 4.
The profile of a PHP encompasses a young professional (79% < 41 years old), predominantly female (66%), who holds a bachelor related to human health on the areas of medicine, psychology, nursing, nutrition, dentistry, or physiotherapy (42%), most specialized in epidemiology, biostatistics, health economics, and environmental health TREVIÑO-REYNA ET AL.
(62%), and completed or continuing education after finalizing Europubhealth (39%). Detailed education information can be found in Appendix 5.

| Employment outcomes
The respondents represent a total of 61 nationalities from all continents, 38 % of PHPs were working in a different country from their country of origin (Figure 1), being the major host countries The United Kingdom (26%), Spain (12%) and France (11%). Detailed information of nationalities and employment mobility can be found in Appendix 6 and 7.
The majority of the PHPs were employed (80%), followed by those who were seeking employment or seeking continuing education (7%), those who were following continuing education, being part of a training programme or volunteering summed up a 11%, and those not employed nor seeking employment (2%). The mean length in current employment was 3 years ± 40.23 SD (minimum 1 month, maximum 20 years). More than half (61%) of PHPs found their first public health-related job in less than 6 months, and 77% found their first job within one year. At the time of the survey, 5% of the PHPs were still looking for a job with a mean of 11 months ± 5.55 SD (minimum 4, maximum 22). The PHPs who did not find a public health-related job and decided to start working in another field were looking for a public health-related job during a mean of 16 months ± 18 SD (minimum 3, maximum 48) before deciding on employment in another area.

| Employment market
Most PHPs had filled vacancies in the health or public health workforce at the time of the survey (95%), 80% identified their job as public health related, and 5% of PHPs were not working either in health-related or public health-related jobs. The majority were employed in not-for-profit (78%).
Further analysis concerning the PE, JS and participation in the COVID19 pandemic responses only includes PHPs who were employed in health or public health-related areas (n = 147).

| Precarious employment
Two of the three dimension of PE were present in the PHPs' employments: job insecurity (60%), and lack of social protection and rights (55%). On the dimension of job insecurity, the most frequent element was the temporary work contract (self-employed, fixed-term, payment per project; 54%), and uncertainty about the next contract renewal (28%). In the dimension of lack of rights and protection, the lack of unions was present in more than half of the PHPs (53%), of those who had a union available, only 35% responded that they were part of it, being the 16% of the total population. All reported wages were above the lowest income quartile, which would mean that all the PHPs had adequate income ( Table 2). The 81% of the PHPs experienced one dimension of PE, and 34% had two dimensions of PE in their jobs (job insecurity and lack of social protection and rights).

| Job satisfaction
Results of the Minnesota questionnaire showed that in general the PHPs were 'satisfied' with their job with 50% of PHPs 'very satisfied', 42% 'satisfied', and 8% 'neutral'. The items rated lowest were 'The way company policies are put into practice' and 'The chances for advancement on this job,' which were both extrinsic factors. Detailed information of JS can be found in Appendix 10.
Participation in the COVID-19 pandemic response.
The 70% percent of PHPs considered having adequate training to participate in the COVID-19 pandemic response, and from this percentage, 65% were participating in the response. From the entire population, 57% of PHPs were involved somehow in the response of the COVID-19 pandemic and 63% of those who did not, expressed their willingness to be involved.

| DISCUSSION
The study presents the profile of a PHP being a young professional, predominantly female, specialised in classic public health disciplines, following continuing education, with diverse backgrounds mostly related to human health, representing various nationalities and with a high level of international job mobility. Most of the PHPs are employed in public health and health related jobs located in six sectors, sharing five main employment titles among them. Two of the three dimensions of PE are present in the employment of PHPs, and yet PHPs are satisfied with their job. Slightly more than half of the PHPs participate in the COVID-19 response with others expressing their willingness to do so. A relatively high percentage of PHPs report having adequate training to respond to COVID19 pandemic.
Our findings show that common specialization paths are still the classical ones: epidemiology and biostatistics.
This mirrors a prevalence of traditional public health pathways which is also documented in the USA. 27 However, Such as protection against unfair dismissal, protection from authoritarian treatment, protection against discrimination, or protection against sexual harassment.
(2012-2016) despite of the increment of PHPs graduated in those years. 11 These findings support the theory that governmental bodies are no longer the sole principal recruiting institutions; private companies now represent a significant part of the employment sector for PHPs, 11,35 suggesting greater acceptance and recognition of public health amongst the population that it serves.
Both managerial and consultancy areas need a set of skills that rarely can be obtained from typical public health education alone. 36 These areas require years of expertise and are not entry level jobs, making it difficult for graduates to find a job in the public health employment market. 34 Since a decade ago the mismatch between the educational pipeline and public health employment was raising concerns due to the outpacing supply of graduates that were forcing PHPs to find jobs outside of the public health area. 37 Although there are studies that forecast the public health workforce shortage, specific details on worker's discipline, training level, and functional ability remains unclear. 38 Public health workforce crisis has been exacerbated by poor recruitment and retention strategies causing harmful impact on population health and its systems. 39 Certainly, a continued assessment of EOs of graduates is needed to increase awareness in the current trends of employment and to give opportunity to improve the academic curricula with the aim to prepare PHPs with the competencies needed in the public health employment market.
Contributing factors such as the existence of PE make the employment market for PHPs even more challenging. The presence of employment insecurity (60%), and lack of social rights and protection (55%) in our population were evidently high. Temporary employment (employment insecurity) limits the capacities of PHPs to deliver quality competencies, typically temporary workers get fewer professional trainings and opportunities to develop their careers. 40 While the lack of labour unions already puts PHPs in a vulnerable position, unable to demand their lawfully benefits and rights, professional chambers are documented to be largely non-existent for PHPs. 41,42 Where professional chambers exist, they contribute to safeguard the rights and privileges of the represented professionals, for example, by formally providing license and credentials, setting standards for education, skill levels and competences, and serve the profession in a sense of a collective voice. 41,43 A precursor of a PHP chamber can be the Faculty Public Health (FPH) in the UK with national professional regulation, for example, devising the curriculum for specialist public health training and being part of the three Royal Colleges of Physicians in the UK. 42 Labour unions are expected to manage both collective bargains and agreements in the workplace, regulate wages and working conditions covering all employees regardless if they are members or not of a union. 44 Our study results highlighted that professionalisation of the public workforce and the absence of professional chambers had played a role in EOs for PHPs. 11 Despite the fact that 81% of our population had one dimension of PE, and 34% had two of three dimensions of PE in their jobs, our population was satisfied with their job. Our results echo the theory that argues that in some specific cases, such as in highly skilled workers, when the non-standardized employment conditions are chosen voluntarily, it can enhance JS and quality of life. 45 Besides, our results showed lower scores on the extrinsic area, studies suggest that this is an area of opportunity as particularly extrinsic factors are easy to improve and thus help both productivity and job retentions of PHP. 34 JS is one of the key drivers for the mobility of PHPs. 46 The nature of the Europubhealth programme could be driving PHPs mobility by supporting professional networking and international professional experiences. As with other Erasmus Mundus programmes, Europubhealth provides the opportunity to study and live in at least three different European countries. In addition, during the last month of the academic programme, students have the possibility to select another country (worldwide) for professional practice and final thesis. 13 Drawing upon the findings, it was reported that 38% of participants were employed in a different country to that of origin. PHPs mobility to other countries can provide both better health and access to healthcare opportunities to the host populations, although there is also danger of contributing to the well-known brain drain. 15 The mobility of PHPs from the place of origin has negative consequences as there is a loss of PHPs who are unable to participate in public health responses particularly in times of crisis. 7 Motivators to move to other 132 -TREVIÑO-REYNA ET AL.
countries include poor remuneration, poor working conditions, unstable and oppressive political climate and discrimination. 47 On a career frontier, PHPs face a limited career structure and poor intellectual stimulation. 48 Developing nations may not be able to harness the full potential of PHPs of their home country and it is exacerbated by lack of funding and poor facilities.
Our findings seem to reveal some of the weaknesses of the public health system and its preparedness in times of COVID-19 pandemic: mismatches between education and employment market, presence of PE and mobility of PHPs. However, a bold percentage of PHPs (43%) were not participating remains. Further research could explore the reasons behind this phenomenon to understand better the reasons PHPs are not participating in pandemic response.
The COVID-19 outbreak has illustrated the obstacles that public health faces where the workforce emerges as largely outside the medical profession yet still within the biomedical model. 49 In order to bolster future pandemic preparedness, public health roles should expect further investment in all areas, including basic and continued education, research to better understand the current situation and needs of the employment market, as well as to assure that the objectives of academic and social programmes are reached. 37 A strong advocacy of a clear competency-based recruitment, personnel and human resource system need to be implemented in order to reform both hiring practices and related salary structures. 38 The COVID-19 pandemic has reinforced the wider need in public health workforce of a plethora of skills including economic evaluation, behavioural psychology, social investigation in the field of inequality, healthy public policy, environmental science and protection, and community development.
Furthermore, the figure of a PHP as an expert on public health needs to be fostered to create the sense of leadership and expertise for future health challenges, improving the trust and communication between experts and population, giving more weigh to the knowledge of the PHPs as experts on the public health area. 50

| Limitations
This study explores a specific population of Europubhealth alumni; individuals with a wide range of backgrounds and nationalities, more than half of them awarded with academic excellence scholarship, which frames their academic prowess. The selective nature of the programme may influence their EOs in public health. However, caution must be placed as this study is not representative of all PHPs and limited research is available.
The method executed in this study was a self-reported questionnaire exposing possibility of bias. 32 To diminish the social desirability bias, the objectives of the research and planned data management were explained in the invitation letter, full anonymity was provided, force-choice items were present and a self-administrate instrument was used. To decrease the order bias, descriptive questions were located first, followed by the JS questionnaire, and lastly, questions regarding employment conditions. Nonresponse bias was another potential limitation of this study.
It was counteracted by trying to get as many participants as possible; e-mail surveys and reminders were sent in weekdays and weekends, in the morning and afternoon trying to catch different participants' time zones and schedules, a general invitation was posted on the social media groups of Europubhealth alumni to raise awareness about the survey. Non-responders were contacted to offer support to complete the survey; available data on the numbers of alumni by generation was compared with the results, having a mean generational participation rate of 66%. 32 Finally, recall bias could be present as some of the questions were related to events in the past. 32

| CONCLUSIONS
This study documents a relatively high employment rate among PHPs who graduated from the EU Erasmus Mundus Europubhealth, which contributes to global job mobility of professionals. Academic programmes such as Europubhealth can prepare PHPs with competencies that assist and prepare PHPs for public health challenges such as TREVIÑO-REYNA ET AL.
-133 the COVID-19 pandemic. Such programmes should combine scientific evidence based public health knowledge and interpersonal competencies, including communication, response, and preparedness. These competencies also fit with the needs of the current employment market, as they are expected for managerial and consultancy positions.
This group of PHPs is satisfied with their job, but their employment situation is unstable due to employment insecurity and lack of professional protection entities to safeguard their employment rights. It is necessary to continue the monitoring and evaluation of EOs of PHPs to identify the evolving job market needs and to prepare the graduates of public health programmes to address adverse situations. It is necessary also to continue to lobby for increasing professional recognition and standards and for formal professionalisation of the public health workforce.
Strengthening preparedness for the COVID-19 pandemic, requires significant and continuous investment in  � I didn't find a job in PH after # months or years and start working in another field *open to add the time.
� Not seeking/sought for a job in PH. 12. What is your current employment status?