Photo Credit: Nostos Media
In Western North Carolina, eight rural counties lie within the Southern Appalachian Mountains, where geography creates steep divides, long travel times, and isolated communities. Collaboration becomes harder when even routine coordination requires navigating winding roads and mountainous terrain.
“We’re separated by actual mountain chains,” says Transylvania Public Health Workforce Development Director Sarah Richey. “On paper, it looks like you’re just the next county over, but you may have to go around the whole mountain chain.”
Beyond geography, rural health departments in Western North Carolina face several other challenges that shape their work. Limited broadband slows down basic coordination. Some counties have no Federal Qualified Health Centers or community health centers, leaving the health department as the sole safety‑net provider. Recruitment and retention can be extraordinarily difficult for a range of reasons, from limited housing availability to fewer employment opportunities for spouses and partners. As a result, vacancies can remain open for years, even when candidates are interested in the work.
These counties are small. Populations range from 8,000 to 50,000, and their tax bases are even smaller. That matters because most public health funding formulas distribute dollars based on population size, which means rural counties might receive $12,000 for activities that realistically require a full-time position, while a larger county might receive $70,000 for the same deliverables. With too little money to carry out the work required, rural counties sometimes have to turn down funding.
For years, these realities have shaped everything. Systems were isolated, efforts were siloed, and collaboration was difficult, not for lack of interest, but because geography, limited funding, and small tax bases made regional work feel out of reach. The workforce was stretched thin, burned out, and often isolated.
Rural health departments know their challenges intimately and how to stretch limited resources, get creative, and serve their communities with deep local knowledge and commitment. They are often nimble, trusted, and deeply connected to the people and places they serve. Still, they rarely have the capacity to participate in or fully leverage workforce data. Without quantitative evidence, it is difficult to convince funders and policymakers that rural public health is fundamentally different from rural healthcare and requires different solutions.
Then came a turning point with PH WINS 2021.
Just as mountains have a pass, a narrow opening that offers a way through, Richey needed a way to cut through the barriers facing her region. She and her colleagues knew their workforce was strained, but they lacked the data to prove it.
Rural health departments often struggle to participate in large workforce surveys, and even when they do, they rarely have the staff or infrastructure to analyze the results. “I kept looking for the data… but everything out there was healthcare workforce,” Richey said. “It just wasn’t completely relevant.”
PH WINS 2021 became that pass. It provided the missing evidence she needed to help these rural counties secure needed resources.
For Richey, seeing national data that mirrored her region’s lived experience was validating.
After COVID-19, the national data was stark. It showed the public health workforce was strained everywhere — not just in rural North Carolina.
- Fifty-six percent of public health workers reported at least one symptom of PTSD.
- Twenty-five percent reported three or more symptoms.
- Seventy percent played a direct role in the COVID‑19 response, and many faced harassment while doing their jobs.
For Richey, those national findings put numbers to what she and her colleagues had been seeing across rural Western North Carolina. “We kind of anecdotally knew that, but we didn’t have a lot of quantitative data. To actually see data about mental health and burnout… was very compelling.” Richey said. This trusted, public health‑specific workforce data validated what rural staff had been experiencing for years.
Having PH WINS data really helps me do my job and be successful. It’s amazing…that data has really helped me get these grants.
Photo Credit: Nostos Media
From Data to Grants
With PH WINS data in hand, in 2024, Richey wrote a planning grant provided by the Health Resources and Services Administration (HRSA), a major workforce development investment for the region. The data allowed her to demonstrate that rural public health departments were not simply smaller versions of larger agencies. They are fundamentally different systems facing different challenges. It helped her differentiate public health workforce needs from healthcare workforce needs, something funders had repeatedly misunderstood.
The HRSA grant funded a first-of-its-kind regional strategic planning process for public health department workforce development, uniting eight counties around shared priorities and laying the foundation for a new regional workforce partnership. It also opened the door to additional grants, seven in total, building a budget of more than $1.16 million.
“Having PH WINS data really helps me do my job and be successful. It’s amazing,” Richey said. “That data has really helped me get these grants.”
PH WINS data gave her credibility, leverage, and momentum, and the regional plan showed funders that the counties had a clear, coordinated approach. The data provided national, state, and regional evidence to justify the need for investment, and strengthened arguments around burnout, PTSD, turnover, and rural capacity gaps. Taken together, these were the tools Richey needed to transform a set of isolated rural counties into a coordinated regional system.
From Grants to Strategy
The HRSA planning grant allowed Richey to convene leadership from all eight counties and develop the region’s first formal workforce strategic plan. Guided by PH WINS data, the group articulated a shared vision of healthy, resilient Western North Carolina communities supported by thriving, trusted local public health agencies. Their mission focused on strengthening public health through cross‑county cooperation, shared resources, and shared infrastructure.
The plan identified several priorities that reflected both the PH WINS findings and the realities of rural practice.
- Regional peer networks. Staff working in similar roles now meet regularly in communities of practice. Billing and coding teams, disaster preparedness staff, and environmental health specialists share challenges, troubleshoot issues, and learn from one another. For small departments, these networks have become essential sources of support.
- Shared regional positions. The counties are piloting roles that would be impossible to fund individually, including a regional disaster preparedness coordinator and a shared WIC staffing model.
- Standardized core policies. The region is developing shared policy frameworks that each county can adapt. This reduces duplication and improves consistency.
- Training priorities identified by PH WINS. Gaps in legal and regulatory knowledge led to new trainings on communicable disease law, animal control, and environmental health statutes. An environmental health internship program places university students in rural departments, expanding capacity and building a pipeline for the future workforce.
- Regional communications response. When a measles outbreak occurred across the state border, the region created unified messaging that each county could tailor locally.
- Research on funding formulas. In partnership with East Tennessee State University, the region is studying how funding formulas may disadvantage rural counties, and exploring strategies that may better support the needs of rural North Carolina counties.
Together, these strategies represent a level of coordination that would have been unimaginable before PH WINS and the HRSA grant.
PH WINS 2024 Data Includes a Regional Dashboard
When PH WINS 2024 data became available, some counties were eligible to receive agency‑level dashboards. Region 1, where these counties sit, was one of those regions. And this provided meaningful insights even closer to home.
Richey used the new data to conduct a spot check on the strategic plan. Leadership reviewed trends, validated priorities, and made small adjustments where needed. In some areas, the data showed worsening trends, including an increase in the number of staff planning to leave their jobs within one year. For Richey, this reinforced the urgency of continued workforce investments and confirmed that the region’s strategies were not only relevant but essential.
Why PH WINS Matters to Rural Leaders
For Richey, PH WINS has become indispensable. The data helps her do her job and be successful. It provides clarity, validation, and national context. Seeing national data helps her feel less isolated.
“That national PH WINS data… showed public health is chronically underfunded… we kind of anecdotally knew that, but we didn’t have a lot of quantitative data.” “We’re not alone,” she said, noting that rural challenges often feel invisible without data to back them up.
Sharing dashboards with staff has also built trust. It demonstrates transparency and reinforces the idea that survey responses directly shape strategy. Staff can see that their experiences matter and that leadership is acting on their employees’ perspectives.
PH WINS is also becoming increasingly important as North Carolina moves into its Rural Health Transformation work. Although Richey is not directly involved at the statewide level, she knows that states must dedicate a portion of Rural Health Transformation funding to workforce development. At the regional and local level, she plans to advocate for the public health workforce to be included, and PH WINS will be her evidence base. The data helps her highlight the unique needs of rural public health staff and make the case that rural workforce challenges differ fundamentally from rural healthcare challenges.
Looking ahead, Richey plans to push for higher PH WINS response rates now that trust has been built and staff have seen the value of the data. She will continue annual strategic plan check-ins using new PH WINS findings and will rely on the data for all future grant applications.
With the region’s five-year strategic plan underway, PH WINS will remain a central part of its evaluation and evolution, helping to inform the vision and shape the future of rural public health in North Carolina.
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