For the first time, all eight U.S. territories and freely associated states have been included in PH-WINS, or the Public Health Workforce Interests and Needs Survey. Rachel Hare Bork joins the show to discuss how this landmark pilot effort came together, why it took extensive travel and collaboration to make it happen, and what the results reveal about the public health workforce across the islands.
For the first time, all eight U.S. territories and freely associated states have been included in PH WINS, or the Public Health Workforce Interests and Needs Survey. Rachel Hare Bork joins the show to discuss how this landmark pilot effort came together, why it took extensive travel and collaboration to make it happen, and what the results reveal about the public health workforce across the islands. She explores key findings, like the islands’ notably younger workforce, gaps in public health education, and the powerful new data leaders can use to advocate for resources. She also digs into why counting these communities matters for both territorial planning and the national public health conversation, and what it will take to continue this work in future PH-WINS cycles.
JOHN SHEEHAN:
This is Public Health Review Morning Edition for Thursday, December 18, 2025. I'm John Sheehan, with news from the Association of State and Territorial Health Officials.
Today, we hear about newly collected data concerning the needs, challenges, and demographics of public health workers from all eight U.S. territories and freely associated states. The information was collected as a pilot program of the PH-WINS, the Public Health Workers Interests and Needs Survey, which is run jointly every three years by the de Beaumont Foundation and ASTHO. The survey hadn't included U.S. public health workforces in island territories until now.
RACHEL HARE BORK:
Puerto Rico and the U.S. Virgin Islands in the Atlantic; in the Pacific, we have American Samoa, the Commonwealth of the Northern Mariana Islands, and Guam. And then we have three freely associated states, the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.
SHEEHAN:
This is Rachel Hare Bork, director of PH-WINS for the de Beaumont Foundation.
HARE BORK:
I am so excited that all of the eight U.S. territories and freely associated states participated in some shape or form on our PH-WINS islands pilot. We sent the survey to almost 9,000 individuals working in government public health, and it had a response rate of 28% among eligible employees, which is something that we are really excited about.
SHEEHAN:
And how did you get such a high participation rate?
HARE BORK:
We worked really hard in conjunction with ASTHO and the Pacific Island Health Officers Association, PIHOA, to really explain the survey. We did a lot of travel, attending national meetings, going out to these specific islands to meet with leaders, explaining to them what the survey is, what the survey is not. We also worked with them to adjust some of the questions so that the survey did match the unique context of the islands.
SHEEHAN:
And it's some pretty far-flung places.
HARE BORK:
Yeah, I have a lot of air miles.
SHEEHAN:
No doubt... this is the first time this survey has taken data from- from these territories.
HARE BORK:
Yes, it was something that we always had wanted to do, but were never able to. And we're really fortunate that we got financial support from CDC to make this happen. And we're thrilled that now these islands have a voice. And it's really great that since the islands participated, we now have data that expresses how they are similar to the rest of the country and also their unique characteristics.
SHEEHAN:
That's great. So, what were some results?
HARE BORK:
Yeah. So, we found some really interesting things when we ran the survey, places in which these islands are really similar to the mainland United States, and places where they are a bit different. So, one area that we really focused on in the survey is understanding the workforce that is 35 years old or younger. And what we see is that the islands have a much younger workforce than the mainland of the United States. So, here in the mainland, 25% of our workforce, about one in four folks, are going to say that they are 35 years old and under. In the islands as a whole, that number goes up to 32%, and when you just look at the Pacific Islands, it's 36%. So, that cuts both ways. On the one hand, it's really great to have young people with fresh ideas entering the workforce. At the same time, they may lack institutional knowledge, and they may, in some places, lack training. And this is another interesting finding. So, within the mainland, it's actually 36% of those who are 35 and under have a degree in public health. That's compared to 17% of older folks in the mainland United States; in the islands, it is reversed. So, in the islands as a whole, only 30% of that younger population has a degree in public health. And in the Pacific, it's really low. It's only 12% of people who are 35 and under have a degree in public health, which shows that there needs to be more opportunities for education and training for the younger islands workforce, because they don't have it at the same levels as their peers in the mainland.
SHEEHAN:
And did you find that this- these survey results were surprising to- to the territorial leadership?
HARE BORK:
Yes and no. I think in a lot of times, PH-WINS gives you the numbers of things that you kind of already know. But that- and that is powerful, right, to be able to go to leaders with those numbers. I think in the Pacific, they know it is an issue. They have training programs that they're really proud of, that they're working to expand. I think the number itself maybe was a little jarring exactly how low it is. And I also think it's really powerful, and this is about PH-WINS in general, is that the survey allows you to compare to, so that they can now go to leadership and say, hey, we have a real training problem. Only 12% of our U.S. API, under-35 workforce, have a degree in public health. We are behind the rest of the islands, and we are way behind the mainland, and that is, I think, a really powerful narrative that leaders can use that they couldn't say before they participated in PH-WINS.
SHEEHAN:
Yeah. Is that an example of one of the directions, maybe one of the takeaways that leadership can bring from the data results?
HARE BORK:
Yeah. I think a lot of the leaders have talked about using this data to go to territorial leadership or freely associated state leadership, to say, hey, we need more money for public health in our island. And here are findings that show kind of the the extent of our need, what our workforce is saying they need, how the skill level or lack thereof of- of our workforce, because at the end of the day, they're fighting with lots of other issue areas to get a piece of the pie as- as happening in states across our country, right? So, I think the fact that they have this PH-WINS data is a really powerful advocacy tool that public health leaders now have to try and get more resources for public health in their islands.
SHEEHAN:
Yeah. Is the hope that it will influence the national conversation as well now that you can sort of compare data from the Pacific Islands to the continental U.S.?
HARE BORK:
Yeah, exactly. I think it'll be really powerful that they are now part of the narrative. And this was a criticism that we got in previous cycles of PH-WINS, that was fair, that islands weren't counted, and if you're not counted, then you can't be part of the story.
SHEEHAN:
And finally, so this was a pilot program. Is the intention for it to continue?
HARE BORK:
That is our hope. CDC funded this pilot, and we were really grateful for their support, and we are having conversations with them about continuing this work, because one of the most powerful things about PH-WINS is that it is a survey that is taken over time. So in, you know, for ASTHO members, right, those that have participated can look at how their data has changed over time. This PH-WINS islands pilot gives us a baseline for the islands, but of course, we'd love to run it on the same cadence of about every three years, so that these islands can track their progress across these metrics.
SHEEHAN:
Rachel Hare Bork is the director of research and impact at the de Beaumont Foundation, and holds a Ph.D. in politics and education from Teachers College, Columbia University. Oh, and one more thing...
HARE BORK:
For those folks who are interested in learning more, we really encourage you to go to our website, phwins.org. There's a drop-down menu there, and under '2024 Findings,' you'll see another tab that says, 'PH-WINS Islands Pilot.' There you'll find tons of data, infographic reports, and, of course, all of the data is publicly available on our dashboards. We hope interested individuals will take a look at the data and explore on their own.
SHEEHAN:
Join Manisha Juthani, M.D., commissioner, Connecticut Department of Public Health and ASTHO President, and John Auerbach, M.B.A., senior vice president for public health, ICF, for a webinar that examines how clear, purposeful leadership strengthens both internal and external trust through insights and reflection, we will examine how leaders embody steadiness amid uncertainty, set a sustainable pace and provide calm direction that builds trust and drives performance. This conversation aims to inspire participants to recognize their composure and capacity, not as a personal indulgence, but as a fundamental leadership function that shapes the overall tone, focus, and confidence of their organizations.
Stay current on all ASTHO news by subscribing to Public Health Weekly and Legislative Alerts for updates, analysis, resources, and events on pressing issues in state and territorial public health. You can find it all at astho.org or the link in the show notes.
This has been Public Health Review Morning Edition. I'm John Sheehan for the Association of State and Territorial Health Officials.
