Public Health Perspectives on the Cost and Value of Certification for Disease Intervention Professionals

Abstract

Objectives:

Enhancing the disease intervention (DI) workforce through professional certification has been a national goal for several decades. The objectives of this qualitative study were to (1) understand facilitators and barriers to obtaining Certified in Disease Intervention (CDI) certification and (2) identify potential strategies to improve access to certification.

Methods:

We used a grounded theory approach to accomplish these objectives and develop a conceptual framework of the major factors that influence DI specialist decisions to obtain professional certification. We conducted 9 virtual listening sessions in 2026 with 9 representatives from health departments across the United States. We used constant comparative analysis to collect data and perform data analysis.

Results:

We organized key themes into a conceptual framework to explain influences on certification at 3 levels: societal/systems, organizational, and individual. At the societal/systems level, the major influences were availability of government funding to support certification, the overall movement to professionalize the DI workforce, and current political priorities. Funding, workload, local population needs, and the organizational structure and staffing model influenced the ability of organizations to support certification. At the individual level, the main influences were ability to pay, perceived value and benefit of CDI certification, and time to study and take the certification examination.

Conclusions:

CDI certification was viewed as a positive step toward enhancing the DI workforce by offering standardization, development of skills, and opportunities for career growth. The financial barrier of employees paying the full cost of CDI certification should be considered by employers and certification organizations. Cost subsidization and support are necessary to improve CDI certification uptake and sustain CDI recertification.

Keywords

community health disease intervention prevention workforce public health

Disease intervention specialists (DISs) have existed in the United States since the 1940s as a federally funded workforce to confirm cases of syphilis and prevent its spread in communities.^1,2 Since then, the role of DISs has expanded to include confirming cases and preventing the spread of gonorrhea and HIV. In the early 2000s, many DISs contributed to bioterrorism readiness and response as part of broader public health preparedness efforts after September 11. In 2009, DISs were mobilized during the H1N1 pandemic and, since that time, have supported responses to hepatitis, measles, and mpox outbreaks.¹ More recently, DISs expanded their role during the COVID-19 pandemic to confirm cases and prevent the spread of the disease.^3,4 DISs help to reduce the spread of infectious diseases through activities such as contact tracing, partner services, health education, and improved access to health care.⁵

The Centers for Disease Control and Prevention (CDC) initiated a national certification project to help standardize and professionalize the disease intervention (DI) workforce in 2022. The Certified in Disease Intervention (CDI) certification program is being implemented by the Association of Schools and Programs of Public Health, with a CDI examination planned for 2026 in collaboration with the certification provider, the National Board of Public Health Examiners. The CDI certification is a skills-based national standard that aims to validate and unify the DI workforce.⁶

Prior research provides limited evidence on how DISs and public health departments view professional certification.^7,8 However, Leider et al found that public health professionals perceived cost as a major barrier to taking the Certified in Public Health examination.⁹ Ibe et al found skeptical views on the perceived utility of certification for improving wages and future job prospects among community health workers.¹⁰ A 2017 report found that CDI certification would have several anticipated benefits for the DI workforce, such as greater visibility of DISs, improved retention by establishing a minimum baseline of competencies and skills, and greater DIS job satisfaction by fostering learning through the sharing of best practices.¹¹ Currently, DI training differs from state to state and allows for regional variation. To expand CDI certification uptake, it is important to understand perspectives and address concerns from DISs and leaders at public health departments.

The primary objectives of this study were to gather insights from DISs on (1) facilitators and barriers to obtaining certification, (2) existing programs or incentives that may be used to support certification, and (3) strategies to improve access to CDI certification. A secondary objective was to develop a conceptual model explaining the factors that influence DIS decisions to obtain CDI certification.

Methods

We used a general grounded theory approach for qualitative research, as originally described by Glaser and Strauss,¹² to accomplish the study objectives and to develop a conceptual model of the major factors influencing DIS decisions to obtain CDI certification. We used grounded theory methods, such as systematically gathered and analyzed data, to generate a theory based on the perspectives of those involved in DI work.¹³

The George Mason University Institutional Review Board reviewed all research protocols for the listening sessions and determined that the project was not human subjects research. All participants provided verbal informed consent at the start of the listening sessions.

Sampling and Recruitment

We used a snowball sampling approach, beginning with a small number of initial participants (“seeds”) who met the inclusion criteria of working in DI, such as DISs, epidemiologists, case managers, and/or public health leaders involved in DI work at state or city health departments in the United States. These individuals were then invited to identify others in their social or professional networks who fit the study criteria. This process allowed the sample to expand iteratively through participant referrals. We continued recruitment using a theory-derived sampling approach that allowed our team to examine concepts from various angles and question their meaning,¹⁴ which assisted in the process of developing a theory on what influences the decision to obtain DI certification.

Data Collection

We conducted 9 virtual listening sessions with DISs, managers, and related workers from June through September 2025. Each listening session comprised 1 to 6 participants and lasted 55 to 60 minutes. All sessions were facilitated by an experienced qualitative researcher (D.G.G.) and recorded and transcribed by Zoom videoconferencing software. During the listening sessions, we asked participants about their perceptions of the value of CDI certification; the facilitators and barriers to obtaining certification; the participants’ ability to pay for CDI certification and recertification; the availability of financial assistance within and external to their organization; and other support for CDI certification, such as leadership encouragement and time availability for training and examination testing (Supplemental Material). Because this study took place prior to an established fee for CDI certification, participants were asked to discuss their ability and their organization’s ability to pay for CDI certification without knowledge of the actual costs associated with certification or recertification.

Data Analysis

We used NVivo 15.3 software (Lumivero) to analyze the transcripts, using constant comparative analysis in which we concurrently collected data and performed data analysis. Before analyzing the transcripts, we developed a list of a priori codes based on a literature review of the DI workforce and our study objectives. We expanded the codebook with inductive codes that emerged from reviewing and coding the transcripts. We also grouped responses to questions about the value placed on certification into the following categories: low, moderate, and high. Two experienced researchers (D.G.G., G.G.) and a graduate research assistant (A.L.R.) conducted qualitative data analysis. Analysis involved multiple rounds of data coding and analysis with biweekly team meetings to identify emerging themes.

Results

Participant Characteristics

We held listening sessions with employees from 9 organizations that represented state and city health departments from across the United States (Table 1). State health departments involved in the project included Arizona, Maine, New Hampshire, New York, Vermont, Virginia, and Wyoming. City health departments included New York City and Washington, DC. Listening session participants included case managers, DISs, epidemiologists, field managers, lead investigators, program directors, public health advisors, regional health directors, and supervisors.

Table 1.

Characteristics of listening session participants on the cost and value of certification for DISs by US Department of Health and Human Services region

Health department	Listening session date	No. of attendees	Participant titles	Population density: high/low
Region 1
Maine Department of Health and Human Services	September 3, 2025	4	Manager, DIS supervisor, DIS	Low
New Hampshire Department of Health and Human Services	July 28, 2025	3	Supervisor, DIS	Low
Vermont Department of Health	July 7, 2025	3	Program chief, disease intervention workers	Low
Region 2
New York State Department of Health	July 2, 2025	5	Director, DIS case managers, DIS lead investigators	High
New York City Department of Health and Mental Hygiene	July 17, 2025	6	Director, supervisor, public health advisors, epidemiologists	Very high
Region 3
Virginia Department of Health	August 19, 2025	4	Director, managers (DIS) (state level)	High
DC Health	June 16, 2025	6	DIS case manager, DIS lead investigator, DIS	Very high
Region 8
Wyoming Department of Health	August 20, 2025	4	Manager, STD investigator, epidemiologist, DIS	Low
Region 9
Arizona Department of Health	August 18, 2025	1	Case manager (DIS)	Low

Abbreviations: DIS, disease intervention specialist; STD, sexually transmitted disease.

Listening Session Themes

The key themes from the listening sessions centered on the perceived value and benefits of certification, facilitators and challenges to certification, and strategies to overcome these challenges (Table 2).

Table 2.

Themes and supporting quotes from 9 virtual listening sessions with individuals involved with disease intervention on their perspectives on certification, United States, 2025

Theme category: theme	Definition	Supporting quotes
Benefits
Standardization	Establish consistent practices and expectations across the workforce	I think a DIS certification is good in the sense that it ensures across the board to ensure they have a standard skill set, and that whether you’re in Vermont or Miami, you know that this DIS is going to come with the same package of skills.—Program chief
Professional recognition	Gain validation and credibility for skills and DI expertise	A certification could make themselves (DISs) marketable to an employer working in the same role because they want that employer to recognize that they were coming in with a certain amount of training or approach to the subject matter.—DIS case manager
Career development	Expanding opportunities for advancement, training, and growth	The benefit to something like certification is also networking, and so having access maybe to, like, a network of other certified disease intervention specialists, that can be really beneficial.—DIS supervisor
Barriers
Financial limitations	High costs of certification or training reduce accessibility	Just as a person, I think that if the burden of paying for a certification were on me, I would probably not opt into doing it.—DIS workerI’ve never been in a situation at a local health department where we were about [to] actually pay for our employees’ professional development.—Regional health director
Moderate-low importance	Certification is not viewed as essential by some employers or staff	I think as a supervisor, it is moderately important.—Case manager
Time	Competing work and personal responsibilities make it difficult to complete certification	I mean, are people busy juggling high caseloads. I don’t know what kind of time they might necessarily have at some point, but I think we could support that, it’s just, I don’t know how much time they’d have.—DIS supervisor
Facilitators
External financial support	Grants, scholarships, or organizational funding that reduce personal costs	I feel like a big facilitator that could encourage certification would be the state supporting this and allocate funding for it or receiving federal support.—Human resources staff member
Willingness to facilitate	Employers or organizations showing openness to supporting certification efforts	It’s part of our agency mission and our strategic plan to have a valued and competent workforce, and upskilling your workforce like this would fall very neatly into that bucket.—Program chief

Abbreviations: DI, disease intervention; DIS, disease intervention specialist.

Theme 1: Importance of CDI certification is moderate or low for many DI workers

Although some individuals were enthusiastic about CDI certification, many participants rated CDI certification as having moderate or low importance to their current work and career. Individuals who rated CDI certification as having moderate or low importance were those who had worked in the DI field for a long time (≥5 y), were proponents of on-the-job training, or thought that their current DI training courses were sufficient. One DIS supervisor said,

I understand the value of certification, but as a supervisor providing extensive hands-on training, what really matters to me is the materials and training provided to prepare for the certification . . . and whether those can effectively prepare someone to be a successful DIS.

Most participants valued on-the-job training programs, which was perceived as critical for gaining essential skills for DI work. Numerous participants mentioned that the focus and organization of DI work can differ across states and reflect local or regional differences in populations and culture, which requires on-the-job training. One DIS supervisor said, “I have high confidence in our in-house training, you know, we know our community needs really well.”

Participants raised concerns that merit careful consideration in the implementation of a CDI certification program. These concerns encompassed challenges related to the cost of CDI certification and recertification; the possibility that the CDI credential might overlook local or regional disease pathways and care delivery mechanisms; apprehension that CDI certification could diminish on-the-job training opportunities; and fears that it might devalue the contributions of individuals with extensive field experience and prior training in DI. A DIS noted, “Every state is different, and I think we have come up with an excellent training model for our DISs in this state and the populations we serve.”

Theme 2: Benefits of certification include standardization, professional recognition, and career development

During discussions on the value and outcomes of certification, participants identified benefits that would result from CDI certification. Key subthemes for participants who rated the importance of certification as “valuable” included increased standardization and skills, increased professional credibility, and increased number of job opportunities and career advancement possibilities. Many participants reported greater standardization as a key benefit to certification and discussed a need for standardized knowledge of communicable diseases and community resources, skills in motivational interviewing and data collection, and expertise in coalition building. A program chief of a DIS unit said,

DIS certification is good in the sense that it ensures across the board . . . standard skill set, and that whether you’re in Vermont or Miami, you know that this DIS is going to come with the same package of skills.

Several participants stated that certification would lead to increased professional credibility because most DI workers do not have a professional credential or license. Several participants described situations where physicians discounted their perspectives regarding disease management strategies and care support plans for clients. These participants believed that the CDI certification would give them more professional credibility when interacting with health care providers. A DIS supervisor said, “Having a certification will give them that level of credibility with providers. A lot of the role is doing provider education and ensuring that the providers are following CDC’s treatment recommendations.”

Many participants thought that CDI certification would lead to professional development and job opportunities. Several participants thought that CDI certification would offer the opportunity to interact with other DISs at conferences or training events. Numerous participants also thought that certification would allow them to transfer into other positions within the same organization or to DI positions at health departments in other areas.

Theme 3: There are many barriers to certification, including cost of the certification examination and time for training and taking the examination

Major participant barriers to certification included paying for the cost of training and the additional time involved in training and taking the certification examination. These barriers were compounded by the moderate to low value that many DISs attribute to CDI certification. Many DISs expressed concern about paying out of pocket for training and the CDI examination, considering that they were low-wage public health workers. Although some participants said that they would pay for the CDI examination out of pocket, most participants stated that they did not have disposable income to cover these expenses. Organizational support to pay for training and the CDI examination was also seen as a potential barrier because many participants stated that their organizations currently did not have dedicated funds to support certification examination fees. A DIS manager noted, “A lot of those certification exams are pretty pricey, like $500 plus . . . for jurisdictions expecting DIS to pay for it themselves, a high cost could really be a barrier.”

Participants expressed concern about the additional time needed for training and taking the examination. Several participants stated that they could use time on the job for training and taking the examination. However, most participants said that their high workload and the need to meet CDC-required metrics would prevent them from completing certification activities on the job. A DIS noted, “Being able to use work hours to study could be a facilitator, but it really depends on morbidity levels and priorities. If multiple new syphilis diagnoses need immediate intervention, we can’t just set aside whole afternoons for studying.”

Theme 4: Facilitators for certification include external financial assistance, organizational support, and professional development

A large part of the listening sessions was spent discussing the facilitators and barriers to CDI certification. Participants most often pointed to external financial assistance, organizational support, and professional development as key facilitators for CDI certification.

We asked participants whether their organization offered education or tuition benefits for full- or part-time employees. Education/tuition benefits, if offered, were strictly intended to support employees with expenses associated with higher education coursework. We also asked participants whether their organization covered the expenses associated with certification for other types of workers, such as the Certified in Public Health credential. Responses from participants were mixed, with several stating that they knew of other health department employees who received financial support for certification and others stating that their organization did not provide financial support for certification.

Most participants stated that the largest facilitator for CDI certification would be external financial support through state or federal grants or through foundation funding. Another facilitator described by many participants was organizational support for time to train, prepare, and take the CDI certification examination. There were mixed responses from DI managers and supervisors on whether the organization was able to provide time to employees for on-the-job training and to take the CDI certification examination. Most participants indicated that they received on-the-job training for their current DI work. DI managers and supervisors stated that they were supportive of providing time on the job for certification training and the examination; however, this would depend on the workload and availability of other staff to complete required tasks. Several participants described current staff shortages as a barrier to taking time on the job for certification training and taking the examination.

Multiple participants remarked that another facilitator would be if certification/recertification was tied to national or regional conferences that also provided networking opportunities. A DIS supervisor said, “To encourage others to pursue certification, it could be tied to a conference or other networking opportunities. It’s really beneficial to learn from other states.”

Conceptual Framework

Key themes were organized into a conceptual framework (Figure) to explain influences on certification from 3 levels: societal/systems, organizational, and individual. At the societal/systems level, the major influences are availability of government funding to support CDI certification and DI work, the overall movement to professionalize the DI workforce, and current political priorities that influence funding and workforce development. At the organizational level, funding and workload were major influences on the ability of organizations to support DISs in their pursuit of certification. Other influences at the organizational level included the needs of the population served and the organizational structure and DI staffing model. At the individual level, the main influences were the ability to pay and the value/benefit of CDI certification. Other influences at the individual level included time to study and take the certification examination.

Figure.

Factors that influence the decision of disease intervention specialists (DISs) to pursue certification.

Discussion

One of the most prominent themes was the financial obstacle encountered by DISs when considering voluntary CDI certification, as noted in prior studies.⁷ In the absence of external financial support, numerous DISs indicated that they would probably not pursue certification. This finding is consistent with other public health credentials, such as the community health worker certification¹⁰ and the Certified in Public Health examination.⁹ One recommendation from participants was to include funding for CDI certification in federal and state grants, such as the STD Prevention and Control Program. This financial support would promote increased CDI examination uptake. State and federal initiatives could implement scholarship competitions or voucher programs, where candidates submit brief applications outlining their professional aspirations. For example, states might purchase prepaid packages of 10 to 20 examination vouchers at a discounted rate and distribute them to local health departments.

The listening sessions revealed that organizations can be an important catalyst for participation in the CDI examination, especially when a full subsidy is provided, encompassing examination fees and the additional time for training and taking the examination. Promoting the integration of CDI certification into existing professional development activities can help establish the credential as an indicator of professionalism.

Other recommendations for DI workforce development include offering professional conferences to provide opportunities for networking, recognition, and skill development.^7,15 Participants highlighted the importance of peer exchange and the professionalism associated with CDI certification. Regional and/or national DIS conferences could function as platforms for knowledge sharing, facilitating connections between certified and noncertified personnel, and promoting best practices across various states and localities. A national gathering could function not only as a training venue but also as a forum for recognition and building morale. Additionally, a national platform could strengthen the voice of DISs by emphasizing their important role in infectious disease prevention and outbreak response.

To promote CDI certification and recertification, participants suggested that organizations could offer tangible rewards. Incentives such as salary increases, promotion opportunities, or bonuses linked to CDI certification may help align individual workers’ motivations with organizational objectives. However, salary increases may require additional grant funding to cover increases in personnel expenses. Participants suggested that salary increases would need to be reflected in future grant applications, which would increase the amount of the grant award.

The listening sessions revealed 3 contextual considerations. First, DISs have traditionally depended on hands-on training. Consequently, the introduction of a national certification may need to be framed as complementing on-the-job learning. Second, unions representing public health workers in some regions can influence the adoption of CDI certification. Unions may support certification if it is linked to clear advantages, such as salary raises, career growth, or improved safety. Conversely, unions could oppose certification if viewed as an unfunded mandate demanding new obligations without proper funding or job security guarantees. Early involvement of unions in designing and implementing CDI certification policies is essential to securing their support. Third, a key challenge is the potential politicization of CDI certification. Some participants worried that a centralized, national certification could be exploited for political motives, and some voiced distrust in federal oversight. To address these concerns, transparent communication and a clear explanation of the benefits of voluntary CDI certification for workers and communities are recommended.

Limitations

This study had several limitations. First, the small number of participating organizations may have limited the diversity of perspectives. Second, snowball sampling may have introduced selection bias, both of which may limit transferability of findings. It is also important to note that the goal of this study was to understand participants’ perceptions of CDI certification, which did not include quantitative assessment of certification outcomes.

Conclusion

Many participants viewed CDI certification as a positive step toward enhancing the DI workforce by offering greater standardization and development of skills for career growth. The financial barrier of employees paying the cost for CDI certification out of pocket was a prominent theme in this study. Therefore, cost subsidization and support are necessary for CDI certification uptake and to sustain CDI recertification in future years. Another prominent theme was that many DISs rated the importance of CDI certification as moderate or low. This study highlights the need for transparent communication about the benefits of voluntary CDI certification for DISs so that it can be viewed as a positive strategy to empower workers, instead of an added burden.

Supplemental Material

sj-docx-1-phr-10.1177_00333549261453024 – Supplemental material for Public Health Perspectives on the Cost and Value of Certification for Disease Intervention Professionals

Supplemental material, sj-docx-1-phr-10.1177_00333549261453024 for Public Health Perspectives on the Cost and Value of Certification for Disease Intervention Professionals by Debora Goetz Goldberg, Anna Laurel Reiss and Gilbert Gimm in Public Health Reports®

Footnotes

ORCID iDs

Debora Goetz Goldberg, PhD, MHA, MBA

Gilbert Gimm, PhD, MBA

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) through Notice of Funding Opportunity (NOFO) number CK20-2003 titled Improving Clinical and Public Health Outcomes Through National Partnerships to Prevent and Control Emerging and Re-Emerging Infectious Disease Threats. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the US government.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

A detailed table of themes with corresponding deidentified quotes is available from the corresponding author upon request.

Disclaimer

The contents are those of the authors and do not necessarily represent the official views of, or an endorsement by, the Centers for Disease Control and Prevention/US Department of Health and Human Services or the US government.

Supplemental Material

Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th Edition.

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