Public Health

Workforce Research in Public Health

A new collaborative consortium

BY J.P. Leider, PhD

Questions of how to recruit and retain a competent workforce have long been a challenge in managing a clinical practice, just as they have been in governmental public health, through boom and bust times alike. Labor shortages have always been an issue. How long have we talked about looming physician shortages, or nursing shortages, or physician assistant shortages? Today it seems that they are worse than they have ever been. What seems different now is that the crunch is everywhere, and since all labor is more interconnected than ever, shortages in some areas affect others. One such area is the public sector generally, and in public health specifically. This is where the University of Minnesota’s School of Public Health (SPH) is conducting nationally-oriented research that will address some of the most challenging workforce issues in the field.

These changes reduced the carbon footprint of this existing facility by over 95 metric tons per year.

Workforce Development Research in Health Care Delivery

There are nine health workforce research centers in the United States. They focus on a variety of areas, all with a similar focus- how do the issues facing our health care workforce affect the delivery of care and, ultimately, the population’s health? These nine centers cover the emerging workforce, allied health, oral health, behavioral health, and other areas. Public health has recently been added to the list and this new focus likely reflects the challenges wrought by response to COVID-19. We have seen declines in this particular workforce, which has the potential to impact areas of population health such as the delivery of clinical services, protective inspections, and population based services in our communities. SPH leads an endeavor to research the public health workforce through a new collaborative model called the Consortium for WOrkforce Research in Public Health (“CWORPH”), which includes five additional universities:, Columbia, Eastern Tennessee State University, Indiana University, Johns Hopkins, and University of Washington. CWORPH also includes additional partners that represent and serve public health practitioners across the U.S..

Diversity of Workforce Training

Substantial investment in public health workforce development was made in the aftermath of the bioterrorism attacks of 2001. Primarily this was in the space of preparedness training, but also there were somewhat broader investments in public health research. It wasn’t until the late 2000s that public health centers started to take hold and many online trainings became widely available. SPH is well known for developing a number of these trainings, some which are still available today. As part of the new “Minnesota Prepared” joint partnership with the Minnesota Department of Health, SPH is revitalizing some of these offerings by updating technology and content. Additionally, SPH partners with the Region V Public Health Training Center (RVPHTC), based out of the University of Michigan. Any provider can get training for free from the RVPHTC regarding public health and preparedness issues, as well as relatively inexpensive continuing education credits. There is also a new leadership institute available to public health and primary care practitioners through the RVPHTC, which CPHS supports. It is our charge to better connect the public health and primary care workforces, and ensure training is available to all.

Range of Projects

While training is, by volume, the largest portion of workforce development, research plays an incredibly important role. The new Public Health Workforce Research Center, supported by HRSA and CDC along with CWORPH, is tasked to help solve some of the most persistent questions in our field. Largely these relate to how to count the workforce, how to recruit and retain the workforce, and how to build and maintain pathways from colleges and universities into the workforce. Each year, CWORPH conducts at least eight projects, and rapidly disseminates their findings in concert with practice partners. It is definitely not a situation where we unilaterally identify problems for the field and provide answers when the projects conclude. The community tells CWORPH what the problems are and everyone works together to find those answers and quickly share the data. Projects include:

• Turnover assessment of the public health workforce
• Description of roles of nurses in COVID-19
• Strategies to convert a temporary surge of workers into a permanent workforce
• Characterizing variation in workforce composition
• Comparison of occupations in the public health vs. private sector workforces
•  Identifying gaps from agency workforce development plans 
• Review of state hiring laws
• Estimating workforce supply
• Roles of community health workers
• Career ladders in recruitment and retentionAir-Change Analysis

Resource Allocation

Some of these projects are more technical than others. Some may be a little more exciting. Not all of them reach out and grab you - it is workforce research, after all. All of our projects have a focused and important role to play in understanding why and how the public health workforce has withered over the past 15 years. A major reason is the lack of top-down investment and misuse of initial funding. But it’s not just about money and the lack of it. Those in a clinical setting can connect with this idea - that resource allocation is more than just about top-line decision making. There are cascading consequences of dollars and cents, and so to rebuild the system, we have to understand so many components of the budgets that got cut and how those systems got set up ages ago.

A growing potential for savings has been identified  in older and aging facilities.

In our first year, our aim is to understand some very fundamental aspects of the public health system. This includes understanding nationwide geographic and demographic population distribution, examining public and private sector methods of collecting data, and comparing this data and ways in which occupations are changing over time. Two topics may be of particular note to physicians. One is that HRSA and CDC are particularly interested in how nurses operated in the context of COVID-19 response. Over the last 40 years, the role of nurses in the public health sphere has dramatically changed. Previously, nurses operated mostly in a clinical context because, throughout the mid 1900s, public health provided extensive safety net clinical care. Starting in the 1970’s and throughout the 1980’s especially, there was a push to have public health offload a lot of its clinical care to community health centers and the private sector. The thinking that changed the landscape was that public insurance was more widely available, allowing an increased number and more providers to take on the extra work. In theory, public health could leave that side of care to the people who could deliver it best, between private providers and FQHCs and other community health centers. Then public health could focus on what it does best - population-based services, direct inspection/regulation, and some clinical prevention if needed. But where did that leave nurses? Nurses had been the largest part of the public health workforce, essentially forever. In many parts of the country they still are, but in the past several decades the size of the public health nursing workforce has shrunk drastically. Part of that has been competition from the private sector, and part of that is that now over a third of nurses in public health do non-clinical work, jobs that might be better performed by staff with other training. Nurses are often placed into jack-of-all-trades type positions, and what one of the things we are trying to find out is what they were asked to do in the context of COVID response. Everything, perhaps? 

A second question and study that is being undertaken this year is the rise of Community Health Workers (CHWs). CHWs largely did not exist in the public health workforce two to three decades ago. There were some states that had strong contingents of this workforce, but CHWs were not highly utilized nationally, though they played incredibly important roles in the delivery of health care services. Now we are seeing that more health departments are employing CHWs. Indeed, in Minnesota the CHW is one of the positions that health departments say they are trying to hire and having a hard time doing so in the context of the labor market challenges we are currently experiencing. Our study seeks to characterize that CHW workforce especially.

A New Research Partnership

While the projects themselves are interesting, the story of how CWORPH came to be is as well. We constructed our six-member consortium to cover a number of topical areas and expertise in the space of public health and health care workforce research. My specialty is public health systems generally, and Janette Dill, the Deputy PI on the HRSA/CDC-funded Center has worked for many years on topics related to the health care workforce. Heather Krasna at Columbia University is an expert in topics of recruitment, while Michael Meit at East Tennessee State University and the ETSU Center for Rural Health Research is a national leader in rural public health and health care. Valerie Yeager at Indiana University is a qualitative methods expert and has broad expertise in public health workforce, including on issues of workforce development and recruitment, while Beth Resnick at Johns Hopkins University is a public health systems researcher that has worked extensively during COVID-19 on issues of bullying and harassment. Betty Bekemeier at the University of Washington is a public health nurse and researcher with extensive experience across a broad array of public health workforce and systems issues.

CWORPH is advised by the National Consortium for Public Health Workforce Development, and it has a number of practice partners on a technical expert panel, including:

• Association of State and Territorial Health Officials (ASTHO)
• National Association of County and City Health Officials (NACCHO)
• Association of Schools and Programs of Public Health (ASPPH)
• Big Cities Health Coalition (BCHC)
• Public Health Accreditation Board (PHAB)
• MissionSquare Research Institute
• de Beaumont Foundation (dBF)
• State Associations of County and City Health Officials (SACCHOs)
• Public Health Training Centers (PHTCs)

Conclusion

Oftentimes, federal RFPs let you submit under different models. This one would have let an applicant go in as an individual university or as a consortium. Submitting as a consortium was the only thing that made sense, even though we would have been competitive as single universities. The issues facing the public health workforce are just too thorny for one organization to tackle on their own. It made sense to leverage everyone’s strengths to figure out together what the problems were and to try and solve them, together. Public health is inherently collaborative, and it would be counter to this idea for a single university to create a model -no matter how well-meaning - that would attempt to solve all these problems on its own. A consortium where many perspectives collaborate to identify the problems and work with federal partners to pick, research and solve them means that we identify the most important issues, apply the most rigorous methods to solve them and then rapidly disseminate the results. This sort of rapid cycle approach is an exciting way to do applied research at a time when public health workforce issues are in the lime-light and actually getting investment - and at a time when workforce shortages in health and health care face an unprecedented need for quick and concise resolution.

J.P. Leider, PhD, is the director of the Center for Public Health Systems at the University of Minnesota School of Public Health. He is a senior fellow in the Division of Health Policy and Management and on the affiliate faculty at the Center for Bioethics.