For the first time in 2021, the Public Health Workforce Interests and Needs Survey (PH WINS) included responses from small local health departments — those with fewer than 25 employees serving fewer than 25,000 people. It wasn’t easy to get in touch with these departments, let alone convince them to participate in a voluntary survey during the throes of the COVID-19 pandemic. But the value in doing so was clear: these departments make up an important swath of the country’s public health system, and without their insight, the PH WINS data are incomplete.
“PH WINS is great, but it left out this huge aspect of the public health workforce that is underexamined,” said Betty Bekemeier, PhD, MPH, RN, FAAN, director of the Region X Public Health Training Center, which is known as the Northwest Center for Public Health Practice (NWCPHP) at the University of Washington. Small local health departments, often located in rural areas, make up a big chunk of Region X, which spans Alaska, Idaho, Oregon, and Washington. And while Bekemeier and her colleagues understood why these small health departments hadn’t been included in past PH WINS — their size made securing a representative sample just too challenging — they knew that, without surveying these organizations, PH WINS would only be telling part of the story regarding the training needs, interests, satisfaction, and demographics of the nation’s public health workforce.
As we come out of the pandemic, we’re going to really need to understand what the needs are in the workforce.
Bekemeier said it’s no mystery to her or her colleagues at the NWCPHP why it’s been difficult to reach these small, local, and often rural health departments. “They’re tiny, there’s lots of them, and they’re just less able to participate in this kind of thing. Our job is to reach out more deeply and widely into our public health systems, and we have these connections and relationships in our regions, so we thought, ‘Well, we can help with this.'”
And help with it they did. Together with the Region V Public Health Training Center at the University of Michigan — which serves Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin — Bekemeier and her colleagues at the NWCPHP partnered with the de Beaumont Foundation and the Association of State and Territorial Health Officials (ASTHO) in a logistically difficult, yet ultimately successful, push to include small local health departments in PH WINS.
Through what would come to be known as the PH WINS for All pilot program, the two regional Public Health Training Centers coupled their connections to the local health departments in their regions with de Beaumont’s resources and PH WINS expertise to secure participation from 8,097 individuals across 223 local health departments. Their outreach was a success: 47 percent of employees at these organizations participated, exceeding the 35 percent national response rate. Through its partnership with the Regional Public Health Training Centers in Regions V and X, de Beaumont was able to expand PH WINS representation in these regions 10-fold, and include small local health departments for the first time. This led to an overall increase of 400% in our national sample of local health departments.
‘It’s not like you can just go down a telephone list and call them all up.’
Both Bekemeier and Phoebe Kulik, MPH, CHES, senior director of workforce development for the Region V Public Health Training Center, said the connections they’d spent years establishing with the small health agencies and the State Associations of County and City Health Officials (SACCHOs) in their regions were crucial when it came to helping de Beaumont and ASTHO reach these health departments.
“There were about 500 agencies that we were supposed to be reaching out to in our region (V), so we needed the SACCHOs and public health associations to help us get in front of people aside from just emailing them,” Kulik said. These organizations, according to Kulik, helped by either sharing information at meetings with health officials in their states or inviting Kulik and her colleagues to join those meetings to share. de Beaumont provided resources for this effort, including talking points and templates. Health officers helped to identify workforce champions in individual departments, and then Kulik, Bekemeier, their colleagues at the Public Health Training Centers, and de Beaumont all worked together to communicate with these workforce champions about securing additional information on these small health departments — including the best points of contact — to implement the PH WINS survey.
“It’s hard work to reach these agencies,” Bekemeier said. “It’s not like you can just go down a telephone list and call them all up or send out an email. It just doesn’t work that way.”
This was particularly challenging amid the COVID-19 pandemic. “Sometimes you’d have five minutes at a meeting where most of the health departments were represented, and you’d say what you could, but it was clear they had other things they needed to be talking about,” she said. Those other things, of course, were the immediate task of protecting their communities from further COVID spread and, later, drumming up vaccination participation.
“Being responsible and flexible and respectful of what was going on helped,” Kulik said.
Bekemeier added that, although she would have liked the PH WINS response rates in her region to be even higher, the circumstances were a feat to navigate in and of themselves. “The fact that we had as much response as we did is really remarkable,” she said. “We did this during a pandemic.” Even with the survey’s yearlong delay — it was originally supposed to take place in 2020 — the pandemic was still deeply affecting small local health departments when Bekemeier, Kulik, and their colleagues began reaching out. Part of what helped secure responses was a recognition that the insights collected through PH WINS would be even more valuable following the pandemic.
“They were saying, ‘We’re going to need this more than ever,'” Bekemeier said. “As we come out of the pandemic, we’re going to really need to understand what the needs are in the workforce.”
Insights underscore value
Now, having collected and reviewed PH WINS data from small health departments for the first time, Bekemeier and Kulik both say it’s even clearer that these departments have unique workforce needs, and that including them in the national findings is vital.
“You can see in the findings that have come out since, how important the data were,” Kulik said.
The demographics alone underscore the unique characteristics of these small local health departments, which differ substantially from national averages, PH WINS data showed. For instance, 89 percent of respondents from small local health departments were white and none were Black or African American, whereas nationally, 55 percent of total PH WINS participants were white, and 15 percent were Black or African American. Additionally, 17 percent of respondents from small local health departments had attained a master’s degree as their highest level of education, whereas the same was true of 30 percent of respondents nationally. Eight percent of small local health department respondents had any level of formal public health degree, versus 14 percent of the national total.
These differences have important implications for workforce development and the type of learning opportunities that Bekemeier and Kulik’s training centers develop and provide. “Learning frameworks emphasize that training should meet people where they are in terms of existing knowledge and readiness for change and be relevant to the learner’s job and context in which they work,” wrote Kulik, Bekemeier, and coauthors in a Journal of Public Health Management and Practice supplemental article published in early 2023. Knowledge of these demographic differences, in other words, will help tailor future training opportunities to these small local health departments. Indeed, one of the findings that came to light in PH WINS was that these small local health departments needed more training in diversity, equity, and inclusion.
The 2021 PH WINS survey also revealed unique findings for the small local health departments that served rural communities. For instance, rural public health staff were more likely than urban public health staff to say they were proficient in community engagement, cross-sectoral partnerships, and systems and strategic thinking. They were also more likely to say they need more training in data-based decision-making and diversity, equity, and inclusion, and reported leaving their jobs due to stress, bullying, and COVID-19. These findings were published in the American Journal of Public Health earlier this year.
Bekemeier, who was one of the paper’s authors, said the study would not have been possible with the data gathered in PH WINS, which, in turn, would not have been possible without the PH WINS for All pilot program. “The field has never been able to do a study like that before,” she said.
Since that study came out, Bekemeier said there’s been palpable interest from public health leadership and public health departments of all sizes.
“Nationally and from a practice perspective, there’s really interest in this,” she said. “It’s helped drive the national conversation.”
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