Jeffrey Oxendine, the founder and chief executive officer of the Health Career Connection and the director of health workforce and diversity at the University of California Berkeley School of Public Health, began the final session highlighting earlier themes including the historical contexts of the population health workforce and the development of innovative solutions to 21st century population health workforce challenges. Then he listed the objectives of the final session: defining the competencies and characteristics required in an effective population health workforce, and identifying approaches that will attract and retain the population health workforce of the future and allow them to achieve their life goals. Oxendine then introduced the panelists for the session: JP Leider, senior fellow of the Division of Health Policy and Management at the University of Minnesota School of Public Health; Montrece McNeill Ransom, the director of the National Coordinating Center for Public Health Training at the National Network of Public Health Institutes (NNPHI); Bianca Frogner, a professor in the Department of Family Medicine at the University of Washington (UW) School of Medicine and director of the UW Center for Health Workforce Studies; Tia Benally, a master of public health candidate at the University of Washington School of Public Health; and Joana Fernandez Nuñez, a master of public health and master of social welfare candidate at the University of California, Los Angeles (UCLA) Fielding School of Public Health.
To set the stage, Oxendine provided a framework from the California Future Health Workforce Commission that included focus areas and foundational elements for a future population health workforce, such as employing a workforce with the appropriate competencies and capabilities to effectively promote health and deliver health services in the communities in which they serve. Oxendine added that building a diverse and competent population health workforce requires “shared ownership” among government agencies, philanthropic organizations, the private sector, and schools and programs in public health. He described three main strategies identified by the California Future Health Workforce Commission: increase opportunity for all Californians to advance in the health professions, align and expand education and training to prepare health workers to meet California’s health needs, and strengthen the capacity, effectiveness, well-being, and retention of the health workforce.
Oxendine next listed a number of groups that will be key to improving population health: the COVID-19 workforce (for mitigation, contact tracing, vaccine ambassadors, etc.); participants in expanding programs (the Public Health Associate Program, Public Health Corps, Centers for Disease Control and Prevention (CDC) Undergraduate Public Health Scholars program, public health fellows, etc.); pipeline program grad-
uates; public health certificate, undergraduate, graduate, and doctoral students and recent graduates; novel degree program participants (e.g., those earning an M.S. in community medicine); members of the incumbent governmental public health workforce; workers and clinicians in other health sectors; community health workers (CHWs) (e.g., health coaches and health navigators); and professionals from other industries (e.g., social services, school-based services, veterans, and digital health). Oxendine said that new funding opportunities exist to expand the public health workforce, citing $7.2 billion in the American Rescue Plan for public health workers, new Public Health AmeriCorps programs, expanded Public Health Associates programs and increased funding from the Centers for Disease Control and Prevention to state and county public health agencies.
Oxendine also pointed to many different sectors of the current population health workforce, including governmental public health and health agencies, population health collaboratives (e.g., whole person care, health exchanges and intersectoral partnerships), hospitals and health systems, community-based organizations, community health centers, tribal community health, medical groups, private-sector groups (e.g., start-ups, biotech, health plans and digital health), private foundations, academia, schools, behavioral health, older adult health, and global health. “We need to widen our lens of where we send people into public health in addition to governmental public health and find ways we can all work together,” he said.
Oxendine acknowledged the importance of organizations such as the Council on Linkages and Council on Education for Public Health in identifying and characterizing educational competencies. Oxendine also emphasized the value of “upstreamist” approaches for public health workers who can maintain trust with a community in which they serve and identify the factors that most influence community health in a given area. He also listed several other competencies such as promoting advocacy and power building; addressing systemic racism and social inequities; highlighting the role of diversity, equity, inclusion, and belonging; working effectively in inter-professional teams; applying and integrating data and technology; developing and using critical thinking and problem-solving skill sets; and leveraging the role of leadership. According to Oxendine, each of these competencies is crucial for public health workers.
Oxendine also spoke of the importance of emerging competencies, specifically expertise in various areas within the field of public and population health, such as the social determinants of health; behavioral health; chronic disease management; disaster and infectious disease preparedness; systematic and intuitional bias and racism; diversity, equity, and
inclusion and cultural humility; geriatric health; climate change; and self-care and wellness.
Oxendine underscored the earlier theme of a workforce being reflective of the population, having a broad range of lived experiences, and being diverse in race/ethnicity, socioeconomic status, thinking and learning styles, sexual orientation, gender, geography, religion and political affiliation, and other dimensions.
Next Oxendine spoke about the importance of identifying opportunities amid challenges for the population health and public health workforce. To illustrate “perfect storm challenges,” he cited COVID-19 fatigue and burnout among public health workers, the “Great Resignation,” an aging population and workforce, hiring process challenges and delays within governmental public health, inadequate compensation and opportunities for advancement, competition for talent with other health sector industries, poor alignment of academic preparation with industry needs, and enumeration of the public health workforce and defining problems or areas of need and then making the business case to address these needs. To best address these challenges, Oxendine identified several “perfect storm opportunities.” These included increased public health awareness and the need to address public health workforce shortages, prioritizing equity and racial justice imperatives, improving public health and health workforce investment, expanding pathway and pipeline programs, fostering capable and diverse public health workforce candidates, growing access to scholarships and loan repayment, using capable leadership, and creating opportunities for shared ownership of solutions.
In conclusion, Oxendine offered three steps in getting to a successful, sustainable, and equitable public health workforce:
- Connect passionate and capable workforce candidates with roles in sectors and communities that are in need;
- Develop inclusive, affordable, and empowering education and training rooted in practice, technology and community; and
- Offer accessible and attractive work opportunities with equitable, competitive compensation and ability to “do well by doing good.”
MEETING THE NEEDS OF THE 21ST CENTURY PUBLIC HEALTH WORKFORCE
The first presenter, JP Leider, spoke about various key trends in the field of population health and about meeting the needs of the governmental public health workforce. Over the past 10 years, he said the size of the governmental public health workforce at state and local levels has declined by more than 40,000 staff, according to data from the 2021 Pub-
lic Health Workforce Interests and Needs Survey (PH WINS). Based on composite estimates, there are roughly 210,000 staff at the state and local levels along with a slight increase at the federal level. Leider emphasized the importance of being able to measure state, local, tribal, and federal workforces to provide the most accurate data on governmental public health in the United States. He acknowledged a variation of roles and responsibilities, as well as agency size. Because public health is a field and not a discipline, Leider said, it contains many different professions, ranging from technical and scientific roles to programmatic and administrative support roles. Leider listed several common public health jobs divided into four main categories: management and leadership, professional and scientific, technical and outreach, and support service roles. Management and leadership roles included such positions as agency directors, program directors, and health officers. Professional and scientific roles included public health emergency preparedness coordinators, epidemiologists, public health nurses, dietitians, sanitation and health inspectors, and policy analysts. Technical and outreach roles included disease intervention specialists, CHWs, peer counselors, and community health navigators. Support service roles included administrators, accountants, and human resource staff. People in different occupations generally have different trainings, different backgrounds, and different needs, Leider said.
Despite the diverse array of professions in the governmental public health workforce, Leider said, there is one commonality among them: many of the workers in each intend to leave. According to PH WINS 2017 data, about 22 percent of state and local public health staff were planning to retire within 5 years, while an additional 25 percent were considering leaving for other reasons. Leider emphasized that these data differ dramatically by government type and said that the percentage planning to leave has increased at the state and local governmental public health levels since 2014. These data suggest that around 40 percent of the workforce will turn over by 2023, signaling a need to effectively recruit and retain a new generation of governmental public health workers. According to pre-COVID-19 survey data, the correlates of intent to leave among governmental public health workers include job satisfaction, pay satisfaction, employee engagement, supervisory satisfaction, supervisory status, perceptions of organizational support, educational attainment, tenure in organization, age, race and ethnicity, and workplace setting. Additional research has organized reasons for attrition into three main categories, Leider said: greener pastures, internal trajectory, and holistic dissatisfaction. These categories were determined based on participant responses to questions on lack of recognition, burnout, stress, compensation, weakening of employee benefits, workplace environment, and lack of career growth opportunities, among others.
During his presentation, Leider identified certain skill sets that are at risk within the governmental public health workforce if there is not a concentrated effort to recruit and retain new workers successfully and sustainably. Working from the PH WINS training needs assessment, Leider highlighted some skills that survey respondents reported as requiring training, such as effective communications; data collection and informed decision making; delivering socially, culturally, and linguistically appropriate care and messaging; supporting agency priorities, missions, and vision; and working collaboratively. “We have tens of thousands of [person] years of experience during a mass exodus like we have experienced,” Leider said, “but there are specific skills that we are going to have to train up or replace with a new workforce.” Leider also discussed how educational attainment may affect replacing a sufficient and sustainable governmental public health workforce. For example, about 14 percent of governmental public health workers on state and local levels have a public health degree, according to PH WINS 2017 data. However, younger, more educated individuals (e.g., master’s and doctoral level) report a greater desire to leave governmental public health than their peers. Based on these data, Leider concluded that despite a new generation that may have higher educational attainment, if governmental public health agencies cannot retain staff, these agencies may not be able to retain their highly skilled workforces. Leider shared a graph showing that 36,000 undergraduate and graduate public health degrees were awarded between 2000 and 2020. There was a growth in number of bachelor’s degrees being awarded between 2000 and 2020 as well as an increase in the numbers of students attaining master’s degrees, up until 2015. Despite the growing popularity in public health degree attainment, Leider said, only about 20 percent of graduates with a public health degree enter the governmental public health workforce, although he added that there are “substantial differences based on their education, where they are geographically and earning potential and debt.”
Prior to COVID-19, Leider estimated that approximately one-third of the governmental public health workforce would leave or retire. Since then, early indicators have shown that COVID-19 caused that trend to increase dramatically. For example, between 2017 and 2021, the rate of turnover in the governmental public health workforce was estimated to be two to three times higher than in the 2014–2017 period. One result, Leider said, is that in the future governmental public health workforce jobs may be filled with workers trained in areas other than public health. However, he continued, “If we do a better job competing for and then retaining public health graduates, we might be able to have them replace a substantial amount of the workforce.” To be competitive and recruit and retain skilled governmental public health workers, Leider proposed that justice, equity, diversity, and inclusion should be central factors in hiring
practices. He concluded his presentation with a series of questions: “What will public health education look like in the future?”; “Will the COVID-19 “bump” overtake the pre-COVID slowdown?”; and “What skills will the new workforce need?”
PROMOTING A ROBUST AND SUSTAINABLE PUBLIC HEALTH AND POPULATION HEALTH WORKFORCE FOR THE FUTURE
Ransom said, “If there is one lesson we have learned from COVID-19, it is that the public health workforce that we have right now consists of some of the most committed, hardworking, selfless, and essential members of … our society.” But what can be done to ensure that this workforce remains effective in the future? She listed four core areas that must be addressed: supporting the public health workforce, racial health equity, gender equity, and public relations.
Centering the Public Health Workforce
The past two years have shown that without the public health workforce, the efforts to combat the COVID-19 pandemic could not have been accomplished, including such things as setting up testing centers, staffing call centers, and tracing contacts Ransom said. Supporting the public health workforce will require, for instance, investing in education and training as well as in mental health. “We have to ensure that we are treating the public health workforce as whole people,” she said, “not just cogs in this machine that we call public health.” Ransom shared some statistics from CDC’s Morbidity and Mortality Weekly Report, which indicated that during the pandemic, state, Tribal, and local public health workers frequently experienced symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation. The July 2021 survey found that among 26,174 public health workers, 53 percent reported symptoms of at least one mental health condition, 32 percent reported symptoms of depression, 30.3 percent reported symptoms of anxiety, 36.8 percent reported symptoms of PTSD, and 8.4 percent reported symptoms of suicidal ideation. To address mental health concerns among public health workers, Ransom proposed that workplaces should “promote wellness, cultivate cultures of belonging, and destigmatize the requests for mental health assistance” by offering high-quality employee assistance programs, raising awareness of mental health conditions, and learning about emotional intelligence.
Racial Health Equity
Principles of racial health equity are essential across all elements of public health policy and practice, Ransom said, citing Will Jawando,
a city councilmember in Montgomery County, Maryland. The goals of racial health equity are informed by police-involved killings, disparate health outcomes for Black patients, financial redlining, food deserts, and inadequately built environments—all of which can be traced to systemic racism. Furthermore, she continued, high rates of poverty, unemployment, housing, toxic exposures, limited access to quality medical care, and other social determinants of health contribute significantly to health disparities. All systems are staffed by human beings, which means that racism, bias, and discrimination are as much a part of public health practitioners as they are a part of the general population. “If you are breathing, you are biased,” she said. People in positions of authority have the power to exert, consciously or unconsciously, influence over other individuals’ experiences and health outcomes, and such influences can be profound, long-lasting, and generational. The next generation of public health leaders has to be courageous enough to identify implicit and explicit bias in organizations, Ransom said, and racism will need to be rooted out from the ways in which it is operationalized in the data collected in public health, in the policies that are enacted, in whose voices are given credence, in community presence and partnerships, in management, in the distribution of resources, and in hiring practices. To achieve this, NNPHI and the National Coordinating Center for Public Health Training are working with 10 regional public health training centers funded by the Health Resources and Services Administration to create the Racial Justice Competency Model,1 which was under development at the time of this workshop.
Gender Equity and Pay Parity in Population Health and Public Health Workforce and Leadership
“No matter where you go in this world, the default frontline health worker is a woman,” Ransom said. Women hold 70 percent of jobs in the public health workforce but only 25 to 30 percent of leadership roles, she said, making public health a field that is “served by women but led by men.” Various metrics also show disparities, such as in scholarly citations and income gaps. For example, women in public health earn 10 cents less on the dollar than men in the profession; women in public health are 36 percent less likely than men to earn at least $95,000 per year, and the wage gap is even more severe for women of color. Inequity in the field of public health is harmful to women’s health, socioeconomic status, earning potential, and sense of purpose and belonging, Ransom said, and she proposed that society must simultaneously address racism and gender equity as
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public health issues. A unique opportunity exists to resolve gender equity in public health, Ransom said. “The evidence base is there. We know that health systems function better when the women who manage them have an equal say in design and delivery.” For example, involving nurses in decision-making processes has been shown to lead to better health service delivery, improved health outcomes, and workforce retention and innovation. Furthermore, she said, “Women in leadership expand the agenda, which is an important issue for us to focus on.” It will be the responsibility of the next generation of public health leaders to shepherd these crucial changes, she said.
The Public Relations Problem
The population and public health workforce must repair what Ransom described as a public relations problem, which can be thought of as consisting of two parts: mistrust and political reasons, and the history of racism. “We are not trained to be skilled communicators,” she said. She called for the entire workforce, not just the leadership, to be trained in risk communication competencies. For example, everybody from janitorial and custodial staff to those in positions of leadership has been questioned about the COVID-19 pandemic. Thus, the entire workforce should have the communication competencies necessary to deliver the most accurate information possible.
Looking to the Future
Ransom then discussed education, training, and competency-building tools and models. She spoke about what NNPHI has to offer, such as the opportunities to collaborate with 40 member institutes. This partnership network has served as a conduit to hire, train, and retain the next generation of the public health workforce. Ransom also described NNPHI’s curated training paths and certificate programs available through the organization’s Learning Navigator Pathways.2 Joint degree programs, such as for a law degree and Master of Public Health, have been growing in popularity recently, Ransom said. Speaking of her own experience, she said that obtaining both degrees allowed her to “move farther, faster and create multiple opportunities and options that I have been able to pursue throughout my career.” And she said that joint degree programs promote public health workforce retention by allowing students the flexibility to
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2 https://nnphi.org/introducing-the-new-public-health-learning-navigator/ (accessed July 28, 2023).
pursue different opportunities in the field of public health and population health.
Next, Ransom described a report that was created by NNPHI in partnership with the Kresge Foundation, “Challenges and Opportunities for Strengthening the US Public Health Infrastructure.” This report is “an action agenda for the next decade” for laboratories, public health law, and the public health workforce, she said, elaborating that the report defines public health infrastructure as “the foundation for planning, delivering, evaluating, and improving public health,” summarizes the findings of peer-reviewed and gray literature, identifies weaknesses and challenges affecting the U.S. public health system’s infrastructure, and discusses opportunities for addressing these issues. Ransom then offered key findings from the report. First, a severe and consistent shortage of public health workers exists, and these deficits will continue to grow because of high workforce turnover and retirement. Second, CHWs are an underappreciated resource for disadvantaged populations that is not properly integrated into the health care system, limiting the effectiveness of these workers in improving health outcomes at the community level. Third, teaching public health in middle and high school can expose students to public health early, increasing the chances that a career in public health will be contemplated, understood, and ultimately adopted. Fourth, health departments have made efforts to provide training programs for their staff, but health departments lack the funds to provide professional training and lack the coverage that would allow staff members to attend trainings during work hours. Fifth, community colleges offer fertile ground to influence a motivated, racially and ethnically diverse group of students to pursue public health-related training and education that could lead to public health work. Finally, work practicums and mentorship programs that expose students to careers in public health are effective strategies for creating and maintaining a strong and stable public health workforce.
AREAS OF WORKFORCE OPPORTUNITY
To begin, Frogner spoke about how the population health workforce is divided between the health workforce that provides health care in health care settings and the health workforce that provides health care in community settings, although she said that there is an increasing overlap between these two groups.
Frogner echoed an earlier observation that some health care workers actively know that they contribute to the population health workforce, while others may not be as aware that they work in addressing issues of population health. She suggested that there are opportunities to create greater awareness of the many different types of roles involved in
addressing population health challenges. She also said that there is a growing recognition of the importance of population health within different areas of the health care industry, such as hospital settings, ambulatory care, and long-term care. Furthermore, she said, these settings are investing in initiatives to help them best serve the communities in which they operate by, for example, hiring leaders and staffing teams with professionals with public health backgrounds and as well as a variety of other competencies. There are also individual workers in the community who interact directly with those most in need of high-quality health care, helping them navigate and access social services that can improve health. Other workers who are indirectly involved with population health include sanitation workers and those who are working to address climate change. Finally, there is an increasing overlap between what is happening in the community and what is happening in traditional health care settings, and the people working in that overlap, Frogner said, make up the population health workforce.
Frogner identified three areas for population health workforce opportunities: the clinical laboratory workforce, the behavioral health workforce, and the safety net clinical workforce. To begin, she spoke about work funded by the Siemens Foundation that she and her colleagues at the American Society for Clinical Pathologists have conducted to more fully characterize the clinical lab workforce. A key result from this research was that there are many types of careers in the clinical lab workforce. Frogner and colleagues looked at a variety of clinical lab careers, such as histotechnicians, histotechnologists, medical laboratory assistants, medical laboratory technicians, medical laboratory scientists, and phlebotomists, to understand the variety of titles, roles, and responsibilities, and the educational pathways for each of these positions. Another key result of the report was the lack of consistency in job titles in the clinical lab workforce, an issue that has been recognized by the field. Furthermore, Frogner said, there are a variety of educational and training pathways. For example, histotechnologist positions often only require a 4-year degree program or prior clinical lab experience or training. The variety of pathways is an advantage of the field, Frogner said, as it leads to a range of opportunities” said Frogner.
Turning next to the behavioral health workforce, she said that it varies on complexity of care. According to a table Frogner showed that illustrated the interactions between physical health and behavioral health needs, more providers are needed to support patients with complex physical health and behavioral health needs. Furthermore, Frogner said, as the number of providers needed to support patients increases, it becomes more likely that these providers reside in community settings (e.g., community paramedics).
Third, Frogner spoke about safety net clinics, such as federally qualified health centers (FQHCs), which can employ many different types of providers. To illustrate this, Frogner presented data from the Health Center Uniform Data System developed by the Health Resources and Services Administration, which showed that a wide variety of professionals are employed in these settings, including physicians, advanced practice nurses, nurses, lab personnel, oral health professionals, behavioral health professionals, pharmacy professionals, and case managers. Frogner described different percentages of full-time employment status based on the varying professions, which ranged from 17.3 percent advanced nurse practitioners to 1 percent lab personnel. Frogner said that FQHCs may also vary in terms of the combination of professions that exist within a care setting and that there may also be variability in full-time employment rate within any one profession. She proposed further examination of which populations have access to different kinds of workers.
Frogner also listed some common challenges that broadly affect the population health workforce, including the fact that career opportunities in population health are not always obvious or easy to find, a lack of clear pathways to the jobs and career advancement, a lack of the financial support needed to follow certain pathways, and a fragmentation of health care and social care systems. Concerning career opportunities in the clinical lab workforce, for example, Frogner said that there are many different occupations in the clinical lab, and it is not always obvious that a particular job offers an opportunity to work in population. She also spoke of the need to promote clear career opportunities in primary and secondary education settings (e.g., K-12 and colleges and universities) and beyond. Another challenge Frogner described was a lack of transparency in career pathways and advancement. She suggested that linking credentials to potential future jobs and financially supporting those who seek these credentials, either through loan repayment or grants and fellowships, may work to address this workforce challenge. Finally, Frogner identified the disconnect between social care and health care systems in the United States as another challenge. She emphasized the importance of providing financial incentives that reward traditional health care settings that invest in population health and outcomes.
EMERGING POPULATION HEALTH PROFESSIONALS
Tia Benally and Joana Fernandez Nuñez discussed their motivations to pursue a career in population health and public health and what needs must be met to be successful as a public health professional and leader.
Fernandez Nuñez began by saying, “I was one of those people that didn’t know I was interested in the type of work that is considered public health.” She explained that her passions stemmed from personal experiences, as she witnessed how parents navigated health care and how social determinants of health affected their lived experiences. She also observed how the COVID-19 pandemic exacerbated existing issues. Her goal, she said, is to help reduce or eliminate some of those issues by integrating social determinants of health within health services and creating trauma-informed systems of care. She said she will likely begin her career at the micro level, working within communities and then progressing to macrolevel advocacy work later in her career. Benally began by acknowledging her Native American heritage and how important her community and family are to her. She said that these factors motivated her to pursue a career in public health. Benally said she has also witnessed cultural and language barriers, citing specifically her grandmother’s mistrust in Western medicine. She told how she initially wanted to pursue medical studies but pivoted to public health so that she could contribute more to fixing systems or adding to system change from an equity and social justice perspective.
Oxendine then asked how pathways or program experiences, in addition to life experiences, influenced Fernandez Nuñez’s and Benally’s decisions to pursue public health and their achievements. Benally responded first, saying that she worked in health education and health promotion fields in both clinical and outreach settings, specializing in Native health, with a primary focus on diabetes prevention and commercial tobacco prevention through policy development and advocacy, research, grant writing. She also said wanted to do more and chose to pursue higher education to acquire the skills and knowledge needed to achieve these goals. Benally emphasized that her M.P.H. program at the University of Washington has helped shape her professional identity and her career goals. These goals included research on topic areas in maternal and child health and secondary data analysis focused on Native men’s health and diabetes prevention. She also said that she wants to conduct “research on Native people for Native people.” Benally added that she wants to further develop skills in policy analysis, program development, and health promotion. Fernandez Nuñez said that prior to starting graduate school, she mostly had experience in research and nonprofit organizations and that two programs pointed her in the direction of public health: the CDC Undergraduate Public Health Scholars Program at UCLA, and the Health Career Connection. Both programs provided her with opportunities to engage in a variety of work experiences and learn about what working in public health means, she said, adding that public health can be difficult to define because of the multidisciplinary approaches that
can be used to address public health issues. Both programs also worked to connect Fernandez Nuñez with like-minded peers to help her build a professional network in addition to her professional development.
Oxendine asked both Benally and Fernandez Nuñez what competencies are needed to be an effective public health professional, what competencies are offered in their respective degree programs, and what competencies their degree programs might be missing. Fernandez Nuñez said that some of the core competencies she is learning in her M.P.H. program focus on public health program planning, evaluation, and quality improvement. For her M.S.W. she is learning about generalist practices, counseling, theories of behavioral change and systems, and policy analysis and advocacy. One competency she would like to build on more, she said, is advocacy and leadership, which she plans to do throughout the remainder of her studies and after she graduates. She explained that her M.P.H. program required a summer internship with the Steinberg Institute, where she developed on-the-ground skills and learned about the daily operations of working in public health. Similarly, she is required to complete an internship for her M.S.W. program congruent with her coursework. Fernandez Nuñez described this experience as a “reciprocal learning relationship” in which she can apply her professional skills to her coursework while her coursework can improve her professional skills. Benally said that the community-oriented public health practice program she is enrolled in uses a “problem-based learning approach,” which requires students to have a minimum of 2 years’ professional experience. She said that the work experience requirement benefits those who have coursework experience and who can network with fellow students in their degree program. She has applied many of the theories she has learned in her courses; for example, she is working with a community partner to conduct program evaluations targeted at aiding unhoused families in the Seattle area. The goal of this evaluation is to ensure the program meets the needs of the target population and to enhance accessibility of this program. Benally said that a competency she would like to develop further is community-based participatory research, explaining that she is passionate about working in community settings and using research to improve health outcomes for those who may not have the resources or infrastructure to do so.
Oxendine then asked both students about what public health career pathways they would like to pursue after graduation, what barriers might exist that could prevent them from doing this type of work, and what supports or resources would be helpful as they move forward in their careers. Benally said she is interested in pursuing a doctoral degree because of her interests in teaching, largely because of her experiences with Native
faculty at the University of New Mexico, and that she would like to apply the research skills she has acquired through coursework to Native communities. She also said that her graduate teaching assistantships have been a positive introductory experience to an instructor or professor role and that she wanted to use the networking opportunities available to her immediately following graduation and to advocate for tribal communities. Fernandez Nuñez identified career growth opportunities and inclusive team-based culture as the driving factors in her choice of career after graduation. She also spoke about how professional opportunities in public health are new or changing and how organizational structures have shifted in response to the COVID-19 pandemic.
DISCUSSION
To begin the discussion session, Oxendine asked, “Has the CDC Foundation reported descriptive data on the number and types of positions they filled at the federal, state and local levels during the pandemic?” Leider responded that he was unaware of published descriptive data on governmental public health employment during the pandemic. However, he said that there have been efforts conducted by the National Association of County and City Health Officials to collect provisional data, which will be included in a report to be published that will focus on the public health and population health workforce during the COVID-19 pandemic. He added that financial data have been posted and that the CDC Foundation has released information on programmatic efforts currently being conducted. Frogner said that the lack of data collection is indicative of the challenge in tracking the broad health workforce force, which is less challenging than tracking the population health workforce. Many efforts have been made, she said, to identify the different kinds of public health workers employed in governmental public health. For example, she said, “We are very good at counting people by occupation and head counts, but actually understanding what people’s roles are…that’s a very tricky thing to do,” which makes it difficult to determine whether there are enough people addressing the issues of population health. Oxendine agreed that it is critical to be able to measure the roles and responsibilities of public health workers at the federal, state, and regional levels. He explained that this measurement plays a key role in developing and implementing policy changes to support resource investment in the public health workforce. Oxendine said that it is important to identify current opportunities for individuals entering the public health workforce and to ensure that pathways exist for them to pursue those opportunities.
Referring to PH WINS, Oxendine asked about progress currently being made toward understanding the public health workforce and what
it needs. Ransom said that NNPHI, in partnership with CDC, is conducting a project titled Project Firstline, which is focused on infection prevention and control with an emphasis on COVID-19. The goal of Project Firstline, she said, is to “identify where the public health workforce intersects with infection prevention in the health care sector.” Ransom acknowledged that there are difficulties currently being encountered in determining who is performing what roles and responsibilities in the field of public health across states and localities. Leider said that the most current data related to the makeup of the public health workforce is almost a decade old. He agreed with Frogner that conducting occupation-based assessments is not always appropriate for the field of public health, for several reasons. First, as noted before, public health includes a variety of types of workers, and federal metrics for tracking labor statistics do not include health departments. Furthermore, there is substantial variation at the state and regional levels across the United States concerning which kinds of staff perform what sorts of duties. For example, because of licensure requirements or historical norms, the workers employed in communicable disease control or environmental health who are responsible for conducting surveillance or inspections in one state may be different from the workers performing the same duties in another state. These differences make it “exceptionally hard” to decipher workforce enrollment and responsibilities statistics, Leider said. Frogner suggested that professional forums pose a great opportunity to increase visibility and define what kinds of roles are necessary to address issues in population health. She said that professional societies are key stakeholders in identifying pathways to building a sufficient workforce to address public health, such as the American Public Health Association or clinical lab workforce. Frogner also said that states are working to convene employers from multiple industries to have conversations on addressing public health challenges. For example, Career Connect in Washington State has convened industry partners across sectors to discuss what kinds of jobs are available and what trainings are needed. “This does require a coordinated effort between employers, universities, community colleges, and other training programs out there,” she said, but still it should be done more often.
Oxendine then asked a question related to emergency medical services (EMS): Should EMS be categorized as public health workforce, and, if so, in what capacity? He also asked panelists whether there has been any consideration of claiming EMS professionals as public health providers and how their role affects population health. Frogner replied, “I think EMS providers are certainly providing public health services, whether they know it or not. This goes back to the earlier question, ‘Are people aware they are part of the population health workforce or public health workforce?’” She continued that it is important to clarify what
public health work looks like and what population health work looks like and to identify where the distinguishing lines, if any, exist between the two. Additionally, the EMS profession is grappling with community paramedics who are performing on-the-ground work. This newer title for the paramedics underscores those who provide care within the community rather than executing transport to emergency departments or other place-based health care settings. Frogner said that many community paramedics are responding to mental health-related calls and suggested that there should be a reimbursement system in place so that providers can respond to these calls and administer care within a community setting as opposed to relying completely on traditional transport ambulatory care. Ransom agreed with Frogner’s remarks and said that CHWs should be more effectively integrated into the public health workforce. She also observed that EMS serves as a pipeline line into public health, with emergency medical technicians being recruited with effective explanations of what public health responsibilities look like and how this work affects public health. “That’s a pathway to a career trajectory in public health,” she said, “and can provide a nice long career doing a wide variety of things, starting with EMS.”
“Definitions really matter,” Leider said, explaining that, among other things, definitions can affect spending. For example, the U.S. Census Bureau metrics that determine how much money is being spent across workforces depend on definitions of roles within a workforce rather than on the functions of the roles. Oxendine agreed and stressed the importance of how definitions can affect the allocation of funds, which in turn may affect public health and well-being. He thanked the National Academies of Sciences, Engineering, and Medicine for hosting this workshop and for providing a space to discuss critical issues related to addressing 21st century population health workforce challenges. He also thanked the panelists for their thoughtful remarks and for their leadership in addressing population health workforce issues.
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