Multiple Perspectives on Collaboration Between Schools of Public Health and Public Health Agencies

Since the Institute of Medicine issued its report on the Future of Public Health in 1988, multiple reports and statements have called for greater interactions between public health academicians and practitioners.^1–3 Recommendations include greater support for applied public health research or public health systems research, enhanced opportunities for students to gain practical experience, and better continuing education for the public health workforce.^4–10 As a result of this impetus, new public health competencies have been articulated,^11,12 schools of public health have revised curricula or taken other steps to address these competencies;^13,14 the Centers for Disease Control and Prevention has expanded its extramural research portfolio;^3,6 and there have been noteworthy examples of innovative programs launched by schools to increase practice-based opportunities for students.^15,16 In addition, concern over emergency preparedness has prompted infusions of federal support for strengthening the public health infrastructure, including relationships between health departments and schools of public health.^17–19

Despite these advances, linkages between schools of public health and state and local health departments could generally be much stronger, more structured, and more formalized.^16,20 The relative lack of funding for practice-oriented research,^3,6 and institutional cultures that do not consistently support these types of collaborative undertakings, continue to be major barriers to the formation and maintenance of long-lasting partnerships between schools of public health and health departments.^21,22 In an effort to gain a more in-depth understanding of these obstacles, as well as potential facilitators to ongoing collaboration between health departments and schools of public health, we conducted a series of semi-structured, in-person interviews with deans, faculty, and students at the Rollins School of Public Health (RSPH), and with leadership and personnel in state and local health departments. Unlike previous work in this area, which tends to examine collaboration in relation to specific, funded projects or from an academic standpoint,^{18,19,22–24} we used qualitative methods to systematically look for similarities and differences in perceived barriers and facilitators from the multiple perspectives of faculty, students, and health departments.

METHODS

The Academic Health Department Project

In 2003–2004, RSPH was one of 14 schools funded by the Association of Schools of Public Health (ASPH) to conduct the Academic Health Department (AHD) project,^16,25 which sought to develop and strengthen mutually beneficial linkages between schools and local health departments. Our project, like most others, emphasized enhanced procedures and opportunities for students to work in the state or local health departments, the latter referred to as district health departments in Georgia. Early in the project, lead RSPH faculty and staff met with district health officers and their staff in four health districts and with key personnel in the Georgia Division of Public Health to identify opportunities for public health students. Altogether, students filled 36 positions in 18 projects, ranging from supporting epidemiologic surveillance during the 2004 G-8 Summit to evaluating a child booster seat distribution program.

Study participants

To obtain diverse perspectives from the local health departments, we interviewed district health officers, district epidemiologists, directors of prevention services, the key contacts for the AHD project in each district, and supervisors for one of the student projects in each district (n517). Participants from the Georgia Division of Public Health included a key contact for the AHD grant and four supervisors from different disciplines within public health (n55). From RSPH, we interviewed all five deans, all six department chairs, a faculty member within each department, and approximately half of the students who had at the time completed a health department assignment (n531). The overall response rate from RSPH and the public health agencies was 96% (53 of 55).

Data collection and analysis

Interview guides were tailored for various categories of respondents and covered current and past collaboration, incentives for and barriers to collaboration, and suggestions for improving collaboration between RSPH and health departments. The interviews lasted 20–60 minutes and were audio taped and transcribed verbatim. A codebook was created and each transcript was coded independently by two members of the research team, with discrepancies resolved through discussion. The transcripts were entered into QSR-N6,²⁶ a qualitative analysis software package, and themes were identified by category of respondent.²⁷ The project was approved by the Emory University Institutional Review Board.

RESULTS

Incentives for collaboration

Health department (HD) personnel observed that faculty are a resource for learning new skills and can provide access to newly developed methods and techniques, a theoretical base for day-to-day work, and expertise in program evaluation. Faculty members generally expressed that increased collaboration would support public health research for those with an interest in applied public health and provide real-world perspectives in defining research questions and applying theories to practice. Faculty also commented that HDs have access to populations for research and that participation in collaborative work presents an opportunity to find solutions to local public health problems.

Several HD respondents believe collaborative relationships would be mutually beneficial and advance public health practice at the same time. As described by one HD representative:

… theory, research or practice, one is not more important than the other and I think we know a lot about applied public health and where the problems are and we should be linking with the university to figure out how to solve those problems, because that's what university folks like to do is they like to solve complex problems around public health issues.

Figure.

Strategies for increasing collaboration between health departments and schools of public health

RFA = request for applications

RFP = request for proposals

Both HD personnel and faculty highlighted training and educational opportunities as an incentive for collaboration. Faculty noted that training of public health students would be enhanced by helping to ground coursework in the reality of local public health practice. An additional incentive, mentioned by both faculty and HD personnel, was the possibility of responding jointly for applied research funds. Other benefits mentioned by HD personnel included the ability of faculty to lend scientific credibility to their policy and advocacy work and the opportunity to serve as co-authors on publications in scientific journals.

Respondents were also asked to share what they viewed as incentives for school of public health student/HD collaboration. From the HD perspective, engaging students was seen by some as essential to the viability of projects, either because students possess specific skills that are helpful to the HD or because budget cuts had left the HD with fewer resources including personnel. HD respondents also appreciated the fresh perspective that students often bring.

Working with students also provides HDs with access to candidates for future job openings. Faculty noted that having HD experience enhances students' employability, expands students' networks for future employment, and provides insight into whether they are interested in a career in local public health. Students also thought that working with HDs enhanced career options and opportunities. Working with students was perceived as professionally and personally rewarding for HD personnel, particularly introducing students to public health practice and piquing their interest in applied public health.

Both faculty and HD personnel commented that working with the HD is an opportunity for students to participate in a wide variety of applied public health experiences and to gain valuable experience, sometimes resulting in student thesis opportunities. A faculty member noted, “You really get to experience what it means to work in the front lines of public health. I don't think our students necessarily get that. They get a very elite perspective of what public health is all about.” Gaining such exposure and experience were main reasons that students decided to work in HDs. One student stated, “I wanted to gain a little experience and get exposure to an applied public health setting.” The connection to SPH faculty and facilities when students work in local HDs was another incentive mentioned by HD personnel.

Barriers to collaboration

A prominent theme in both the HD and faculty interviews was a perceived difference in the mission and agenda of HDs and schools of public health. HD personnel stressed that their work was service-oriented and that they viewed the school of public health as research-oriented. One HD respondent commented, “… we don't see ourselves as … very research oriented. We're just kind of day-to-day trying to get things done.” In contrast, faculty members are often interested in etiologic research and many have less interest or background in applied public health research. Faculty also commented that their reward structure was centered on research, publishing, and teaching and that there was no clear way to obtain recognition for collaboration with HDs. Faculty often spoke of the need to generate salary support through research grants and their sense that federal research grants tended to be valued over contracts or other collaborative arrangements with state or local agencies. One faculty member explained:

The difficulty in … is perhaps differences in the agenda. That is, the kinds of things that local health departments would be interested in having done, faculty members, either it's not part of their program of research, or it wouldn't … produce research of sufficient quality to have it appear in refereed places, and would then not be the currency of rewards in academic settings.

Both faculty and HD noted that collaboration takes time, particularly to learn about each other's work and interests as a prelude to collaboration. This was also expressed by the student respondents. Faculty spoke of the pressures they face and how those pressures influence the choices they make about how they spend their time. For example, one faculty member commented, “It takes time, which is a very valuable commodity in an environment where you have to be covered by research grants. Sometimes it's a lot easier to do something that doesn't take so much developmental time.” HD personnel also cited limitations in time and resources as well as the pressures of getting their jobs done as major obstacles to collaboration with faculty. One HD respondent, for example, asked, “How can we do this on top of everything else we're already trying to do?”

Several interviewees were not convinced that closer collaboration would benefit either the HD or SPH faculty. Skeptical faculty members were concerned that problems that could be addressed collaboratively would not present sufficient scientific challenges. Doubtful HD respondents cited concerns about the time commitment and felt it was unlikely that collaboration would actually enhance their work.

Time constraints were also a major barrier to involving students in HDs, given the urgency of much of their work. HD personnel noted that in order to work successfully with students, staff members had to be interested and willing to take the time to provide the needed supervision. Given the other demands on their time, this is not easy to achieve. Not having enough time to recruit students and not being clear on the process for having a student work at the HD were related barriers. Both faculty and HD personnel saw student schedules and academic commitments as another barrier. In addition, lack of awareness of opportunities by students and faculty was noted as a barrier by both HD and faculty.

Lack of financial support for students was another challenge. HD staff felt that they would be reluctant or uncomfortable making demands on unpaid students. One respondent explained: “A lot of people … have a lot of angst about asking a student who's kind of here on a voluntary basis and can come and go as they please to do something that's a deliverable that's so important for the program.” HD personnel felt that students who were paid for their work would be more committed and that unpaid HD internships could not compete with paid opportunities for students elsewhere.

The physical distance and commuting between some local HDs and the school was another barrier, as was lack of space or infrastructure at the HD. Last, a few HD personnel commented that lack of SPH faculty supervision of students placed a burden on the HD staff and that increased faculty involvement might be a way to overcome this problem.

What could the school of public health and health departments do differently?

Participants were asked to comment on what could be done to strengthen collaboration between the two types of institutions. Responses from HD and school participants were similar and fell into four general categories: (1) increase the visibility of health departments and applied public health at the school; (2) increase communication between the school and the HDs; (3) create structural and cultural changes to facilitate student/HD collaboration; and (4) support structural and cultural changes that would increase faculty capacity to conduct applied public health research. Specific suggestions in each of these four categories are summarized in the Figure.

DISCUSSION

Schools of public health and state and local HDs have overlapping but distinct missions involving research, teaching, and service.^28,29 HD personnel and public health school faculty who participated in our study indicated a profound awareness of both the shared and unique missions, and frequently cited the differences as both a practical obstacle and a theoretical benefit to collaboration. Academicians and HD personnel agreed that the purpose of the school is primarily public health research and teaching and that the primary purpose of the HD is providing services and protecting the health of individuals and populations. HD personnel believed that the faculty is mainly interested in research, while faculty expressed the opinion that the service demands of the HDs may not provide opportunities for cutting-edge research.

That said, the majority of interviewees from the HDs and the RSPH believed that a more collaborative relationship would be mutually beneficial and that a bi-directional process was, in fact, essential for both institutions to fulfill their missions. Building truly bi-directional collaborative relationships is not without challenges, however. Removal of barriers involves structural and cultural changes in both institutions. Lack of extramural funding for applied public health research combined with lack of institutional salary support for time used by faculty in collaborative work were frequently cited obstacles. When combined with an institutional culture that rewards scholarly publications and obtaining research grants, many faculty members feel unable to pursue collaborative work with state and local HDs. The cultural change required in schools of public health is an increase in the value placed on applied public health and on collaborative work with state and local HDs. However, a change in culture must be accompanied by the structural and financial changes to provide support for this work.

Likewise, changes are needed from the HD standpoint. The HD is mandated to provide certain services; consequently, collaborative projects not directly related to these mandates often get pushed aside for lack of time. Successful collaboration may require that HD personnel have dedicated time for working with faculty and students on joint projects. In addition, positive experiences in collaborative work with students and faculty will help reluctant HD personnel develop an appreciation for the personal and organizational benefits that accrue from conducting research projects and working with public health students.

Although our findings are consistent with themes identified in a recent analysis of ASPH's AHD grant proposals, they may not be generalizable to all schools of public health.¹⁶ Academic respondents in our study were all affiliated with a private university that has relatively high expectations for external funding. Public universities that receive substantive state funding, in particular, may have cultures with fewer barriers to academic/HD collaborations. Similarly, our findings are not generalizable to all HDs. Those interviewed were all from the Georgia public health system and were all reasonably close (within 90 miles) to the Atlanta metropolitan area. Barriers to collaboration are likely greater for HDs more distant from a school of public health.

CONCLUSION

Since the release of the Institute of Medicine's reports calling attention to weaknesses in public health training and infrastructure, schools of public health have sought ways to meet the challenges identified.^13,30 Schools have examined their structures and cultures, changed core and academic curricula, and increased collaborative research with state and local HDs.^{6,16,22,31–33} Numerous examples of successful collaborations have been developed by schools of public health and HDs, covering a wide range of public health practice areas.^{18,19,23,24,34,35} Developing and maintaining lasting partnerships that endure beyond funded project periods involves a bilateral commitment of resources accompanied by changes in institutional culture that will foster the commitment of resources to collaborative and applied public health work. The value of collaboration from the academic viewpoint is to increase applied research opportunities, provide teaching opportunities in applied public health for students, and contribute to solving public health problems. From the HD viewpoint, the value of collaboration with faculty is increased access to new information and resources that may enhance their ability to carry out their primary mission of protecting the public's health. Given these differing values, the challenge faced by the public health community is the development of models that allow both to fulfill their different missions and to receive the value they seek in collaborative work. In both the HD and academia, this may take the form of providing salary coverage for time committed to this work, developing formal mechanisms to increase communication and networking, and providing institutional recognition for collaborative public health even though it may decrease productivity of HD personnel and faculty in the short-term. Based on our study, we believe faculty and public health officials are realistic about the obstacles and benefits of collaboration, and also understand the institutional changes that will be required to create true and lasting partnerships.