November/December 2015 Issue
Public Health Social Work: Now More Than Ever
With the Affordable Care Act's emphasis on prevention, wider recognition of health disparities, and the demand for individuals and communities to connect to health resources, the need for public health social work has never been greater.
Though it's not yet front and center as an area of specialty, public health social work—which stresses a socio-epidemiological approach to the prevention and management of health issues—is making forward strides in a movement that may have a deep and lasting impact on the health and wellness of Americans.
While it hasn't been a well-traveled career path, public health social work "ultimately will emerge as a dominant model," predicts Betty J. Ruth, MSW, MPH, a clinical professor of human behavior in the social environment and director of the dual degree program in social work and public health at Boston University. "The main reason it's a minority practice at this time is that up until recently, a more narrow model of practice that focused exclusively on individuals held sway," she says. "For a variety of reasons, this is now shifting."
As interest grows, educational institutions are ramping up to prepare social workers for careers in public health. According to Trina Salm Ward, PhD, MSW, an assistant professor and MSW/MPH dual degree program coordinator in the School of Social Work and the College of Public Health for the University of Georgia, "The number of MSW/MPH programs in the U.S. has increased from 20 in 2006 to 37 in 2013, with several more in the planning stages."
In many ways, the driving force in the development of the settlement houses is the same as that which now largely fuels the increased need for, and attention to, public health social work—recognition of the social determinants of health. Then, as now, health disparities and lack of access resulting from economic inequity were key causes of illness and mortality. In these settings in the early 20th century, Salm Ward says, social workers "engaged in infectious disease control and maternal and child health promotion." While these pursuits remain a key focus for social workers, there are now many more problems directly and indirectly influencing health and wellness and demanding their attention. Additionally, in today's world, Salm Ward says, "global issues of terrorism, disasters, war, disease, viral outbreaks, climate change, oppression, health disparities, and social justice reinforce the need for transdisciplinary responses."
Public health social work has a leading role to play in directly preventing and helping manage health issues such as diabetes, tobacco use, HIV/AIDS, suicide, and substance abuse, and in indirectly addressing these and other problems through advocacy for health care quality, broader access to care, and cross-sector cooperation. For example, "The aging of the baby boomers will require innovative collaboration as this population moves into retirement and has longer life expectancies," says Terry V. Shaw, PhD, MSW, MPH, director of the Ruth H. Young Center for Families and Children and an associate professor at the University of Maryland School of Social Work. Furthermore, he says, "issues related to affordable health and mental heath care, to poverty—living wages, segregation, service deserts—to immigration, violence, and child maltreatment are just a few of the issues that continue to plague our society and call for a more comprehensive, integrated approach."
Alongside these issues and overlapping them, a trio of interrelated factors has influenced the growing interest in and need for well-trained public health social workers: the terrorist attack on 9/11, the implementation of the Affordable Care Act (ACA), and increased awareness of economic and health disparities.
In the wake of 9/11, Keefe adds, "People were stunned by how quickly individuals living and working in the New York City area, particularly first responders, developed various health issues, most notably pulmonary problems, and how our public health service delivery system seemed to be slow to respond and not be fully aware of the extent of the problems that followed the catastrophe, despite public health social workers' advocacy efforts for healthy living and work environments. Thankfully, public health social workers and some public health organizations continued to pressure legislators for funding for a strong public health workforce, which includes public health social workers."
"Because the number of uninsured people in the U.S. had been growing steadily for many years, various catastrophic-oriented services such as emergency departments and urgent care centers were flooded with people seeking medical care who could be more easily and efficiently treated in lower-cost settings such as a physician's office," Keefe says. The ACA, he adds, recognizes what public health social workers have long advocated, "that prevention services are more cost-effective than catastrophic services." As a result of the ACA, individuals will have greater access to and greater likelihood to take advantage of preventive care.
"The ACA calls for needs assessment and health care service provision at the community level—tasks that fit well within the skills of public health social workers," Salm Ward adds.
And from a policy perspective, Zelnick says, "It supports new models for treating mental health and substance abuse in the health care system. Integrating primary care with behavioral health is a key focus of the ACA, and social workers have a big potential role to play in new service delivery models." This integration is important in two key ways, she says. "Including screening for substance abuse and mental health in the primary care context means that contacts with health services become potential starting points for intervening on problems before they progress and multiply. Equally important is making sure that people with mental health and substance abuse issues are also getting their other health care needs met."
Zelnick points out that while there's a long history in this country of specializing in health care, there's also a history of separating physical health from mental and behavioral health. "In light of the fact that problems exacerbate one another, providers may not communicate over health care issues and needs, and lower-income people may face many barriers to health care access. These new models have potential to introduce more preventative interventions into our health care system, and this is good for public health."
Julian Chow, PhD, a professor at the University of California, Berkeley School of Social Welfare, sees working on issues related to the ACA as one of the important potential areas of influence and practice for public health social workers. He observes that as more individuals are enrolled and have access to health insurance, a consequence may be a system that is overloaded by greater needs and demands and lacking resources to provide adequate care. Identifying resources becomes increasingly important. Social workers, he says, are trained to provide the crucial connections and link people in need to service providers within a community. They're instrumental, he says, in providing the essential interdisciplinary collaboration across sectors and in fostering a family- and community-centered approach. "We need to advocate for more resources so this safety net can be cast wider."
"People interested in pursuing careers in public health social work, which has such a long history of promoting preventive services, now have an opportunity to work within communities around the country looking to develop preventive services," Keefe says. "Given that primary prevention helps people live longer and more fulfilling lives than other forms of prevention, the ACA will potentially help place new public health social workers in careers where they can have a positive effect on promoting health and well-being, not solely working to eliminate the negative effects that arise from a lack of heath care access," he says.
According to Zelnick, "Inequalities and injustices are literally embodied and expressed as health problems, resulting in chronic disease; decreased mortality; community and workplace exposures; public health challenges intimately related to environmental factors such as obesity and poor food choices; violent communities; reduced exercise due to safety concerns; as well as infectious diseases such as HIV/AIDS and tuberculosis." Health inequality, Zelnick says, is a manifestation of economic inequality—the 99% vs. the 1%—"and an area where social workers are uniquely qualified to make a contribution to both primary and secondary prevention."
Health inequities are preventable, Ruth says. "They reflect ongoing inequalities in society born of systematic disadvantaging of people based on gender, class, race, sexual orientation, immigration status, and more. As a profession concerned with social justice, health equity is a critical issue for us." She's quick to point out, however, that a narrow view focusing on treating one person at a time can't produce lasting change in a whole population. "Health equity requires systemic public health level approaches directed at impacting the social determinants of health—housing, income, access to health care, education, healthy food, clean water, and safe environments, to mention a few. Thus, our work to improve health equity must be directed at these really hard-to-reach issues. This means that we need social workers working at all levels of community practice including social advocacy and the building of a culture of health."
Chow agrees that social workers have a key role to play in raising awareness of the social determinants of public health issues—whether gun violence, food deserts, suicide, alcoholism, or environmental justice—and advocating for more equitable access. Equally critical, he suggests, is becoming involved in research that looks at access and utilization, helping build bridges from policy-making to widening access to services, and facilitating cross-sector collaboration and connection.
Zelnick also argues for the importance of political advocacy by public health social workers, pointing, for example, to efforts to expand Medicaid access. "The political decision by some states not to participate in Medicaid expansion is an enormous social justice issue; social workers should join any actions possible to demand that these decisions be changed," she says. "Ironically," she observes, "the states refusing to participate have some of the lowest Medicaid benefits and highest needs. At a time when federal social welfare actions have become unpopular, it's important for social workers to join with others to point out how these political actions violate human rights." Other groups, she adds, "such as transgendered people or undocumented immigrants, may also face barriers to health care access, and these are important dimensions of other social justice campaigns."
What Social Workers Bring to the Table
The most pressing public health concerns are "persistent, long-standing, and widespread," Ward says. "They require a transdisciplinary problem-solving approach. Public health social workers, especially those who have earned an MSW and an MPH, can bring a transdisciplinary perspective to help understand and intervene to improve the heath and well-being of society."
Public health social work, Salm Ward says, "blends the preventive aspect of public health and the problem solving orientation of social work. Social workers understand the need for tailoring interventions to specific populations; adopt a person-in-environment/family-centered perspective; and provide insight into the social conditions that negatively affect health and the social determinants of health."
Preparing for the Future
As a director of an MSW/MPH program, Ruth believes dual programs provide the depth of knowledge needed for social workers to lead and excel in public health social work. "We need to make them less expensive and better fund those students willing to put in the extra time to become the leaders of this important area of practice. Moreover, MSW/MPH programs need to do a better job of promoting public health social work as a practice specialty." However, she acknowledges that MSW/MPH programs are both expensive and time-consuming; she believes the field must identify additional means of training social workers in public health skills. "Because many practicing social workers need public health training to work in the emerging areas of the new health system, she stresses the need for more continuing education in public health social work, prevention, and population health for social workers with MSWs. In addition, we need MSW programs to integrate public health and wide-lens coursework into their traditional health social courses, and perhaps expand to offer public health social work certificate programs."
Prevention, Ruth concludes, is powerful. "Can you imagine what we could do if even 10% of social workers engaged in prevention?" she asks. She says, however, "We will only be powerful in our impact if we use public health science, work collaboratively across professions, market and rebrand ourselves as ready to do the latter, push past our hyper-focus on individual treatment, and measure outcomes."
The occupational outlook, Ruth says, "will depend on whether social work awakens to its abilities and opportunities in public health social work, begins to expand itself beyond individually oriented interventions, and spreads into prevention and other areas of public health." Furthermore, she says, "opportunities for prevention and public health in general are highly dependent upon society's investment and funding." Ruth, who cofounded The Group for Public Health Social Work Initiatives, a working group affiliated with Boston University that aims to raise the profile of public health social work, sees public health social work's and the nation's progress as dependent on the ACA and the Obama administration emphasis on prevention. "Otherwise," she says, "we will not be able to rein in our health care costs, nor will we be successful in expanding social work opportunities in public health." Society, she observes, can't continue to cover the costs associated with treating chronic illnesses in a growing aging population, most of which, she adds, are preventable.
— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.