Motivators of Continued Participation in Public Health Emergency Response Among Federal Public Health Workers: A Qualitative Study

Abstract

The purpose of this study was to identify factors that motivate public health workers to deploy to the field during an emergency event. We conducted 25 semistructured interviews with employees at the US Centers for Disease Control and Prevention, all of whom had deployed to the field for the 2014-2016 Ebola, 2016-2017 Zika, and 2017 hurricane responses. We used a grounded theory approach in our analysis of the data. Themes that emerged from the interviews related to responder autonomy, competence, and relatedness, which are consistent with self-determination theory. Motivating factors included having clarity about the response role, desire to be challenged, ability to apply existing skills in the field (or apply new skills learned during deployment to their home office), desire to be helpful, and feeling rewarded by working with affected populations, communities, and other response staff. These preliminary findings suggest that introjected and identified motivating factors may form the foundation of willingness among public health workers to assist during an emergency event. Understanding what motivates staff at public health agencies to participate in emergency deployment can inform the development of recruitment strategies, strengthen effectiveness of response activities, and improve overall agency preparedness.

Introduction

Federal, state, local, tribal, and territorial public health agencies routinely respond to disease outbreaks, natural disasters, and other emergencies. Having the capability to conduct effective response operations requires adequate infrastructure to support the ever-broadening array of threats and a workforce with the necessary skills and abilities, motivation, and willingness to respond.

In the last decade, a growing number of research efforts have focused on willingness to respond to emergency events among different types of healthcare workers (eg, emergency medical technicians, physicians, nurses) across different types of public health emergencies, especially an influenza pandemic.^1-9 All studies that focus on public health workers have indicated significant deficits in willingness to respond during a public health emergency.^10-13 Two studies found that approximately half of health department staff surveyed were not willing to report to work to help during an emergency, even if required by their job.^10,11 Barnett et al also found differences in willingness to respond across different public health threats: 14% to 28% were unwilling to respond for weather events regardless of severity, 30% to 56% were unwilling to respond for a radiological event, and 22% to 48% were unwilling to respond for an anthrax bioterrorism event.¹² Given the high variability in willingness to respond among public health workers, there is a need to better understand the motivational and deterring factors that play a role and, subsequently, could impact an agency's overall ability to respond during emergencies. Understanding the psychosocial determinants associated with these factors may help public health agency managers develop and implement interventions that promote public health emergency preparedness.

Self-determination theory is an empirically derived theory of human motivation and personality by Ryan and Deci¹³ that may be well-suited to explain the variability in motivation and willingness among public health workers to respond to emergencies. The theory posits that people need to feel autonomy, competence, and relatedness to achieve psychological growth. Autonomy reflects one's psychological need to feel in control of their own behaviors/goals, and to feel like their actions match internal desires. Competence is the ability to feel effective in one's actions and that one can master specific skills or tasks. Relatedness is the need to feel connected to other people and a sense of belonging with others. Previous metaanalyses^14-16 have indicated that these 3 constructs can foster high-quality motivation and engagement for activities in health contexts. According to the theory, different types of motivation underlie behavior: amotivation (ie, lack of motivation), extrinsic motivation (ie, external motivation, introjected motivation, identified motivation, integrated motivation), and intrinsic motivation (ie, the natural, inherent drive to do something without external influence).

The purpose of this study was to improve our understanding of factors that might motivate public health workers to participate in emergency response activities at the US Centers for Disease Control and Prevention (CDC) from a purposive sample of frequent responders. Elucidating the motivation and willingness to respond to emergencies from the perspective of staff who have participated in multiple public health responses could complement existing research that largely focuses on risk and efficacy to respond. To date, thousands of CDC staff have volunteered to serve in emergency-related scientific, operational, and leadership roles; however, to our knowledge, no peer-reviewed research has been published to assess the willingness and motivation of federal public health workers (such as CDC staff) to participate in emergencies. In this study, we aim to identify the salient behavioral and psychosocial beliefs that drive frequent responders' participation in public health emergencies.

Methods

The CDC Center for Preparedness and Response Office of Science and Public Health Practice reviewed and approved the study in 2018. Purposive recruitment occurred in May 2018 and consisted of sending a single recruitment email to eligible CDC staff. To be eligible for the study, individuals had to be a full-time federal employee and previously deployed to the field for all of the following responses: the 2014-2016 Ebola response, the 2016-2018 Zika response, and the 2017 hurricane response. There is no CDC policy that requires staff to deploy for emergency response, so all CDC deployments are considered voluntary. We identified a total of 37 CDC staff as eligible for the study, 25 of whom agreed to participate and were subsequently interviewed. Study investigators obtained verbal informed consent from each participant. Interviews included questions on demographics, background related to current job, deployment experience, motivation and barriers to field deployment, and emergency response training. This analysis is based on the following interview questions: 1.

You have responded to the field for CDC multiple times. In your opinion, what motivated you to be a field deployer?

What would discourage you from participating as a field deployer for any given response?

For someone at CDC who has not been part of an emergency response in the field and is seeking your opinion, what are the positives/negatives of participating in an emergency response that you would share (as someone with significant experience in deployment)?

We digitally recorded all interviews to audio files and used a REDCap data collection tool to document answers to questions.¹⁷ We then checked audio files for quality and transcribed them for analysis. Based on a grounded theory approach,¹⁸ the primary investigator open-coded 12 interviews and developed an initial codebook. The research team discussed and elaborated upon the coded text and emerging themes and conducted recoding as needed until consistent definitions and examples were generated. The primary investigator completed coding of all interviews based on the revised codebook. A blinded dual coder reviewed a random sample of about half of the interview transcripts (n = 11). Internal consistency between these 2 coders was determined by overall percentage agreement of codes applied and Cohen's kappa statistic (k) using SAS version 9.4 (SAS Institute, Cary, NC). The 2 coders achieved strong overall cumulative percentage agreement (81.63%; k = 0.80). Any subsequent discrepancies were reviewed and reconciled according to the codebook. Drawing on grounded theory principles, the research team conducted a literature review after the coding process. The team found that the 3 constructs identified in the self-determination theory—autonomy, competence, and relatedness—closely matched the interview themes.¹³ We modified the framework presented in this article to reflect the constructs of the theory.

Results

Of the 37 eligible CDC workers invited to participate in the project, 25 (67.6%) agreed to be interviewed. Participant characteristics are summarized in Table 1. Participants were on average aged 45.8 years (SD = 9.4) and had been employed at the CDC for 11.9 years (SD = 8). Approximately half were male (56%), a majority were married (68%), and all but 1 had a master's level education or higher (96%). Of the 25 participants, 52% were US Public Health Service Commissioned Corps officers, 20% were supervisors, and 76% worked in agency divisions that routinely support CDC response operations.

Table 1.

Participant Characteristics (N = 25)

Demographics	n (%)
Mean age (SD)	45.8 (SD 9.4)
Sex
Male	14 (56)
Female	11 (44)
Education
Bachelor's degree	1 (4)
Master's degree	13 (52)
Doctoral or other advanced degree	11 (44)
Marital status
Single	5 (20)
Married	17 (68)
Other (ie, divorced, widowed)	3 (12)
Work Background	n (%)
Mean years with CDC (SD)	11.9 (SD 8.0)
USPHS Commissioned Corps officer	13 (52)
Supervisor position	5 (20)
Works in division that routinely supports emergency response operations	19 (76)

Abbreviations: CDC, US Centers for Disease Control and Prevention; SD, standard deviation; USPHS, United States Public Health Service.

Themes related to autonomy, competence, and relatedness—consistent with self-determination theory—emerged from the interviews. Major themes and codes are summarized in Table 2.

Table 2.

Classification and Description of Codes Assigned for Interview Responses

Self-Determination Theory Constructs	Code Assigned	Description
Autonomy	Uncertainty of duty or role	Any statements about clarity (or lack thereof) in response role as it relates to willingness to respond
Autonomy	Challenge seeker	Desire about being challenged by the complexity of the work or the high intensity of situations
Competence	Applying existing skills	Any mention of applying skills learned from past public health experience (in an emergency setting or not) or having the needed skills to participate
Competence	Learning experience	Any mention of learning and skills that were acquired during the deployment or skills they can bring back to their home office
Relatedness	People	Interaction with other responders (CDC or individuals from other organization) in the field, including positive (eg, camaraderie) and negative (eg, difficult personalities)
Relatedness	Desire to be helpful	Statements about their desire to help other humans and provide assistance where it is most needed or any mention of ability to make immediate impact

Abbreviation: CDC, US Centers for Disease Control and Prevention.

Autonomy

Clarity of Role

Some participants noted that having a clear role in the response event was an important motivator to wanting to deploy. Participants noted that if a deployer is trained and prepared to perform a specific job but is assigned something different after arrival at the worksite, they may not be as effective in the new response role, which could discourage them from deploying again. Lack of clarity around roles and responsibilities can lead to frustration in deployers when their relative contribution to the mission becomes less evident. One participant noted that having an active, hands-on role during deployment was most important (they were less concerned with being assigned a specific function or role).

A lack of understanding of one's role and seeing the big picture of how that role interfaces with others may also discourage me. (#2, Male, 50)

Challenge Seeking

The desire to be challenged by fast-paced, high-intensity work was a motivator for some participants. Some noted that long and exhausting workdays during deployment can be challenging but stimulating, especially when they know they are helping a community in need. Additionally, some participants reported enjoyment solving problems in rapidly changing (sometimes unfamiliar) situations and that they liked the chaos and stress typically associated with emergency management and response operations.

“It's a challenge personally, working all day and being exhausted, going to sleep feeling fulfilled, and waking up excited—it's a good feeling to know that what you are doing means something to somebody else. (#4, Female, 44)

Competence

Applying Existing Skills

Almost all participants reported that having the opportunity to apply their public health skills to emergency response work in the field was motivating. Some participants described the importance of being able to apply their skills in a different way. For example, they can apply the skills used at their home office to different public health problems in a new context of emergency response or use public health knowledge or skills in a real-world, hands-on setting. Other participants mentioned the importance of using a different skill set than what they primarily use in their home office. For example, they can directly implement occupational health and safety activities at the incident site or work with impacted populations, rather than evaluating grantees who conduct occupational health and safety work in the field. Several participants also commented on the helpfulness of skills learned through past military experience (eg, working in international settings, dealing with adversity) and how those background experiences helped them cope and adapt to issues encountered while on deployment for public health emergencies.

[I want to] take advantage of what I have developed over a lifetime […] you don't get this privilege elsewhere. (#1, Male, 63)

Learning Experience

The opportunity to learn new skills during deployment that can be used back at the home office was described as a motivator by some respondents. When the work in the field is similar to the work at the home office, the responder can learn more efficient or effective methods for accomplishing the same tasks and can incorporate those new methods into their job after they return. Similarly, responders may be exposed to new perspectives of a public health problem on the ground that can inform how they conceptualize and analyze their work back at the office. Sharing information about deployment experiences with colleagues at the home office (eg, in a group presentation) can also inform and strengthen the work of others (many of whom may have similar focus areas). A few respondents also reported being motivated by the development of personal skills that came through deployment experience, such as the ability to have patience, be flexible, and adapt to different, sometimes difficult, work environments.

Relatedness

Desire to Be Helpful

Many participants expressed a desire to help people impacted by the disaster or emergency and were motivated by knowing they were providing assistance in areas where it is needed most. Working in the field provides an opportunity to do hands-on public health work in the community where the direct impact of the work is immediate and readily visible, which may not always be possible for work conducted at the home office. Some participants noted they felt a sense of responsibility or duty to help people during an emergency, which is why they initially chose a career in public health.

During an emergency, the needs are so great, I feel internally motivated to help fellow human beings. I think that's a big part of it. (#23, Female, 34)

Camaraderie and Social Connectedness

The most common factor underlying the motivation to respond to emergencies mentioned by participants was the people they worked closely with on the ground during deployment. Many described the camaraderie and social connectedness that comes from working closely with individuals from other US agencies or other countries during an emergency, including the opportunity to bond under unique circumstances. They also noted the positive aspects of working with professionals who have a range of backgrounds and expertise and how these individual differences, which could be viewed as problematic on the surface, can actually result in a stronger team with complementary skill sets.

Understanding the other deployer, where they are coming from, figuring out a way to problem solve together—I find that fun, but others may not. (#4, Female, 44)

On the other hand, the work can suffer and be demotivating if there are differences in work styles, approaches to problem solving, or if skill sets are not adequately matched to deployment roles. One person pointed out that preexisting political sensitivities between agencies can create a difficult work environment if staff from both agencies are working together on a single team in the response.

Discussion

Several factors related to self-determination theory constructs emerged as important motivators of CDC staff to respond during an emergency. These factors primarily relate to extrinsic motivation factors—specifically, introjected and identified motivations. Participants expressed feeling a sense of achievement from being deployed for major CDC response events, indicating they were motivated by “making a contribution,” which gave them a feeling of personal achievement. This mapped well onto introjected motivation, which involves engaging in an activity due to self-enhancing contingencies (eg, self-esteem). On the other hand, participant statements such as “making a difference” and “sense of satisfaction from helping others” reflected identified motivation, which involves the internalization of specific values (eg, responsibility for others or contributing to a cause).

Many participants also expressed feeling “more engaged” in field deployment settings, which were typically described as fast-paced or exciting. Others mentioned they wanted to stay longer with their field deployment to do more work, while expressions of not wanting to return to their typical job were also mentioned. These statements indicate that the idea of being involved in public health emergencies, and related values and behaviors, had become part of their self-identity, such that the participants felt a desire to continue to be involved and be part of the emergency response.

Recognition by others was not found to be an important factor by any of the participants, which indicates that external factors, such as awards or financial incentives, may not influence motivation among public health workers in an emergency response. The factors and values mentioned earlier (eg, sense of responsibility, satisfying personal needs and wants) may better explain the findings in this study. It is possible, however, that some participants could be motivated by awards or financial incentives but chose not to express this during the interview because they preferred to be seen as altruistic (thus, introducing social desirability bias). Future studies may consider further investigating the role of recognition in the context of public health emergency response recruitment and consider strategies that could reduce social desirability bias in responses.

Findings from this study have several important practical implications. For example, almost all participants mentioned factors related to competence as a motivator—this suggests that interventions to increase self-efficacy and competence may encourage agency staff to become involved in future response efforts. Most recently, Barnett et al¹⁹ tested a threat- and efficacy-based intervention with local health department workers and found increased self-efficacy, response efficacy, and response willingness for those who received the intervention. Future studies may consider building on the current study to understand the different conditions that may improve self-efficacy and subsequently enhance motivation to participate in emergency response. Additionally, understanding the factors that motivate people to volunteer for public health emergencies have important implications for workforce planning and recruitment strategies. Using effective recruitment strategies could lead to less time required to send someone to the field and subsequently, better emergency response outcomes. The current COVID-19 response brought to light implications for which autonomy, competency, and relatedness could play important roles in public health workers' motivation to stay engaged in responses. For example, public health workers may experience less social connectedness, a motivational factor found in this study, due to remote work conditions or social distancing requirements associated with the pandemic, or public health workers may experience less clarity about their roles in a response setting given the rapidly evolving situation. Organizations that participate in public health emergencies may consider how they can leverage self-determination theory to better understand how to best support their response staff during COVID-19 and future responses.

This study represents an important step toward understanding the reasons why federal public health workers are motivated to participate in emergency response events. The use of qualitative methods used in this study were appropriate given that little is known about the motivation and willingness of public health workers who continue to participate in emergency responses. Furthermore, based on the self-determination theory framework, this study found salient beliefs in its constructs of autonomy, competence, and relatedness. If our findings are consistent with additional studies, they may serve as the foundation for theoretically based interventions to increase public health emergency preparedness.

This study should be interpreted in light of several limitations. First, all participants had been engaged in public health emergencies for several years and deployed on at least 3 different occasions. Staff who have never deployed or who have less experience may have different beliefs and motivating factors. Additionally, we did not assess scenario-based differences in responders' motivation to participate in public health responses. As noted earlier, variability exists in public health workers' willingness to respond to different public health threats.¹² However, our study provided initial evidence that there may be crosscutting motivational factors (regardless of the type of public health threats) that warrant further investigation. Furthermore, CDC's mission includes a range of disease prevention and control activities, in addition to responding to public health emergencies. Factors that motivate CDC staff to voluntarily deploy for public health emergencies may be different from the factors that motivate people who work at other federal agencies or in healthcare settings. Lastly, although the use of self-determination theory as a framework is appropriate and is considered a strength for the study, it should be noted that the theory focuses on fundamental psychological needs toward intrinsic motivation and integration. As such, it does not explicitly posit how nonindividual factors, such as organizational factors, policies, and other contextual factors, may also influence individual motivation. Indeed, our previous work around public health preparedness²⁰ has also indicated that organizational factors and other contextual factors (eg, types of responses) may influence one's willingness and motivation to participate in a response. Future studies may consider expanding and integrating self-determination theory into existing empirical evidence around public health preparedness to explore contextual issues not addressed by the theory.

Conclusion

In our sample of 25 public health workers at CDC who have frequently participated in emergency responses, we identified constructs in self-determination theory that provide a useful framework for assessing the motivations underlying public health workers' engagement. External factors such as feeling a sense of achievement (autonomy), applying and learning public health skills (competence), and having a sense of responsibility/desire to help affected communities (relatedness) emerged as important motivators among participants. Given the importance of public health workers in emergency response settings and the increasing array of public health threats, including the COVID-19 pandemic, there is an urgent need to further examine how to motivate public health workers in ways that encourage them to remain engaged in emergency response work.

Footnotes

Acknowledgments

The authors would like to acknowledge all CDC staff who took the time to participate in this study.

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