Social workers from the Los Angeles County Department of Mental Health deliver food in April 2020. Public health professionals are experiencing high levels of stress, anxiety and depression as they serve their communities during the outbreak.
Photo by Michael Baker, courtesy County of Los Angeles
More than a year into the COVID-19 pandemic — and many months into an unprecedented vaccination campaign — a significant number of U.S. public health workers are reporting symptoms of mental distress.
In a study of more than 26,100 state, tribal, local and territorial public health workers conducted this spring, 53% reported symptoms of at least one mental health condition in the past two weeks.
More than a third reported symptoms of depression, over 30% reported anxiety, nearly 37% reported symptoms of post-traumatic stress disorder, and more than 8% reported symptoms of suicidal ideation.
The study, published June 25 in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, found that the severity of symptoms increased as weekly work hours rose and as more time was devoted to COVID-19 response.
“Public health workers are exhausted. Just like health care workers, but they don’t get lifted up and praised as often.”
— Marcus Plescia
Public health professionals who reported being unable to take time off work were more likely to report adverse mental health symptoms. The highest prevalence of symptoms was among those 29 years old and younger and among transgender or nonbinary people of all ages.
While a number of research efforts have focused on the well-being of health care workers during the pandemic, the MMWR study is one of a select few to capture the pandemic’s mental health impacts specifically on public health responders.
“We were feeling from our members a level of distress that we’d never seen before — a demoralization,” said Lori Tremmel Freeman, MBA, CEO of the National Association of County and City Health Officials, which worked with study researchers to make sure the survey reached workers throughout the country’s thousands of local health departments.
Freeman, an APHA member, said she was initially worried the mental health survey would have trouble engaging front-line workers, as other field surveys had experienced roadblocks during the pandemic. Instead, she said the large response underscored just how much the public health workforce needed to be asked about their mental well-being.
“We knew we’d see some signals of impact to mental health, but we weren’t prepared for the extent of signals,” Freeman told The Nation’s Health. “The rates of PTSD and suicidal thoughts are significant enough that those findings alone need to be addressed with action. This is serious.”
More than 90% of respondents in the MMWR study were working directly on COVID-19 response, with the majority working 41 hours or more in a typical week since March 2020. Workers who were unable to take time off were nearly twice as likely to report symptoms of an adverse mental health condition. The top reasons for not taking time off included concerns about falling behind on work, no work coverage, feeling guilty, and not being allowed to take time off.
More than 23% of workers said they felt bullied, threatened or harassed because of work, and nearly 12% had received job-related threats. Almost 20% of respondents said they needed mental health services in the prior month but did not receive them. While employee assistance programs were available to about 66% of respondents, only about 12% accessed them.
Marcus Plescia, MD, MPH, chief medical officer at the Association of State and Territorial Health Officials, which also helped conduct the survey, said long-term pandemic response is inevitably stressful, but future workforce development should better account for mental health impacts.
In April 2020, Rosita San Diego, MD, an L.A. County Public Health Department physician, and Absalon Galat, MD, of Northeast Valley Health Corporation, discuss where COVID-19 cases are located and where they should deploy testing activities.
Photo by Mayra Vasquez, courtesy County of Los Angels
“Public health workers are exhausted,” he told The Nation’s Health. “Just like health care workers, but they don’t get lifted up and praised as often.”
Plescia, an APHA member, said one thing that has become clear is the need for peer support — a gap that professional associations may be especially well-suited to address. For example, he said that ASTHO-hosted, biweekly calls among state health officials typically attracted high rates of participation, “partially because I think they just needed to talk with one another and hear from peers who were also struggling.”
Carol Rao, ScD, a coauthor of the study and an epidemiologist with CDC’s COVID-19 Emergency Response Team, said acting on the findings will require organizational changes, pointing to the association between adverse mental health impacts and being unable to take time away from work.
“The last line of defense is self-care,” Rao told The Nation’s Health. “There’s only so much employees can do if their employers don’t let them do it.”
Though research on the topic is sparse, the MMWR study is not the only one to capture the pandemic’s effect on governmental public health workers. In a study published in April in the International Journal of Environmental Research and Public Health, researchers found that more than 66% of public health workers reported burnout. The study surveyed 225 public health practitioners from 31 states and Washington, D.C., of which about 80% were governmental public health workers, according to study co-author Jennifer Horney, PhD, MPH, a core faculty member at the University of Delaware’s Disaster Research Center.
Liz Stevens, MPH, RN, Durham County Department of Public Health deputy director, works at a COVID-19 vaccination event in North Carolina in May. Many public health professionals are putting in long hours to save lives during the pandemic.
Photo courtesy Durham County Department of Public Health via Flickr
The study, conducted in later summer 2020, found that people with more experience or who worked in academic settings were most likely to report burnout. In general, it found higher levels of burnout among public health workers than in similar studies done among front-line health care workers. More than 41% of respondents reported poor mental health in at least 14 of the last 30 days.
Especially worrisome, almost 24% fewer respondents planned to stay in the public health workforce for three or more years when compared to their January 2020 intentions.
“If we lose a lot more people, we’re really in trouble,” Horney, an APHA member, told The Nation’s Health.
Across the study, Horney said certain risk factors consistently came up, such as work hours and inability to take time off. She said many workers also mentioned the impact of seeing their work politicized and maligned.
“We had a lot of people who talked about working in communities for years to generate trusting relationships, only to see it vanish in a few weeks,” said Horney, also a professor and founding director of the university’s Epidemiology Program. “It was just devastating.”
Horney said some respondents reported that small actions can make a difference. But larger, systemic changes are needed to address some of the biggest risk factors for burnout, such as long work hours and strained resources.
Even before COVID-19, governmental public health was facing a workforce shortage, and the pandemic and its politicization have worsened it. A year-long investigation from Kaiser Health News and The Associated Press found that at least 248 leaders of state and local health departments resigned, retired or were fired between April 2020 and March 2021.
That gap is about to be targeted with a big infusion of funding, thanks to $7.4 billion in the American Rescue Plan dedicated to hiring new public health workers and getting ready for future public health threats. Making sure funds flow down to the local level as quickly as possible will be key, said Freeman at NACCHO, which plans to create new resources to help health departments support staff mental health.
“This report helped solidify some of my fears,” Freeman said, referring to the MMWR study. “There could be a wave (of more workforce losses) and I’m very fearful about what we’ll see in the coming months.”
To access the study, visit www.cdc.gov/mmwr.
- Copyright The Nation’s Health, American Public Health Association
