Impacts of COVID-19 Response on the Public Health Workforce

Publication Date: 2021

Abstract

The response to the COVID-19 pandemic has placed significant strain on many professionals. While there has been substantial research on the physical and mental health impacts of pandemic response on patient-facing healthcare staff, there has been considerably less research investigating the well-being of the public health workforce. Quick response research was conducted to assess the impact of the pandemic response on public health workers; identify strengths, weaknesses, opportunities, and threats to the mental health of the public health workforce; and describe the key themes of the experiences of public health workers throughout the pandemic. Key informant interviews were conducted with a subset of respondents to a cross-sectional survey. A semi-structured interview guide was used addressing the following topics: professional role during the COVID-19 pandemic; the impact of individual- and organizational-level considerations for mental health; and organizational strengths, weaknesses, opportunities, and threats associated with the pandemic. Participants included 24 epidemiologists, public health nurses, programmatic staff, evaluators, data scientists, and case investigators working in state and local public health. Half had six or more years of experience in public health. Five themes were identified through inductive coding of transcripts: (a) importance of teamwork and camaraderie; (b) potential for growth of the field of public health; (c) considerations for adaptive work environments; (d) ongoing communications challenges; and (e) constrained hiring capacity and burnout. After more than a year of public health emergency response to the COVID-19 pandemic, there are detrimental and supportive factors that must be addressed to ensure both immediate and long-term mental health among public health workers.

Introduction and Literature Review

Over the last year, COVID-19 has placed significant strain on many essential frontline professionals, including those working in health care and public health. A relatively large number of studies have addressed the physical and mental health impacts of the pandemic on frontline, patient-facing healthcare staff (Cai et al., 2020¹; Felice et al., 2020²; García-Fernández et al., 2020³; Lai et al., 2020⁴; Naushad et al., 2019⁵; Preti et al., 2020⁶; Stuijfzand et al., 2020⁷). Multiple rapid and systematic literature reviews have found that healthcare workers are at an increased risk of developing negative mental health conditions such as psychological distress, insomnia, anxiety, depression, and symptoms of post-traumatic stress disorder (Naushad et al., 2019; Preti et al., 2020; Stuijfzand et al., 2020). In meta-analyses, the pooled prevalence of anxiety among healthcare workers during the COVID-19 response was 25% to 43% (Santabárbara et al., 2021⁸), and the prevalence of depression was 25% (Sahebi et al., 2021⁹).

However, data related to the impacts of the COVID-19 response on the public health workforce has been far more limited, in part because the public health workforce remains poorly characterized due to its diverse settings, multidisciplinary nature, and lack of worker classifications (Beck et al., 2014¹⁰; Coronado et al., 2014¹¹; Sumaya, 2012¹²; University of Michigan Center of Excellence in Public Health Workforce Studies, 2013¹³). Although it has remained difficult to enumerate the public health workforce over the last decade, it is clear that the U.S. governmental public health workforce began the response to COVID-19 with both a workforce and a fiscal deficit (Wilson et al., 2020¹⁴). Since the financial crisis of 2008, the U.S. public health system lost 20% of its workforce, or 34,000 jobs, while 62% of local health departments had flat or reduced funding and average overall declines in spending averaged 10.3% (ASTHO, 2020¹⁵; Leider et al., 2018¹⁶; NACCHO, 2019¹⁷). Shortages in the public health workforce in the United States are similar to projections for the global public health workforce (Liu et al., 2017¹⁸).

Evidence related to impacts of the COVID-19 response on the mental health of the public health workforce is limited. In a study of Chinese public health workers who were mostly responsible for infection prevention, control, and containment of COVID-19, the prevalence of depression and anxiety were 21% and 19%, respectively (Li et al., 2021¹⁹). Risk factors for poor mental health outcomes included working conditions, such as working all night for more than 3 days, and concerns about being infected with COVID-19 at work. A cross-sectional survey of public health workers in the United States found a high prevalence of depression (29%), anxiety (41%), and burnout (66%), and identified working more hours per week (Pfender et al., 2021²⁰) and having less job experience as potential risk factors (Stone et al., 2021²¹). A Centers for Disease Control and Prevention (CDC) survey of state, territorial, tribal, and local health departments found negative mental health conditions in 53% of respondents, with the prevalence of post-traumatic stress and depression over 36% and 32%, respectively (Bryant-Genevier et al., 2021²²). To address this evidence gap, we conducted key informant interviews with members of the U.S. public health workforce to identify individual and organizational aspects of the COVID-19 response that impacted mental health, as well as strengths, weaknesses, opportunities, and threats to public health professionals and organizations going forward.

Methods

Research Objectives

This research was conducted to (a) assess the impact of the pandemic on public health workers; (b) identify strengths, weaknesses, opportunities, and threats to the mental health of the public health workforce; and (c) describe the key themes of the experiences of public health workers throughout the pandemic.

Study Site and Participants

As part of a larger cross-sectional survey of the public health workforce (Stone et al., 2021), respondents willing to participate in key informant interviews were identified. A stratified random sample of 48 individuals (24 from states with centralized public health governance; 24 from states with decentralized public health governance) was invited to participate in interviews (ASTHO, 2012²³). The sample was stratified by governance structure because structure has been shown to be associated with multiple public health emergency preparedness metrics, including the ability to rapidly deploy resources during a pandemic and the quality of pandemic plans (Horney et al., 2017²⁴; Klaiman & Ibrahim, 2010²⁵), as well as with the pace and extent of implementation of COVID-19 control measures (Strickland et al, 2020²⁶). Twenty-four of 48 invited participants completed a key informant interview between January 28 and February 23, 2021, for a response rate of 50%. Invitations to participate were sent via email and interviews were conducted using Zoom.

Data, Methods, and Procedures

A semi-structured interview guide was used (Figure 1) to address the following topics: professional role during the COVID-19 pandemic; impact of individual-level considerations on mental health; impact of organizational considerations on mental health; and strengths, weaknesses, opportunities, and threats associated with the pandemic at an organizational or agency level. All materials were reviewed by the University of Delaware Institutional Review Board (IRB# 1641836-1) and determined to be exempt. Recordings and transcripts generated by Zoom were analyzed by a trained graduate researcher and a trained undergraduate researcher to independently identify key themes using inductive coding (i.e., themes were not pre-identified, but emerged through the review process). Independently identified themes were then compared and reconciled by the two reviewers.

Findings

Results

Participants included public health nurses, epidemiologists, programmatic staff, evaluators, case investigators, and data scientists, among other public health professionals, with work experience ranging from less than a year to more than 15 years. Half of interviewees had more than 5 years of experience (n=12), with most respondents having between 1 and 4 years of experience (n=8). More than half (n=15; 62.5%) of interviewees worked in states with centralized health departments, while 9 (37.5%) worked in states with decentralized health departments. Five key themes were identified: (a) the importance of teamwork and workplace camaraderie; (b) potential for professional growth in the field of public health; (c) considerations for adaptive work environments (e.g., work out of jurisdiction; transition to telework); (d) impacts of ongoing communications challenges; and (e) constrained hiring capacity and burnout. Each theme is described in detail below.

Teamwork and Workplace Camaraderie

The most common theme that emerged was the importance of teamwork and cooperation in protecting mental health during the response. Participants highlighted the fact that the stressful work environment, long hours, and need to quickly adapt to new demands and changing guidance had forged strong working relationships between colleagues. While teams within the same departments worked well together, some respondents also indicated that the array of expertise and levels of experience within teams—ranging from psychologists, social workers, and epidemiologists to clinicians and information technologists—created a robust support network for individuals’ mental health and well-being.

Many respondents referred to the phrase “building an airplane while flying it” to describe work demands throughout the course of the pandemic. This sentiment was echoed and elaborated upon by other respondents, noting that the trying circumstances necessitated better and more efficient communication among workplace teams. Even amidst the uncharted territory, high demands, and long hours, effective communication was a strength that bolstered team environments and mitigated negative mental health impacts.

The work environment and my colleagues have been one of the best things. You know, there is a lot of motivation, a lot of camaraderie. Just like, people are exhausted, but everyone has just been so dedicated, like it’s just been unquestionable – people have just done whatever needs to be done and working in a team like that is really awesome. I really enjoyed all of the communication. (Public Health Clinician)

The pandemic has made my working relationship with so many people much closer just because we’re forced to work together, we’re on calls at 11 o’clock at night, that brings you closer together, and so I feel much closer and supported by my peers. (Surveillance System Manager)

Leadership was another key component of the discussion surrounding teamwork and workplace camaraderie. The importance of the quality of leadership was frequently noted in discussions about teamwork. When supervisors functioned as advocates for their staff, the work environment was generally more collaborative, less stressful, and more effective. Others mentioned the importance of opportunities to decompress with colleagues who were having the same experiences. While working in person, being around colleagues helped prevent the sense of loneliness and isolation that has marked this period for many. These sentiments are well summarized by a public health clinician, stating, “In terms of not actually seeing people, I think coming to work and seeing people had really helped my mental health and then it was hard not to see people.”

Potential for Professional Growth in the Field of Public Health

Interviewees’ most frequently mentioned opportunity was the unique prospect for meaningful professional growth of the field of public health due to the COVID-19 pandemic response. This took on three dimensions: collaboration; recognition and awareness; and public perception.

Integration of efforts across public health functional groups and data sharing were mentioned as successes across the interviews. Personal relationships, cultivated through shared experience and collaboration, were critical to good data sharing practices across different levels of public health entities, especially in the absence of the appropriate technological infrastructure, In addition, more public-private partnerships have been forged, improving data management due to both necessity and innovative thinking throughout the course of the pandemic. These channels have enhanced public health response.

[Private companies] are very interested in helping us, which is great. And so, we’ve been able to partner with them pretty effectively to do stuff on timescales that never would have been possible. I mean literally we have probably 15 years’ worth of IT projects either in progress or done in the last 10 months or so. (Incident Commander and Informatician)

Respondents also saw the pandemic as an opportunity to expand the capacity of public health to respond to future events and better incorporate “health in all policies” and equity into public health programs going forward. More generally, respondents highlighted the potential for the expanded role of public health moving forward with groups such as schools and community organizations that will help attract more people to public health careers. While public health is not typically a visible component of patient-facing, frontline health and healthcare work, the pandemic has brought the critical, although sometimes controversial, role of public health in infection control into public view. One respondent noted this as a potential advantage for increased funding and better community buy-in to public health efforts moving forward.

It is just an eye opener for the public, and I would love to think that it would result in greater respect for public health. And of course, respect should either come before the money or money should follow it – I’m not sure of the actual sequence – but that’s what I really hope. (Public Health Nurse)

Considerations for Adaptive Work Environments

Public health work environments, like many workplaces, have had to adapt during the COVID-19 pandemic. For some respondents, working in person was preferable to working remotely because of the sense of community and opportunities for social interaction it offered. However, several interviewees saw the increased flexibility of the workplace as both a strength and opportunity. A contact tracer and case investigator noted that remote work makes certain roles more accessible to more individuals: “This was the first job I could get in a health department because they require a driver’s license.” The health benefits of avoiding commutes were reflected upon by an infectious disease epidemiologist, “When I was working [in person] I faced a significant commute… that had, for years, been causing me really high levels of stress, and that’s gone now.”

Another respondent noted how the shift to working from home allowed for more time to engage in self-care and healthy lifestyle behaviors, while others noted the difficulty of managing work/life balance when working from home, especially in the beginning.

I have really vastly increased my exercise. In some ways, I became much more healthy and less stressed. I get a full night’s sleep every night, you know, so I really like it now and have adapted well to it. (Infectious Disease Epidemiologist)

I think [working from home] was a bit more of a stressor just because that separation of work and personal life was definitely not there as much, especially being compounded with stay-at-home orders where you are kind of there all the time and just not really able to escape that. (Program Evaluator)

The shift to remote work was received better when health departments had the ability to provide staff with the technology needed to work remotely.

I think basically everyone was set up to work from home within probably 10 days after the order… Some people needed to get laptops or new computers or something in order to facilitate that, and they [IT] deployed three or four different technological solutions for that, so we were really fortunate in our IT. (Surveillance Manager and Informatician)

The shift to remote work did not work well when there were appreciable gaps in the provision of technology needed to work remotely. Staff hired or moved from different departments to provide surge capacity since the start of the pandemic did not necessarily have the same technological skill sets as those working in public health response roles before the pandemic. Information technology departments did not have adequate staffing or expertise to address the number of inquiries and remote work needs while maintaining their normal operations. Both staff and systems were pushed to the brink, as highlighted by a quality improvement coordinator, “There are potential security issues, there’s internet slowness, our systems are really pushed to the brink, so opening a file or saving a file can take excessively long.”

Communication challenges

Different expectations and poor communication across varying levels of leadership were frequently identified weaknesses of the public health response to COVID-19 and important stressors for respondents. Changing public health orders and a lack of understanding of the circumstances “in the trenches” resulted in superfluous, unreasonable demands on staff.

The communication was beyond insufficient. There was a lot of duplication of efforts in the beginning. Really, the leadership [should have been] like, ‘this is what you know we’re doing, and you know these are all pieces,’ but there was none of that; there was no plan, you know, no formal plan. (Case Monitor and Project Lead)

I think there needs to be really clear expectations of what public health responders can get to and making sure we are not wasting our time on certain projects or doing just data collection for the point of data collection. (Foodborne Illness Epidemiologist)

One respondent noted the gaps in understanding between political and public health leaders and the public health workforce, saying, “They [the governor’s office] are coming in with a fire hose without understanding anything about the fire.” Another noted the tensions between politics and public health, saying:

I remember watching a news conference with the state epidemiologist and the governor was there. I don’t think it was quite as bad as the Trump-Fauci relationship, but there were definitely things said that I’m not sure how accurate they were. You know, we are not giving our residents the complete picture. I think that’s a point of frustration for me – just the idea that even some communication might be kind of hampered by political influences is frustrating to say the least. (Program Evaluator)

When there was clear communication and mutual respect between political entities and public health entities, there were positive effects on the public health workforce despite facing persistent challenges with the scale and duration of the pandemic:

[The governor] understood, [the governor] trusted experts, [the governor] trusted science, and the modeling, even given the uncertainty that we had, and we got the job done. We’ve continued to do so. We’ve struggled mightily, but the struggles that we have faced, we have had good executive support and policymaker support, basically for us and the value of our work, which has helped a lot. (Incident Commander and Informatician)

Communications between public health staff and the public also emerged as a concern with appreciable mental health impacts. Especially for contact tracers, animosity, misunderstanding, and questions about privacy led to unpleasant telephone encounters that, cumulatively, contributed to burnout and frustration.

It has been really hard to continue our work and our communication and also complete the case investigations and calls when you can’t get people on the phone. This has been hard and frustrating and adding a whole other level to this work. (Case Manager and Contact Tracer)

Constrained Hiring Capacity and Burnout

The ability to surge staff, redistribute workload, and procure needed resources quickly were key factors influencing the mental health of respondents. Poor use of time and resources, limited time off, and significant overtime all negatively impacted the mental health of public health workers. These concerns were present before the pandemic but have been exacerbated, as stated by a public health nurse manager, “We are understaffed, we have been understaffed before COVID but with COVID we are still understaffed so that part has taken its toll…”

The stressors caused by continually working in understaffed settings is contrasted by the experiences of those working in environments that have been able to quickly bring on new, qualified staff to help distribute the workload. Respondents in understaffed environments reported feeling pressure and obligation to work overtime, weekends, and/or holidays because they knew there were no other staff to do the job. On the other hand, the ability to hire new staff to provide surge capacity has been advantageous to mental health and maintenance of a work/life balance. A chronic disease epidemiologist currently working as a contact tracer highlighted the need to maintain new hires, saying, “We were able to quickly increase our staff from three of us to, I believe we have six right now, so that’s been a big benefit to this, and I just hope we can keep it that way.”

Burnout, fatigue, and feeling unappreciated were commonly discussed as ramifications of the high workload and limited support for personal time and mental health. The sustained duration of the pandemic without any workforce relief has taken a heavy toll on some otherwise motivated staff.

When it started picking up last January, we had the mindset, ‘Okay, it’s going to be a rough couple of months but once we get the system set up and ready to collect all of the data that we need to collect, it’s going to be stable, and we will go back to regular.’... But everything is shifting and evolving so quickly that the work never stops. (Surveillance System manager)

One respondent noted that one of their staff had not taken a day off in over six months. Without having breaks, it becomes increasingly difficult for public health staff to separate themselves from issues. The number of hours worked in a week, with or without overtime compensation, also emerged as a significant burden on the mental health of public health staff.

It’s 70 – 80 hours a week for almost a year. I think our whole team is fine with hard work, but when we are being asked to do things under unreasonable timeframes... that is where a lot of frustration comes from. (Surveillance System Manager)

Across all key themes, strengths, weaknesses, opportunities, and threats were often inextricably linked. For example, weaknesses and threats such as lack of communication across various levels of leadership and among leaders in different agencies were discussed in the context of negative impacts on mental health, whereas strong and deliberate communication was noted as a factor that helped staff to maintain better mental health. Many opportunities were contingent upon redoubling the strengths, minimizing the threats, and addressing the weaknesses that were part of public health agency staffing and funding before the start of the pandemic. Respondents unanimously agreed that a year into the COVID-19 pandemic, it is critically important to understand the underlying mechanisms of public health response that prove either advantageous or detrimental to supporting the maintenance of good mental health among staff as the response continues and the vaccination campaigns begin simultaneously.

Discussion of Preliminary Findings

The reality of negative mental health impacts among those who respond to disasters is well-documented, particularly among pre-hospital and hospital personnel (Benedek et al., 2007²⁷; Maunder et al., 2008²⁸; Naushad et al., 2019). The mental health impacts of the COVID-19 response among patient-facing healthcare workers such as nurses, emergency medical technicians, physicians, and medical trainees have also been well documented (Cai et al., 2020; Civantos et al., 2020²⁹; Feingold et al., 2021³⁰; Kannampallil et al., 2020³¹; Khalafallah et al., 2020³²; Restauri & Sheridan, 2020³³; Ripp et al., 2020³⁴; Sagherian et al., 2020³⁵; Soto-Rubio et al., 2020³⁶; Taylor & Blackford, 2020³⁷). However, few studies have included non-clinical staff. Firew et al. (2020³⁸) included technologists, clerical, and security staff in healthcare settings, and Evanoff et al. (2020³⁹) included students, faculty, and post-doctoral researchers at an academic medical center. Despite this work, burnout and the mental health impacts associated with the COVID-19 response among the public health workforce remain poorly characterized (Li et al., 2021). Given the substantial documentation of the psychological strain experienced by patient-facing responders and the unprecedented scale and duration of the COVID-19 pandemic, understanding these strains in the public health workforce is critical for supporting the workforce through the duration of the pandemic and in planning for future disasters.

Key informants in this study identified several factors contributing to burnout and poor mental health among the public health workforce that resonate with themes identified in prior studies of patient-facing healthcare providers. A common theme among respondents in this study was stress and burnout associated with understaffed public health departments and inadequate funding or personnel to manage surge capacity and workload. In clinical settings, patient-provider ratios are similarly predictive of mental health strain (Aiken et al., 2002⁴⁰; Tawfik et al., 2017⁴¹). As seen in Li’s study among public health workers in China (2021), increased work hours were a risk factor for poor mental health among respondents in this study. This was corroborated by the CDC’s study showing more prevalent negative mental health conditions in public health workers who were unable to take time off and/or who worked more than 41 hours in a week (Bryant-Genevier et al., 2021). Working on weekends, on holidays, and before and after hours to ensure that demands are met, especially during high-case periods, contributes to burnout.

Teamwork, camaraderie, and managerial support, commonly discussed protective factors among our key informants, have also been well-documented across health fields (Epp, 2012⁴²; Hunsaker et al., 2015⁴³). The Disaster Mental Health Collaborative Group identified the importance of teamwork and communication as a core competency in disaster mental health (Everly et al., 2008⁴⁴). Recognizing the importance of teamwork in emergency situations, the Disaster 101: Effectiveness of Simulated Disaster Response Scenarios study sought to improve interprofessional collaboration and teamwork to better prepare trainees for real-world emergency response In a review of mental and physical health impacts of remote work, organizational support and workforce camaraderie were critical factors in contributing to successful transitions and protecting staff’s mental health (Oakman et al., 2020). Accordingly, public health entities should invest in building workplace culture and team dynamics to ensure these competencies are integrated into public health practice regardless of disaster or non-emergent scenarios.

Consistent and functional channels of communication—such as through the use of the incident command system (ICS)—are important for mitigating the risk of burnout and negative mental health impacts (Everly et al., 2008). Breakdowns in communication can lead to increased workload, decreased productivity, poor use of resources, and more work-related stress. However, clear organizational and communication structures like ICS can iteratively improve surge capacity, clarity of communication, and workforce wellbeing (Landesman, 2005⁴⁵). In line with insights from our respondents, data sharing and working relationships across departments and agencies are important for a successful response (Capella, 2020⁴⁶). Early communication and coordination among stakeholders—including public health, academia, hospital systems, emergency medical services, and long-term care facilities—were key contributors to a successful regional COVID-19 response in western Washington state (Capella, 2020; Mitchell et al., 2020⁴⁷). Furthermore, gaps, inconsistencies, and lack of transparency in public and workplace messaging leave staff frustrated with the seeming political influence on public health practice (Gollust et al., 2020⁴⁸; Udow-Phillips & Lantz, 2020⁴⁹). Lack of communication both within and outside of public health agencies foments burnout and significant frustration, and this has led to the resignations of dozens of public health officials nationwide (Halverson et al., 2021⁵⁰; Mello et al., 2020⁵¹).

While many factors have negatively impacted the mental health of public health professionals, the COVID-19 pandemic, as well as other public health emergencies, has brought opportunities to further the public health sector (Brownson et al., 2020⁵²; Hargreaves et al., 2020⁵³; Petrovsky, 2010⁵⁴; Poland, 2010⁵⁵). Following the 2003 SARS outbreak in Toronto, organizational resilience and culture, components for protecting the wellbeing of patients and personnel, were identified as key considerations for pandemic influenza preparedness planning (Maunder et al., 2008). Lessons learned from the HIV epidemic underscored the critical need to consider health inequalities in COVID-19 public messaging, response, and care (Hargreaves et al., 2020). The pandemic has forced public health professionals to move toward innovative methods for modeling, surveillance, and transmission control (Morse, 2020⁵⁶). Beyond the functional lessons learned, respondents in this study noted their optimism that the public health response to the COVID-19 pandemic will make the work of public health professionals more visible. This visibility could contribute to more engagement with, and buy-in from, the community, increased funding and partnership opportunities, and more interest in pursuing public health careers. Indeed, in the fall of 2020, applications to graduate-level public health programs increased by over 20% (Smith & Young et al., 2020⁵⁷).

Conclusion

There are interdependent strengths, weaknesses, opportunities, and threats to the mental health and wellbeing of the public health workforce that are consistent with frontline healthcare workers who have been studied more extensively during the pandemic response. These qualitative findings highlight areas where action should be taken now to protect the current public health workforce and, in the future, to ensure the resilience of the workforce going forward in the face of future public health disasters. The authors have presented findings from this report at CSTE Disaster Epidemiology Meeting (May 17, 2021), 46th Annual Natural Hazards Research and Applications Workshop (July 11-12, 2021), and the Boston University collaborative conference Public Health Workforce Burnout throughout COVID-19 (July 30, 2021). The work will also be presented as part of the University of Delaware Graduate Seminar Series (Feb 2022) and the American Public Health Association’s 2021 Annual Meeting and Expo (Oct 24-27, 2021). A paper presenting findings is currently under review at the journal Social Science and Medicine: Qualitative Research in Health.

This qualitative study has several important limitations. First, the pool of potential key informants indicated their willingness to participate in an interview while completing a cross-sectional survey related to public health workforce burnout. Therefore, response bias is possible, and no attempt to assess causation between exposures and outcomes is made. Interviews were conducted in January and February 2021, during the presidential transition and post-holiday surge in COVID-19 cases that impacted much of the United States. Any or all of these events could have influenced responses, which may not be representative of current or prior states of the public health workforce, as both disease dynamics and policy have changed over the course of the pandemic. However, to our knowledge, this is one of the first qualitative studies to assess the factors influencing the mental health impacts of the COVID-19 response on the public health workforce, which will be critical to consider as the response to the pandemic continues in parallel with the implementation of vaccination campaigns.

Another round of key informant interviews will begin in August 2021. This round of interviews will build on this and other work by the authors, addressing questions of perceptions and experiences for both short-term and long-term changes in public health practice across jurisdictional levels as a result of the COVID-19 pandemic.

References