Understanding Low Utilization of Employee Assistance Programs and Time Off by US Public Health Workers During the COVID-19 Pandemic

Abstract

Objective:

Despite high rates of reported mental health symptoms among public health workers (PHWs) during the COVID-19 pandemic, utilization of employer-offered resources was low. Our objective was to understand what barriers and deterrents exist for PHWs accessing employer-offered resources.

Methods:

Four national public health organizations disseminated a national online survey of public health department employees during March–April 2021; 26 174 PHWs completed the survey. We examined 5164 write-in survey responses using thematic analysis to identify key reasons why PHWs were not accessing time off and employee assistance programs (EAPs) and to understand what resources PHWs would like to see their employers offer.

Results:

The top reasons that PHWs reported for not taking time off during the COVID-19 pandemic were financial concerns (24.4%), fear of judgment or retaliation (20.8%), and limitations in the amount of time off offered or available (11.0%). The top reasons that PHWs reported for not using EAPs during the COVID-19 pandemic were difficulty accessing EAPs (53.1%), use of external services (21.5%), and a lack of awareness about EAPs or motivation to initiate their use (11.3%). While desired employer-offered resources varied widely, PHWs most frequently listed financial incentives, paid time off, flexible scheduling, and organizational change.

Conclusion:

Organizations can best help their employees by organizing the workforce in a way that allows PHWs to take time off, creating a positive and supportive organizational climate, regularly assessing the needs of PHWs, clearly communicating the availability of employer-offered benefits, and emphasizing the acceptability of using those benefits.

The COVID-19 pandemic has had far-reaching effects on mental health, with global increases in reported symptoms of mental health conditions, including anxiety and depression. ¹ Health care and frontline workers in the United States report experiencing high levels of burnout,^2,3 psychological distress, ⁴ anxiety,^3,5 posttraumatic stress disorder (PTSD),^3,5 and depression.^3,5 The impact of the COVID-19 pandemic on the nation’s estimated 250 000 public health workers (PHWs) is less well documented.

PHWs have experienced violence, harassment, and bullying from the public as well as opposition and hostility from political figures.^6,7 Results from an online survey of 26 174 PHWs conducted during March–April 2021 suggest that the proportion experiencing mental health symptoms was higher than that among the general population. ⁸ PHWs who were unable to take time off work were twice as likely as those who took time off work to report symptoms of depression, anxiety, PTSD, and suicidal ideation.^8,9 Paid time off (PTO) can reduce workers’ risk for developing physical and mental health conditions.^10-13 It may help protect against depression ¹⁰ and may increase workplace safety; employees with paid leave are less likely than those without paid leave to report to their workplace while experiencing symptomatic respiratory illness. ¹¹ Paid sick leave protects against all-cause mortality, ¹² and enacting equitable sick-leave policies may help reduce gender, racial, and ethnic disparities in communicable diseases and other conditions. ¹³

Employee assistance programs (EAPs) are free or subsidized employer-offered services designed to help employees manage life challenges and stress that can affect their work performance and productivity. These programs often have low rates of utilization for varying reasons, including stigma and lack of employee awareness.^14,15 For example, nearly 1 in 5 PHWs who responded to an online survey reported needing mental health/counseling services but not receiving them. ⁸ Workplace wellness programs also have typically low utilization and limited effectiveness when evaluated.^16,17 Employers often invest substantially in these programs, which are designed to improve employee well-being. Understanding barriers and deterrents to accessing these resources may help increase their uptake and effectiveness and ultimately PHWs’ health. We assessed reasons why PHWs did not use EAPs and employer-offered resources and explored why PHWs did not take time off during the COVID-19 pandemic.

Methods

Four national public health organizations (the Council of State and Territorial Epidemiologists, the National Association of County and City Health Officials, the Association of Public Health Laboratories, and the Association of State and Territorial Health Officials) distributed a self-administered, online, anonymous survey about mental health during the pandemic to their members. A total of 26 174 PHWs completed the survey. Detailed methods and demographic characteristics are described elsewhere. ⁸ Briefly, a nonprobability-based convenience sample of PHWs in the United States was invited to complete the survey during March 29–April 16, 2021. All people who worked at a state, tribal, local, or territorial health department for any length of time in 2020 were eligible to participate. The questionnaire assessed mental health symptoms during the last 2 weeks via standardized questions in the 9-item Patient Health Questionnaire for depression and suicidal ideation, ¹⁸ the 2-item General Anxiety Disorder for anxiety, ¹⁹ and the 6-item Impact of Event Scale for PTSD symptoms. ²⁰ We asked whether participants were able to take time off since March 2020. Of those who answered no, we asked a follow-up question about why they were unable to take time off. We also asked whether their employer offered an EAP; for those who indicated that their employer had an EAP but they had not accessed it since March 2020, we asked why they did not access it. We also asked respondents to select all employer-offered resources that they would access if available and to write in additional resources of interest. Question formats included multiple choice, multiple selection, and free-text write-in responses. We excluded skipped questions from frequency analyses.

Three researchers (J.T.M., C.W., J.G.) analyzed write-in responses using inductive thematic analysis. ²¹ For each question, 2 of the researchers conducted an initial independent review and freely coded responses. After the initial review of the data, the researchers determined that a primary code and a secondary code for written responses to questions about time off and EAP were sufficient, while responses to the question about employer-offered resources were assigned up to 5 codes per answer because respondents listed numerous resources. The same 2 researchers independently re-reviewed and recoded responses. The researchers then compared codebooks, established and defined a standard set of codes for each question, and grouped codes by category. They then recoded responses to questions based on the established set of codes. They calculated interrater reliability as the percentage of codes that agreed between them before any discussion. A third researcher then reviewed discordant codes and made a final determination. Together, the 3 researchers identified broader categories and extracted themes. They conducted analyses using Microsoft Excel. This activity was reviewed by the Centers for Disease Control and Prevention and was conducted consistent with applicable federal law and center policy (eg, 45 CFR part 46.102.l.2; 21 CFR part 56; 42 USC §241.d; 5 USC §552a; 44 USC §3501 et seq).

Results

The number of respondents to each question ranged from 13 155 (50.3%) to 22 668 (86.6%). Overall, the team analyzed 5164 write-in responses, and the number of written responses ranged from 1151 to 2618 per question. A total of 4460 respondents provided written responses for any of the 3 questions analyzed; 634 gave a written response for ≥2 questions; 957 offered a written response only for why they were unable to take time off; 2160 supplied a written response only for why they did not use an EAP; and 709 wrote a response only about employer-offered resources of interest.

We found few differences in the sociodemographic and workplace characteristics among PHWs who provided written responses to the 3 questions of interest and the overall sample (Table 1). However, when compared with the overall sample, a higher proportion of PHWs who provided written responses describing why they were unable to take time off had worked on the COVID-19 response for >75% of their time (54.6%); a higher proportion of PHWs who wrote in responses describing why they did not use an EAP were supervisors (70.5%); and a higher proportion of those who wrote in resources that they would like to see their workplace offer had a master degree or higher (46.8%).

Table 1.

Sociodemographic and workplace characteristics of public health workers who submitted written responses (n = 4460) to a survey on the use of EAPs and time off during the COVID-19 pandemic, United States, March–April 2021 ^a

		Provided written responses, %
Characteristic (no. of respondents)	Overall (N = 26 174), % b	About reasons why unable to take time off (n = 1395)	About reasons why did not use EAP (n = 2618)	Listing employer-offered resources they would access if available (n = 1151)
Age, y (n = 21 843)
≤29	16.1	18.3	10.2	12.2
30-39	25.0	26.9	29.0	28.8
40-49	23.4	23.4	28.5	22.1
50-59	22.5	21.4	21.9	24.0
≥60	13.0	9.9	10.4	12.9
Sex/gender (n = 23 917)
Male	16.3	12.8	9.7	17.2
Female	83.1	86.2	89.3	81.2
Transgender or nonbinary	0.6	0.9	1.0	1.6
Race and ethnicity (n = 23 244)
Hispanic	8.5	9.2	7.2	8.6
Non-Hispanic
AI/AN	0.7	0.4	0.4	0.8
Asian	4.3	4.1	2.5	4.2
Black or African American	9.4	8.4	6.3	9.3
NH/PI	0.4	0.3	0.1	0.2
White	74.1	74.1	80.7	74.0
Multiple races	2.6	3.5	2.8	2.9
Marital status (n = 23 553)
Never married	21.5	25.4	19.5	23.1
Married or unmarried couple	65.1	60.1	66.0	63.5
Divorced, separated, or widowed	13.3	14.5	14.4	13.5
Household size (n = 24 037)
Lives alone	14.3	15.9	14.9	16.2
2 or 3	57.2	55.4	56.4	57.5
≥4	28.5	28.7	28.8	26.3
Household with children (n = 24 058)
Yes	37.1	38.8	41.6	36.0
No	62.9	61.2	58.4	64.0
Region (n = 25 214)
Northeast	12.2	12.6	12.7	13.4
Midwest	28.6	28.1	30.6	29.0
South	35.6	36.4	28.5	32.7
West	23.4	22.5	28.2	24.8
Territory/FAS	0.2	0.4	0.1	0.2
Public health agency (N = 26 174)
State	49.5	50.5	45.3	53.4
Local	49.9	48.9	54.2	45.4
Tribal	0.4	0.4	0.3	1.0
Territorial	0.3	0.2	0.1	0.2
Education, degree (n = 23 941)
High school to associate’s degree	22.5	20.4	15.8	18.3
Bachelor’s degree	38.3	38.1	36.4	34.9
Master’s degree or higher	39.2	41.4	47.8	46.8
No. of years in public health (n = 25 084)
<1	13.2	18.1	5.9	11.2
1-4	26.1	28.0	23.1	25.5
5-9	19.4	18.8	24.7	22.8
10-14	12.8	11.3	16.0	13.3
≥15	28.4	23.9	30.3	27.4
Supervisor (n = 25 042)
Yes	31.8	29.5	42.4	31.7
No	68.2	70.5	57.6	68.3
Agency leadership position (n = 24 778)
Yes	7.1	4.6	9.8	5.8
No	92.9	95.4	90.2	94.2
Interaction with the public (n = 24 461)
A lot	45.6	51.5	48.4	47.3
Some	28.9	26.6	29.1	28.1
Little to none	25.6	21.9	22.5	24.5
COVID-19 response
Work, h/wk (n = 24 477)
≤40	40.8	35.6	24.7	33.6
41-60	46.8	46.5	55.5	48.5
>60	12.3	17.9	19.8	17.9
Time spent, % (n = 24 273)
0	7.4	5.5	4.3	6.3
1-25	21.2	15.4	15.8	19.2
26-50	14.1	11.5	12.6	13.3
51-75	13.5	13.1	13.7	13.0
>75	43.8	54.6	53.6	48.2

Abbreviations: AI/AN, American Indian/Alaska Native; EAP, employee assistance program; FAS, Freely Associated State; NH/PI, Native Hawaiian/Pacific Islander.

^aRespondents to each question are not mutually exclusive; 635 respondents provided written responses to ≥2 of the 3 questions analyzed.

^bPreviously reported via Bryant-Genevier et al. ⁸

Among respondents who provided written responses for any of the 3 questions analyzed (n = 4460), 43.6% reported anxiety symptoms, 45.1% depression symptoms, 50.5% PTSD symptoms, and 12.6% suicidal ideation (eTable 1 in Supplemental Material). Among respondents who provided written responses about why they were unable to take time off (n = 1395), 42.9% reported anxiety symptoms, 44.5% depression symptoms, 49.1% PTSD symptoms, and 13.5% suicidal ideation. Among respondents who wrote in responses describing why they did not use EAPs (n = 2618), 47.2% reported anxiety symptoms, 48.7% depression symptoms, 54.2% PTSD symptoms, and 12.6% suicidal ideation. Among respondents who provided written responses listing additional employer-offered resources of interest, 40.4% reported anxiety symptoms, 43.1% depression symptoms, 49.8% PTSD symptoms, and 13.0% suicidal ideation.

Time Off

Of 22 668 respondents, 79.1% (n = 17 920) reported having PTO for personal and family needs. Of the 8011 respondents who selected ≥1 reason why they were unable to take time off, 1395 selected “other” and provided a write-in response. Responses were 1-313 words long. Eight categories and 25 subcategories were established from the 1395 write-in responses (Table 2). The most common responses were financial concerns (24.4%, n = 341), fear of judgment or retaliation/frowned upon (20.8%, n = 290), and time-off restrictions (15.3%, n = 214). Interrater reliability was 68%.

Table 2.

Categories and subcategories derived from write-in responses (n = 1395) from a national survey of US public health workers (n = 26 174) describing why they were unable to take time off while responding to the COVID-19 pandemic, March 2020–April 2021

Qualitative category	No. (%) of qualitative responses citing a reason	Description of qualitative responses
Financial concerns	341 (24.4)	• No paid time off • Mention of financial hardship caused by taking time off • General mention of financial reasons
Fear of judgment or retaliation/frowned upon	290 (20.8)	• Concerns about supervisory approval • Fear of retaliation or threats of termination • Internal policy forbidding time off • Frowned upon by colleagues
Time-off restrictions	214 (15.3)	• Limited time off due to work status (eg, mention of being a contractor or new employee) • Exhausted medical leave because of previous medical issues • Family responsibilities (eg, maternity leave, sick children)
Coverage	153 (11.0)	• Lack of coverage due to leadership position or specialized skills • Mention of being short-staffed • Limits on number of employees allowed to take time off at same time
Insufficient separation from work	122 (8.7)	• Workload too great • Lack of boundaries and will still be contacted while off • Always on call
Other	109 (7.8)	• Mention of being a contractor without further context • Was able to take time off • Other reasons
Guilt	103 (7.4)	• Guilt due to fear of overburdening coworkers • Guilt due to the severity of the pandemic • Guilt for other or unspecified reasons
Unable to enjoy	101 (7.2)	• Unable to engage in normal activities, such as travel and spending time with friends and family • Unable to relax due to work-related stress • Cannot stop thinking about work • Not enough time to make a difference

The most frequently cited category among write-in responses, financial concerns, included 3 codes: no compensation for time off, uncompensated time off would lead to financial hardship, and mention of finances without further context. Some PHWs (15.3%, n = 214) were contractors and were paid hourly or did not have PTO. Seventy PHWs (5.0%) stated that taking unpaid time off would lead to financial hardship (eg, “If I take time off, no bills will be paid and I will be homeless”). Some PHWs (20.8%, n = 290) also mentioned fear of judgment for taking time off or that time off was frowned upon by the organization (eg, “Stigma around taking any time off. It is highly discouraged in my current division”). Nearly 1 in 10 (7.4%, n = 103 of 1395) respondents described feelings of guilt, either because of the general state of the pandemic or because of increasing the workload of colleagues who would need to cover for them (eg, “I felt like I would be letting my colleagues down; they would be working nonstop when I was resting”).

Employee Assistance Programs

Of 13 155 PHWs who selected ≥1 reason why they did not access an EAP, 51.4% (n = 6766) felt that they did not need it, 23.3% (n = 3064) did not think that it would help, 11.4% (n = 1504) reported concerns about the quality of the counseling, 10.4% (n = 1363) cited concerns about confidentiality, and 3.7% (n = 481) thought that the counselor would not be able to relate to their situation.

Seven categories and 20 subcategories were established from the 2618 write-in responses describing reasons why people did not access an EAP (Table 3). Responses were 1-146 words long. The most common reasons for not accessing an EAP were access difficulties (53.1%, n = 1390), using external counseling services (21.5%, n = 564), lack of awareness or motivation to initiate use of an EAP (11.3%, n = 297), and poor perception of EAP usefulness (7.7%, n = 202). Interrater reliability of responses to this question was 94%.

Table 3.

Categories and subcategories derived from write-in responses (n = 2618) from a national survey of US public health workers (n = 26 174) describing why they did not use EAPs while responding to the COVID-19 pandemic, March 2020–April 2021

Qualitative category	No. (%) of responses citing a reason	Description of qualitative responses
Difficulty accessing EAP	1390 (53.1)	• Difficult to access EAP • EAP available only through disciplinary actions or supervisor referral • Did not have a private location to speak • Did not have time • Financial reasons
Using external counseling services	564 (21.5)	• Established relationship with external counselor • Sought external counseling service
Lack of awareness or motivation to initiate use of EAP	297 (11.3)	• Unaware of or forgot about EAP benefit • Unmotivated or did not think to reach out
Poor perception of EAP usefulness	202 (7.7)	• Previous poor counseling experience or unfavorable of EAP • Do not need EAP or do not think it would help
Insufficient or unavailable	122 (4.7)	• Used EAP benefit for something else • EAP not available to employee or available in insufficient amounts • Not available in preferred format (eg, virtual or in-person)
Other	75 (2.9)	• Accessed EAP • Other reasons • Did not know why they did not access
Stigma or judgment concerns	45 (1.7)	• Fear of judgment or stigma from using EAP • Concerns about job security and documentation of use in employee records

Abbreviation: EAP, employee assistance program.

More than half of PHWs who wrote in responses (53.1%, n = 1390 of 2618) reported problems accessing the program offered by their employer. There were several codes within this category:

• The EAP is difficult to access (eg, “Difficult to get appointments or providers are not accepting new patients, even if they are through the EAP”).

• The EAP is available only through disciplinary action or supervisory approval (eg, “EAP can only be accessed if referred by a supervisor for poor work performance or behavioral issues affecting your job”).

• The respondent did not have a private location to speak (eg, “I live in an apartment with my family and would have nowhere to take the calls and have full privacy”).

• The respondent did not have time (eg, “Did not feel I could take the time away from work to take advantage of this benefit”).

• The EAP was inaccessible for financial reasons (eg, “After two sessions, you have to pay and [I] can’t afford counseling”).

Employer-Offered Resources

Of 21 354 PHWs who answered the multiple-selection question, “What employer-offered resources would you access if available?” the most frequently selected resources included planned/scheduled leave (78.4%, n = 16 749), free food for staff (57.0%, n = 12 168), self-care retreat (50.9%, n = 10 872), and virtual or in-person yoga or meditation (46.6%, n = 9942). The write-in responses of the 1151 PHWs who described additional resources of interest were 1-421 words long (Table 4). Interrater reliability of responses to this question was 85%.

Table 4.

Categories and subcategories derived from write-in responses (n = 1151) from a national survey of US public health workers (n = 26 174) describing additional resources that they would access if offered by their employers, March–April 2021

Qualitative category	No. (%) of responses citing a reason	Description of qualitative responses
Compensation and time off	331 (28.8)	• Bonus • Additional paid time off • Mandatory time off • Extended time away/sabbatical • Mental health days
Other	284 (24.7)	• Childcare provided or paid for by employer • Food provided • Benefits offered • Bring pet to work/animals in office/animal therapy • Job security • Anything offered by employer
Scheduling flexibilities	231 (20.1)	• Ability to work from home • Time in workday allotted for self-care • Scheduling accommodations or flexibility
Organizational changes	184 (16.0)	• Reduced work week or workload • Leadership changes • Internal discussions and debriefs • Acknowledgment of a good job • Additional staff
Health and wellness services	111 (9.6)	• Free or reduced gym membership • On-site gym access • Massage
Mental health	109 (9.5)	• Mental health support or counseling • Webinars, classes, or retreats • Race-based trauma support
Not interested or unknown	49 (4.3)	• Not interested in employer-offered resources • Nothing beyond what is offered • Unknown
Gatherings and social events	44 (3.8)	• In-person gatherings with colleagues • Virtual gatherings with colleagues • Bible study, prayer group, or other religious gatherings

Write-in responses to the question about desired employer-offered resources were wide-ranging; many respondents listed multiple items in a single response. Nearly one-third (28.8%, n = 331) mentioned wanting compensation and time off, including bonuses, additional PTO, mandatory time off, extended time-away options such as sabbaticals, and mental health days. The second-largest category was other (24.7%, n = 284), which included many codes, such as childcare, food, animal therapy, and more. Some respondents (20.1%, n = 231) expressed the desire to have some or additional telework flexibilities and flexible scheduling. About 1 in 6 (n = 184, 16.0%) reported desiring organizational change from their employers, such as internal discussions, additional staff, or acknowledgment of a good job. Responses sometimes conflicted: while some respondents explicitly stated that they were interested only in attending in-person gatherings, others indicated that they would attend only virtual gatherings.

Discussion

In a nationwide survey of 26 174 PHWs, financial concerns, a lack of time (eg, limited time off due to work status, did not have time), and fear of stigma and judgment were key reasons why respondents did not take time off or use EAPs. Low salaries, high workloads, and burnout have been identified as major drivers of staff turnover in public health agencies, ²² and we also observed these themes in our analysis. These findings contextualize the lack of utilization of benefits and supportive services among a sample of PHWs in which more than half reported recently experiencing symptoms of at least 1 mental health condition. ⁸

Previously reported data from the same survey provide additional context. Among 22 093 PHWs, 38.9% (n = 8586) reported being unable to take time off when needed (eTable 2 in Supplemental Material). ⁸ Of the 8586 employees who reported being unable to take time off, 64.4% felt that they would fall even more behind, 60.6% thought that no one would be able to cover their job duties, 59.5% reported feeling guilty, and 18.2% stated that their employer did not allow them to take time off. ⁸ Among those who provided written responses to this question, which are described in the present analysis, many PHWs emphasized the inability to take time away from work because of a lack of coverage. This challenge can be addressed by improving staffing and by paying careful attention to organizational structures in emergency responses, including planning for redundancies in key areas to allow for time off. These findings also highlight the need for employers to emphasize the acceptability of using PTO. Many respondents also reported being recently hired and having little or no time off because of restrictions for new employees or because PTO was not included in their compensation package. More than 1 in 5 respondents (20.9%) did not have PTO. To reduce mental health symptoms, burnout, and turnover among new hires, public health employers may consider extending benefits such as PTO and EAP to all workers, including contractors, regardless of time served.

Perceived inadequate compensation among PHWs likely contributes to financial challenges, stress, and associated mental health symptoms. Another analysis of the present survey found that PTSD symptoms were nearly twice as high among PHWs who felt inadequately compensated for work (prevalence ratio = 1.85; 95% CI, 1.78-1.93) as compared with those who felt that they received adequate compensation. ⁸ PHWs with a master’s degree in public health have a median graduate loan debt >$50 000 and a median starting annual salary of $50 000–$70 000. ²³ Student loan debt is associated with negative psychological well-being and decreased life satisfaction, ²⁴ and debt has been linked to stress and depression. ²⁵ Increasing compensation or offering financial assistance (eg, student loan repayments) may help ease some of the mental health symptoms reported by PHWs. These benefits may also attract more candidates to the field and fill workforce gaps. ²⁶ Improved compensation may help protect against some of the negative mental health outcomes associated with feeling inadequately compensated and having financial challenges.

Many respondents desired acknowledgment and expressions of gratitude; PTSD symptoms were nearly twice as high among survey respondents who felt unappreciated at work (prevalence ratio = 1.82; 95% CI, 1.76-1.90) as among those who did not feel unappreciated at work. ⁸ A positive organizational climate is associated with lower levels of burnout, depression, and anxiety among health care workers, ²⁷ a population similar to and often overlapping with PHWs. Public health leaders can help improve organizational climate and culture by modeling healthy behaviors. Employers may consider scheduling organization-wide self-care breaks, mandatory blocks of time during the workday during which no meetings are held, and mandatory days off across the organization. Some of these strategies can be implemented at little to no cost for employers and may help boost morale and improve performance.

Factors associated with increased utilization of EAPs include written policies describing how an organization’s EAP works, adequate EAP staffing levels, and supervisory training. ²⁸ Among nearly 23 000 PHWs who answered a question about EAP availability, almost one-third did not know whether an EAP was offered by their employer/workplace. ⁸ Of 14 902 PHWs, 11.7% reported using an EAP during the pandemic (eTable 2 in Supplemental Material). ⁸ Many participants wrote in responses describing a lack of knowledge about EAPs or how to access them, suggesting that changes to the ways that information about EAPs is distributed may increase uptake. Additionally, if organizations explain how EAPs ensure confidentiality, employees may be more inclined to use the benefit. Among respondents of the present survey, those whose organizations offered an EAP were less likely than those whose organizations did not offer an EAP to report symptoms of anxiety, underscoring the value of such an offering. ⁹ A study conducted during the COVID-19 pandemic among hospital workers in Shanghai, China, found positive changes in participants’ reported mental health after accessing an EAP, underscoring the potential of these programs. ²⁹ A robust evaluation of an agency’s EAP to assess accessibility, quality of service, and confidentiality can help public health organizations improve the uptake of services offered.

Because responses varied widely, to best serve employees and ensure that their needs are being met, employers should consider routinely conducting organizational climate surveys, such as the National Institute for Occupational Safety and Health’s WellBQ. ³⁰ To best understand how the implementation of various policies and programs impact employees, employers may consider conducting pre- and postimplementation evaluation activities.

The chronic underfunding of public health in the United States likely contributes to the discontent and associated mental health symptoms experienced by PHWs who responded to the present survey. ³¹ This underfunding, exacerbated by the pandemic, has led to staffing challenges, relatively low salaries, and limitations on the benefits that employers are able to offer. ³² Strategies to strengthen the public health workforce could include initiatives to support the mental health and well-being of PHWs and improve the pay and benefits of employees in a manner that prioritizes equity.

Limitations

This analysis had several limitations. First, many write-in responses were lengthy, resulting in low initial agreement among coders. Although the reviewers listed up to 2 codes for the questions about time off and EAPs and 5 codes for the question about resources, some responses may have included information for more than the number of codes used. In those cases, reviewers selected codes for the primary and secondary factors mentioned, which may have led to exclusion of data in some cases. Second, when issuing a tie-breaking code decision, the third reviewer was not blinded and may have been influenced by seeing the codes entered by the first 2 reviewers. Still, the number of responses available allowed for a robust qualitative analysis that can inform organizational policies and change. Third, only 4.4% to 10.0% of all respondents wrote in responses, and these findings might not fully reflect the needs of all 26 174 PHWs who participated in the survey. Fourth, PHWs who wrote in responses to ≥1 question reported a higher prevalence of anxiety, depression, PTSD, and suicidal ideation (ranging from 4.2% to 13.7% higher) when compared with the overall survey population (previously published), ⁸ which suggests that respondents who provided qualitative responses might not be representative of the entire survey population. Finally, these results are not representative of all PHWs, because convenience sampling was used and federal PHWs were not included in the survey.

Conclusion

Safeguarding the mental health of the public health workforce is key to maintaining the nation’s public health infrastructure. Our findings highlight opportunities for employers to improve the delivery of benefits that may improve PHWs’ mental and physical health. Decreasing burnout and improving the mental health of PHWs are important strategies for increasing workforce resilience and performance as public health emergencies continue to arise.