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Much has been written about the burnout of frontline health workers during the COVID pandemic and what must be done to help them. But what about public health workers -- those operating behind the scenes who are also navigating long hours and increased stress?

Helping those workers is the idea behind the Public Health-Hope, Equity, Resilience, and Opportunity developed by the Association of State and Territorial Health Officials (ASTHO). "It came about in the middle of the pandemic -- the late 2020-into-2021 timeframe," said Lindsey Myers, MPH, ASTHO's vice president of public health workforce and infrastructure, in a phone interview.

"A lot of resources come out talking about the healthcare workforce, and HRSA [the Health Resources and Services Administration] released a grant opportunity to provide support for healthcare providers and address their well-being and the injuries they experienced," she noted. However, "it was striking to us at ASTHO that there wasn't any mention of public health."

Although public health workers weren't on the front lines at hospitals, they were doing disease investigations and other important work. "We were seeing great levels of burnout and stress, and health officials were talking about what their staffs were going through," Myers said. "It was an opportunity to do something specific for the public health workforce and provide specialized content and support for them, and acknowledge the role they played in the pandemic."

ASTHO worked with CDC and was awarded a $2.5 million grant to get the program started; it provides onsite workshops and online training materials designed to improve working conditions at state public health departments and promote a more caring workplace culture. That initial funding was spent over 2 years and is now gone, but ASTHO is continuing the program using other grant funding from CDC.

Idaho was one of five pilot sites -- along with Connecticut, Washington, New Mexico, and South Carolina -- for PH-HERO. Even though state public health department staff members weren't at local agencies where there were more physical threats occurring, "there was still the ripple effect within the public health community," said Elke Shaw-Tulloch, MHS, Idaho's public health administrator.

For those that had to come into the office during the height of the pandemic, rather than working at home, "there is the guilt of abandoning your children, just the family stresses," she said. "You're working ungodly hours without any acknowledgement of the level of effort you're putting in. And feeling that nobody knew the answers ... We're good people trying to do good work and working with the information we have, and people are not believing it. And that was incredibly impactful."

The department really benefitted from the guidance that the program provided, said Shaw-Tulloch. "We're listening to what our staff are saying are the issues, and building things into our day-to-day work -- for example, making meetings 45 minutes long instead of an hour, so [not] back to back," she said in a phone interview. "There's a big push from staff on wanting to learn additional skills, so we're trying to identify training about grant-writing and developing budgets," things that the staff has to do on the job but would rather not have to learn while they're doing them.

Meetings are one area that can really benefit from improvement, Shaw-Tulloch said. "There's the concept of 'meeting hygiene' -- what's the purpose, what's the agenda? If you don't need it, don't have it. If you can do a walking meeting if you're working in person, do that."

Another meeting-related tool that the PH-HERO training provided was an assessment of the staff's well-being at the start of the meeting, which is done by having meeting participants look at photos of dogs showing various expressions and picking one that matches how they're feeling.

Connecticut also has benefitted from the program, said Manisha Juthani, MD, the state's public health commissioner. "I came into the department in September 2021 and soon after I came in, we had the Omicron wave. The department was ready and prepared to address the emergency, but we also saw anxiety and flashbacks from what they'd been through."

After Omicron ebbed, "a [staff] survey demonstrated that 47% had at least one symptom of PTSD and 17% met all criteria for it ... That really solidified it for me," she added, noting that the department then decided to participate in PH-HERO.

The PTSD symptoms came about, Juthani said, because "people were working 18-hour days and dealing with the pressure of performance -- getting reports out, producing data," as well as pivoting from setting up mass testing sites to distributing self-test kits.

"They were feeling like no matter how hard they worked, it was never enough, and there was never time for a break, and even if they were told to take a break, they were going to come back to a million emails," she said.

Contractors from the ASTHO program came out and helped the department figure out what needed changing. "We recognized that what we needed to build on was a 'culture of CARE -- Communications, Assistance, Respect, and Empathy,'" she noted. "It was really encapsulating all the core principles of PH-HERO into the work we do going forward."

Examples include making new employees feel seen and welcomed by putting their photos in the employee newsletter, allowing time for breaks between meetings, and acknowledging all religious holidays -- not just those of majority religions.

What makes the training different, said ASTHO's Myers, "is that it focuses on public health specifically, and stresses organization-level policy and practice changes [more than] individual strategies. You can't yoga your way out of this."

The program has gotten such good feedback that it's being expanded, she added. "We will be announcing an opportunity for eight additional pilot sites to come on board in early July ... We plan a kickoff in November."

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