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Workplace Violence and the Mental Health of Public Health Workers During COVID-19

Published:November 13, 2022DOI:https://doi.org/10.1016/j.amepre.2022.10.004

      Introduction

      During the COVID-19 pandemic, public health workers were at an increased risk for violence and harassment due to their public health work and experienced adverse mental health conditions. This article quantifies the prevalence of job-related threats, harassment, and discrimination against public health workers and measures the association of these incidents with mental health symptoms during the COVID-19 pandemic.

      Methods

      A nonprobability convenience sample of state, local, and tribal public health workers completed a self-administered, online survey in April 2021. The survey link was emailed to members of national public health associations and included questions on workplace violence, demographics, workplace factors, and mental health symptoms. Mental health symptoms were measured using standardized, validated tools to assess depression, anxiety, post-traumatic stress disorder, and suicidal ideation. Multivariable Poisson models calculated adjusted prevalence ratios of mental health symptoms, with workplace violence as the primary risk factor. Analyses were conducted in 2021–2022.

      Results

      Experiencing any type or combination of workplace violence was significantly associated with an increased likelihood of reporting depression symptoms (prevalence ratio=1.21, 95% CI=1.15, 1.27), anxiety (prevalence ratio=1.21, 95% CI=1.15, 1.27), post-traumatic stress disorder (prevalence ratio=1.31, 95% CI=1.25, 1.37), and suicidal ideation (prevalence ratio=1.26, 95% CI=1.14, 1.38), after adjusting for confounders. A dose‒response relationship was found between the number of workplace violence events experienced by a public health worker and the likelihood of reporting mental health symptoms.

      Conclusions

      Violence targeted at the public health workforce is detrimental to workers and their communities. Ongoing training, workplace support, and increased communication after a workplace violence incident may be helpful. Efforts to strengthen public health capacities and support the public health workforce are also needed.

      INTRODUCTION

      Coronavirus disease 2019 (COVID-19) had an unprecedented impact on U.S. employees. Regardless of occupation, most U.S. workers faced and continue to face extraordinary stress and uncertainty. One study found that 70% of U.S. workers felt more stressed at work during COVID-19 than at any other point in their professional careers. Public health workers (PHWs) served on the front lines of the pandemic, yet they have been relatively understudied during this event. In 2021, to assess the impact of the pandemic on symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation (SI), the Centers for Disease Control and Prevention (CDC) initiated an online survey of PHWs in all the 50 state, tribal, local, and territorial health departments and found that half of the respondents reported symptoms of at least 1 mental health condition during the pandemic.
      • Bryant-Genevier J
      • Rao CY
      • Lopes-Cardozo B
      Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic - United States, March–April 2021.
      In addition to workplace and personal challenges faced by PHWs during the pandemic, numerous media reports described PHWs facing unparalleled hostility, harassment, and threats.
      • Weber L
      • Barry-Jester AM
      • Smith MR
      Associated Press
      Public health officials face wave of threats, pressure amid coronavirus response.
      • Rizzo S.
      Local health official report threats, vandalism and harassment during the pandemic, study finds.
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      Associated Press
      Pandemic backlash jeopardized public health powers, leaders.
      • Ward JA
      • Stone EM
      • Mui P
      • Resnick B.
      Pandemic-related workplace violence and its impact on public health officials, March 2020–January 2021.
      A recent study found that 21% of surveyed U.S. adults believe that threatening PHWs during the COVID-19 pandemic was justified owing to business closures.
      • Topazian RJ
      • McGinty EE
      • Han H
      • et al.
      US adults’ beliefs about harassing or threatening public health officials during the COVID-19 pandemic.
      This was an increase from the previous study cycle, and increases were most apparent among those with more education and those most trusting of science. These violent incidents may have played a role in the burnout and subsequent resignation of many public health (PH) officials during the pandemic.
      • Smith MR
      • Weber L
      Associated Press
      Public health official are quitting or getting fired in throes of pandemic.
      Although the spectrum of workplace violence (WPV) can range from exposure to offensive language to homicide, nonphysical forms of WPV such as bullying, verbal abuse, and threats are most common and have greater negative impacts on the worker.

      Violence in the workplace. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. www.cdc.gov/niosh/docs/96-100/default.html. Updated June 6, 2014. Accessed August 3, 2022.

      • Liu J
      • Gan Y
      • Jiang H
      Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis.
      • Gerberich SG
      • Church TR
      • McGovern PM
      • et al.
      An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study.
      • Konda S
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      • Grubb PL.
      Nonphysical workplace violence in a state-based cohort of education workers.
      • Di Martino V.
      Relationship Between Work Stress and Workplace Violence in the Health Sector.
      These adverse effects could include increased fear, job-related stress, anxiety, depression, and fatigue.
      • Liu J
      • Gan Y
      • Jiang H
      Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis.
      • Gerberich SG
      • Church TR
      • McGovern PM
      • et al.
      An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study.
      • Konda S
      • Tiesman HM
      • Hendricks S
      • Grubb PL.
      Nonphysical workplace violence in a state-based cohort of education workers.
      • Di Martino V.
      Relationship Between Work Stress and Workplace Violence in the Health Sector.
      The impact of WPV directed at PHWs during the COVID-19 pandemic has not been fully investigated. More recently, concerns about the well-being of the PH workforce and their ability to confront future PH crises have been raised.
      • Topazian RJ
      • McGinty EE
      • Han H
      • et al.
      US adults’ beliefs about harassing or threatening public health officials during the COVID-19 pandemic.
      ,
      • Baker M
      • Threats ID.
      resignations and 100 new laws: why public health is in crisis.
      This study utilized data collected in the 2021 CDC survey to describe the prevalence of nonphysical WPV directed at state, tribal, local, and territorial PHWs. The association between nonphysical WPV and symptoms of depression, PTSD, anxiety, and SI was also explored.

      METHODS

      Study Population

      A cross-sectional design and nonprobability-based convenience sample of U.S. state and local PHWs in all the 50 U.S. states, the District of Columbia, Tribal Nations, and U.S. territories were employed in 2021.
      Membership associations that participated were the Association of Public Health Laboratories, the Association of State and Territorial Health Officials, the Council of State and Territorial Epidemiologists, and the National Association of County and City Health Officials.
      A link to an anonymous, online survey was distributed to a representative at each of the 4 national PH organizations that agreed to participate and represented the target audience. These representatives distributed the survey link to members of their organizations through e-mail. Members of these organizations in leadership roles circulated the link to employees in their respective PH departments. All persons who worked at a state, tribal, local, or territorial health department for any time in 2020 were eligible to participate. The survey link was open between March 29, 2021 and April 16, 2021. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.
      45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44:3501 et seq

      Measures

      The survey included questions on sociodemographics, work variables, and stressful experiences and was pilot tested by state, local, and federal PHWs. Questions were constrained within specific timeframes; for example, respondents reported on WPV since COVID-19 was declared a pandemic in March 2020.
      • Bryant-Genevier J
      • Rao CY
      • Lopes-Cardozo B
      Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic - United States, March–April 2021.
      Respondents also self-reported symptoms of anxiety, depression, and SI for the previous 2 weeks.
      • Bryant-Genevier J
      • Rao CY
      • Lopes-Cardozo B
      Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic - United States, March–April 2021.
      Respondents used prespecified response options developed using the National Association of County and City Health Officials job categories (NACCHO).
      National Association of County and City Health Officials
      NACCHO. 2019 National Profile of Local Health Departments.
      All job titles were coded to 2010 Standard Occupational Classification system codes using the NIOSH Industry and Occupation Computerized Coding System.

      Standard occupational classification. U.S. Bureau of Labor Statistics. https://www.bls.gov/soc/?msclkid=9055efcdcf9711eca932dd78a410a05f. Accessed November 28, 2017.

      ,
      Welcome to the NIOSH industry and occupation coding system (NIOCCS)
      CDC - NIOSH Industry and Occupation Computerized Coding System (NIOCCS).
      Detailed Standard Occupational Classification codes were collapsed into major occupation groups, excluding healthcare practitioners and support workers who were categorized separately.

      Standard occupational classification. U.S. Bureau of Labor Statistics. https://www.bls.gov/soc/?msclkid=9055efcdcf9711eca932dd78a410a05f. Accessed November 28, 2017.

      WPV questions were developed by the research team and included 3 yes/no questions: Experienced stigma or discrimination due to your work; Received job-related threats due to your work; and Felt bullied, threatened and/or harassed due to your work. This definition excludes physical WPV such as kicking, beating, and hitting but includes stigma and/or discrimination. These nonphysical WPV events will be collectively referred to as WPV.
      Mental health symptoms were measured using standardized tools. The 9-item Patient Health Questionnaire measured depression symptoms.
      • Kroenke K
      • Spitzer RL
      • Williams JB.
      The PHQ-9: validity of a brief depression severity measure.
      Each question was scored from 0 to 3, with a final score range of 0–27. Respondents were considered symptomatic for moderate-to-severe depression if they scored ≥10.
      • Kroenke K
      • Spitzer RL
      • Williams JB.
      The PHQ-9: validity of a brief depression severity measure.
      A single 9-item Patient Health Questionnaire question measured SI (How many days have you thought that you would be better off dead or thought of hurting yourself?). Any positive response indicated SI in the previous 2 weeks. Anxiety was measured using the 2-item Generalized Anxiety Disorder scale.
      • Sapra A
      • Bhandari P
      • Sharma S
      • Chanpura T
      • Lopp L.
      Using generalized anxiety Disorder-2 (GAD-2) and GAD-7 in a primary care setting.
      Each 2-item Generalized Anxiety Disorder item was scored from 0 to 3, for a total score of 0–6. Respondents were considered symptomatic if they scored ≥3.
      • Sapra A
      • Bhandari P
      • Sharma S
      • Chanpura T
      • Lopp L.
      Using generalized anxiety Disorder-2 (GAD-2) and GAD-7 in a primary care setting.
      PTSD was measured using the 6-item Impact of Events Scale.
      • Hosey MM
      • Leoutsakos JS
      • Li X
      • et al.
      Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6) [published correction appears in Crit Care. 2020;24(1):37].
      The 6-item Impact of Events Scale questions were scored from 0 to 4, with a mean score range of 0–4. Respondents were considered symptomatic for PTSD if their mean score was ≥1.75.
      • Hosey MM
      • Leoutsakos JS
      • Li X
      • et al.
      Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6) [published correction appears in Crit Care. 2020;24(1):37].
      Questions on job stress and work support were developed for the study by the research team.

      Statistical Analysis

      Descriptive statistics were calculated for the sample demographics and work characteristics across the 3 WPV questions. WPV was categorized into a dichotomous experienced any type of WPV or a combination of WPV variables. To determine the strength and significance of the association between WPV and variables of interest, prevalence ratios (PRs) and 95% CIs were estimated using Poisson regression with a robust SE.
      Multiple imputation was performed to address missing data on the multivariable analysis using 25 imputed data sets. The imputation data set included the 4 mental health outcomes, 3 WPV variables, and other covariates of interest. Multiple imputation was performed using the fully conditional method discriminant function with the class effects option (Version 9.4, SAS Institute Inc, Cary, NC). Ordinal variables were treated as continuous for the imputation and rounded back to the original ordinal scale.
      A factor analysis was used to create construct scales to combine highly correlated variables. These construct scales were used as explanatory variables in the Poisson regression. A Spearman rho correlation matrix of all binary and ordinal variables was used as the basis for the factor analysis. Scales were created of related variables, which loaded on specific factors. Orthomax rotation with equal weights was used to distinguish the loadings for each factor beyond the original principal component results.
      Separate multivariable Poisson models were constructed to calculate the adjusted PRs of the WPV variable for each of the 4 mental health outcomes. For modeling, WPV was defined as experiencing any 1 of the WPV responses versus not experiencing any of the WPV responses. The total number of WPV outcomes that a respondent checked yes was also used for modeling. State of residence was included as the cluster effect employing generalized estimating equations adjustments with an exchangeable working correlation matrix, which assumes that respondents within a state are correlated. All variables were first included in the model, with only the dichotomous WPV variable. If the included variable was not significant (p>0.1) and did not change the PR for WPV by >10%, it was excluded from further consideration. All variables not excluded were fit together in a full model. Variables not significant in the full model and did not change the PR for WPV by >10% were then removed to create a final model. Years of working in PH were used as surrogates to age because of missing data. Analyses were conducted in 2021–2022.

      RESULTS

      In total, 26,174 PHWs responded to the survey. Table 1 shows the work characteristic and sociodemographics by WPV using the unimputed data. Overall, 26% of respondents experienced stigma due to their PH work (n=5,962), 12% received job-related threats (n=2,688), and 24% were bullied or harassed (n=5,350). A total of 32% experienced at least 1 form or combination of forms of WPV (n=8,244). The occupations most likely to report WPV were management (n=1,396; 46%), art/design/entertainment/sport/recreation (n=247; 44%), and nursing (n=1,416; 41%). Nearly all the job titles under the arts/design/entertainments/sports/recreation category were public relations specialists (97%). As the number of hours worked per week increased, so did the likelihood that the PHW experienced WPV (<20 hours=16%, 20–40 hours=25%, 41–60 hours=41%, 61–75 hours=52%, >75 hours=61%). This same trend was seen for the degree of public interaction (little interaction=22%, some=31%, a lot=46%).
      Table 1Work Characteristics and Sociodemographics of Public Health Workers by Workplace Violence, March 2021–April 2021, U.S.
      VariablesExperienced stigmaReceived job threatsWas bullied or harassedAny type or combination of workplace violence
      n (%)PR (95% CI)n (%)PR (95% CI)n (%)PR (95% CI)n (%)PR (95% CI)Total
      Totals do not sum to the total number of survey respondents owing to nonresponse for each variable.
      Occupation
       Art, design, entertainment, Sports, recreation156 (28)ref117 (21)ref185 (33)ref247 (44)ref615 (3)
       Business and financial operations158 (19)0.71 (0.57, 0.88)62 (8)0.37 (0.27, 0.50)120 (15)0.45 (0.36, 0.57)200 (25)0.57 (0.47, 0.68)910 (4)
       Community and social service1,211 (25)0.90 (0.76, 1.1)487 (10)0.48 (0.39, 0.59)1,115 (23)0.69 (0.59, 0.81)1,707 (35)0.80 (0.70, 0.92)5,410 (22)
       Computer and mathematical74 (16)0.57 (0.43, 0.75)18 (3.8)0.19 (0.11, 0.30)58 (12)0.37 (0.28, 0.51)104 (22)0.51 (0.40, 0.64)525 (2)
       Life, physical, and social science1,143 (28)1.0 (0.86, 1.19)576 (14)0.68 (0.56, 0.83)1,081 (26)0.80 (0.69, 0.94)1,586 (39)0.89 (0.78, 1.02)4,493 (18)
       Management1,036 (34)1.23 (1.04, 1.46)586 (19)0.93 (0.76, 1.14)993 (32)0.99 (0.85, 1.16)1,396 (46)1.05 (0.92, 1.20)3,281 (13)
       Office and administrative support524 (19)0.71 (0.59, 0.84)213 (8)0.38 (0.31, 0.48)472 (17)0.53 (0.45, 0.63)748 (28)0.64 (0.55, 0.74)3,096 (13)
      Health practitioner
       Health practitioner, doctor36 (22)0.78 (0.55, 1.13)30 (18)0.87 (0.58, 1.29)47 (28)0.86 (0.63, 1.18)63 (38)0.86 (0.66, 1.14)184 (<1)
       Health practitioner, nurse1,110 (32)1.16 (0.98, 1.37)454 (13)0.63 (0.51, 0.77)946 (27)0.83 (0.71, 0.97)1,416 (41)0.93 (0.82, 1.07)3,748 (15)
       Health practitioner, other366 (19)0.70 (0.58, 0.85)96 (5)0.25 (0.19, 0.32)244 (13)0.39 (0.33, 0.48)477 (25)0.58 (0.50, 0.68)2,073 (15)
       Other30 (17)0.63 (0.43, 0.94)15 (9)0.43 (0.25, 0.73)20 (12)0.36 (0.23, 0.57)38 (22)0.52 (0.37, 0.73)198 (<1)
      Supervisor2,259 (31)1.29 (1.23, 1.36)1,227 (17)1.78 (1.65, 1.92)2,109 (29)1.37 (1.30, 1.45)3,082 (42)1.29 (1.23, 1.35)7,957 (32)
      Years of public health experience
       <1 year603 (21)ref237 (8)ref534 (18)ref880 (30)ref3,316 (13)
       1–4 years1,628 (27)1.32 (1.20, 1.45)729 (12)1.50 (1.30, 1.73)1,460 (24)1.34 (1.21, 1.48)2,260 (38)1.26 (1.16, 1.36)6,559 (26)
       5–9 years1,311 (29)1.42 (1.29, 1.56)597 (13)1.65 (1.41, 1.91)1,183 (27)1.45 (1.31, 1.60)1,750 (39)1.30 (1.20, 1.41)4,868 (19)
       10–14 years815 (28)1.34 (1.20, 1.48)389 (13)1.62 (1.38, 1.90)735 (25)1.36 (1.21, 1.52)1,078 (37)1.21 (1.11, 1.32)3,216 (13)
       ≥15 years1,585 (24)1.17 (1.07, 1.29)744 (11)1.40 (1.21, 1.62)1,452 (22)1.21 (1.10, 1.34)2,151 (33)1.09 (1.01, 1.18)7,125 (28)
      Interaction with public
       A lot of interaction3,514 (34)2.06 (1.91, 2.22)1,878 (18)4.05 (3.56, 4.62)3,440 (33)2.79 (2.57, 3.03)4,826 (46)2.12 (1.99, 2.26)11,143 (46)
       Some interaction1,476 (23)1.38 (1.27, 1.50)553 (8)1.90 (1.64, 2.20)1,228 (19)1.59 (1.45, 1.74)2,017 (31)1.42 (1.32, 1.52)7,061 (29)
       Little to no interaction952 (16)ref259 (4)ref688 (12)ref1,272 (22)ref6,257 (26)
      Hours worked
       <20 hours/week35 (10)ref10 (3)ref31 (9)ref58 (16)ref385 (2)
       20–40 hours/week1,575 (18)1.81 (1.30, 2.54)555 (6)2.24 (1.20, 4.19)1,307 (15)1.70 (1.19, 2.43)2,182 (25)1.52 (1.17, 1.98)9,608 (39)
       41–60 hours/week3,198 (30)3.04 (2.18, 4.24)1,382 (13)4.6 (2.48, 8.59)2,847 (26)3.06 (2.15, 4.36)4,333 (41)2.49 (1.92, 3.22)11,466 (47)
       61–75 hours/week803 (38)3.85 (2.74, 5.40)495 (23)8.36 (4.47, 15.64)831 (39)4.51 (3.15, 6.46)1,098 (52)3.18 (2.44, 4.14)2,232 (9)
       >75 hours/week339 (46)4.69 (3.31, 6.64)249 (34)12.16 (6.46, 22.88)346 (47)5.44 (3.76, 7.85)450 (61)3.77 (2.87, 5.0)786 (3)
      Time spent on COVID-19 response
       0%188 (11)ref54 (3)ref129 (8)ref250 (15)ref1,787 (7)
       1%–25%802 (17)1.47 (1.25, 1.72)237 (5)1.51 (1.13, 2.03)577 (12)1.54 (1.27, 1.86)1,083 (23)1.49 (1.30, 1.71)5,151 (21)
       26%–50%762 (24)2.07 (1.77, 2.43)258 (8)2.46 (1.84, 3.30)586 (18)2.34 (1.93, 2.83)1,008 (32)2.06 (1.80, 2.37)3,432 (14)
       51%–75%873 (28)2.48 (2.11, 2.90)379 (12)3.76 (2.83, 5.00)808 (26)3.35 (2.78, 4.03)1,197 (39)2.55 (2.23, 2.92)3,283 (14)
       ≥75%3,308 (33)2.89 (2.49, 3.34)1,760 (18)5.37 (4.09, 7.03)3,250 (32)4.14 (3.47, 4.94)4,562 (46)3.0 (2.63, 3.39)10,620 (44)
      Type of public health agency
       State2,472 (22)ref937 (8)ref2,133 (19)ref3,377 (30)ref12,951 (49)
       Local3,451 (30)1.34 (1.28, 1.42)1,744 (15)1.80 (1.66, 1.95)3,216 (28)1.46 (1.38, 1.54)4,715 (41)1.35 (1.29, 1.41)13,051 (50)
       Tribal/territorial39 (28)1.28 (0.93, 1.75)18 (13)1.56 (0.98, 2.49)27 (20)1.03 (0.71, 1.51)48 (35)1.16 (0.87, 1.55)172 (<1)
      Sex
       Female4,991 (27)ref2,102 (11)ref4,436 (24)ref6,744 (36)ref19,872 (83)
       Male797 (22)0.80 (0.75, 1.87)520 (14)1.25 (1.14, 1.38)786 (21)0.90 (0.83, 0.97)1,178 (32)0.88 (0.83, 0.94)3,904 (16)
       Nonbinary54 (39)1.44 (1.1, 1.88)18 (13)1.15 (0.73, 1.84)40 (29)1.21 (0.88, 1.65)64 (46)1.27 (0.99, 1.62)141 (<1)
      Race/ethnicity
       Hispanic435 (24)0.89 (0.81, 0.98)181 (10)0.79 (0.68, 0.92)332 (18)0.72 (0.65, 0.81)555 (31)0.82 (0.75, 0.89)1,974 (8)
       AI/AN, NH48 (32)1.2 (0.91, 1.59)29 (19)1.53 (1.06, 2.21)40 (27)1.06 (0.77, 1.44)58 (39)1.04 (0.80, 1.34)156 (<1)
       Asian, NH184 (20)0.74 (0.64, 0.85)82 (9)0.70 (0.56, 0.87)164 (18)0.69 (0.59, 0.81)256 (28)0.74 (0.65, 0.84)1,009 (4)
       Black, NH394 (20)0.74 (0.67, 0.83)121 (6)0.49 (0.41, 0.59)262 (13)0.52 (0.46, 0.59)479 (25)0.66 (0.60, 0.72)2,177 (9)
       NH/PI, NH16 (18)0.68 (0.42, 1.11)5 (6)0.44 (0.18, 1.07)13 (15)0.58 (0.33, 0.99)20 (23)0.61 (0.39, 0.94)96 (<1)
       White, NH4,414 (27)ref2,083 (13)ref4,191 (25)ref6,197 (38)ref17,218 (74)
       Multiple races, NH170 (29)1.07 (0.92, 1.24)72 (12)0.96 (0.76, 1.22)139 (24)0.92 (0.78, 1.09)220 (37)0.99 (0.87, 1.14)614 (2)
      Age group (years)
       <29934 (28)ref412 (12)ref893 (27)ref1,339 (40)ref3,525 (16)
       30–391,570 (30)1.11 (1.03, 1.19)737 (14)1.15 (1.02, 1.30)1,357 (26)0.98 (0.90, 1.06)2,111 (41)1.01 (0.94, 1.08)5,461 (25)
       40–491,424 (29)1.08 (1.00, 1.16)645 (13)1.07 (0.95, 1.21)1,216 (25)0.93 (0.86, 1.02)1,857 (38)0.95 (0.89, 1.02)5,102 (23)
       50–591,071 (23)0.83 (0.77, 0.90)501 (11)0.86 (0.75, 0.98)1,021 (22)0.81 (0.74, 0.88)1,499 (32)0.79 (0.73, 0.85)4,925 (23)
       ≥60406 (15)0.55 (0.49, 0.61)187 (7)0.55 (0.46, 0.66)417 (15)0.57 (0.51, 0.64)633 (23)0.58 (0.52, 0.63)2,830 (13)
      Total
      Cells may not sum to 100 owing to rounding.
      5,962 (26)2,688 (12)5,350 (24)8,244 (32)
      Note: The public health workers included are state, tribal, local, and territorial.
      AI/AN, American Indian/American Native; NH, Non-Hispanic; PI, Pacific Islander; PR, prevalence ratio.
      a Totals do not sum to the total number of survey respondents owing to nonresponse for each variable.
      b Cells may not sum to 100 owing to rounding.
      Table 2 shows the unadjusted PRs and 95% CIs for WPV and the mental health symptoms using the unimputed data. Experiencing any type or combination of WPV was significantly associated with an increased likelihood of reporting symptoms of depression (PR=1.95, 95% CI=1.87, 2.03), PTSD (PR=2.0, 95% CI=1.93, 2.07), anxiety (PR=1.87, 95% CI=1.80, 1.94), and SI (PR=1.99, 95% CI=1.83, 2.18). Because dose‒response relationship was found between the number of WPV events and the likelihood of reporting symptoms for each mental health outcome. As an example, the proportion of PHWs reporting symptoms of depression was 1.7-fold greater if they experienced a single type of WPV, twofold if they experienced 2 types, and 2.4-fold greater if they experienced all the 3 types of WPV.
      Table 2Workplace Violence, Depression, PTSD, Anxiety, and Suicidal Ideation Among Public Health Workers, March 2021–April 2021, U.S.
      Type of violenceDepressionPTSDAnxietySuicidal ideationTotal
      Clinical, n (%)PR (95% CI)Yes, n (%)PR (95% CI)Yes, n (%)PR (95% CI)Yes, n (%)PR (95% CI)
      No violence3,235 (23)ref3,790 (27)ref3,380 (23)ref894 (6)ref14,443 (64)
      Any type or combination of violence3,505 (45)1.95 (1.87, 2.03)4,216 (54)2.0 (1.93, 2.07)3,514 (43)1.87 (1.80, 1.94)983 (12)1.99 (1.83, 2.18)7,964 (35)
      Single type of violence1,537 (40)1.72 (1.62, 1.83)1,775 (46)1.70 (1.61, 1.79)1,567 (39)1.68 (1.58, 1.78)392 (10)1.60 (1.42, 1.80)3,966 (18)
      Any 2 types of violence1,076 (46)2.00 (1.87, 2.15)1,337 (57)2.12 (2.0, 2.25)1,073 (44)1.91 (1.78, 2.05)309 (13)2.1 (1.84, 2.39)2,382 (11)
      All 3 types of violence892 (56)2.43 (2.26, 2.62)1,104 (69)2.57 (2.40, 2.74)874 (53)2.28 (2.18, 2.46)281 (17)2.82 (2.47, 3.22)1,616 (7)
      Total
      Cells may not sum to 100 owing to rounding.
      6,740 (31)8,006 (37)6,894 (30)1,877 (8)
      Note: The public health workers included are state, tribal, local, and territorial.
      PR, prevalence ratio; PTSD, post-traumatic stress disorder.
      a Cells may not sum to 100 owing to rounding.
      Table 3 shows the top 4 factors in terms of variance explained by the factor analysis using the imputed data. The numbers represent the factor loadings, with numbers closer to ±1 indicating variables with a high factor loading. Survey items with high loadings were used to develop 3 scales for the models: perceived work support, perceived job stress, and perceived stress due to environment. Perceived work support was defined as the sum of felt supported by coworkers/peers, felt supported by supervisor/leadership, felt supported by organization/agency, and felt unappreciated at work. Perceived job stress was the sum of felt disconnected from family/friends because of work, felt overwhelmed by work load or family/work balance, felt inadequately compensated at work, able to take time off work when needed, percentage of time spent on COVID, and hours worked in a typical week. Perceived stress due to environment was the sum of felt stressed due to civil unrest and felt stressed due to racial tensions.
      Table 3Top Factors With Corresponding Loadings for Workplace Characteristics and Workplace Violence
      VariablesPerceived job support
      Scale=1/4 (supported by coworkers) + ¼ (supported by supervisor/leadership) + ¼ (supported by organization/agency) + ¼ (felt unappreciated at work).
      Perceived job stress
      Scale=1/5 (percentage time on COVID-19) + 1/5 (hours worked in a typical week) + (felt disconnected from family/friends due to work) + (overwhelmed by work load) + (inadequately compensated at work) + (able to take time off work when needed).
      Perceived stress due to environment
      Scale=stressed owing to civil unrest + stressed owing to racial tensions.
      Workplace violence
      Experienced stigma or discrimination owing to public health work–0.1400.1670.1220.673
      Received job threats owing to their public health work–0.0430.0880.0180.795
      Felt bullied, threatened, or harassed owing to their public health work–0.1030.1580.0770.821
      For most of 2020, the percentage of time spent working on the COVID-19 response0.1320.676–0.0710.185
      A supervisor in 2020?0.0410.239–0.0140.056
      Years of experience working in public health–0.088–0.134–0.0380.049
      Degree of interaction with the public in the course of their work–0.069–0.3390.154–0.358
      Since the COVID-19 pandemic, hours worked in a typical week–0.0110.602–0.0130.125
      Highest level of education0.0280.1590.195–0.072
      Number of children aged <18 years in the household0.0130.091–0.1480.001
      Received counseling or therapy from mental health professional in last 4 weeks–0.0230.0490.1160.043
      Since the COVID-19 pandemic, got divorced or separated0.012–0.023–0.0670.082
      Since the COVID-19 pandemic, felt stressed owing to civil unrest–0.0600.0430.8270.106
      Since the COVID-19 pandemic, felt stressed owing to racial tensions–0.053–0.0020.8410.065
      Since the COVID-19 pandemic, worried about the health of family and loved ones–0.0370.1750.541–0.018
      Since the COVID-19 pandemic, experienced the death of a loved one–0.0230.0030.2170.044
      Since the COVID-19 pandemic, felt isolated and alone–0.2220.2490.3870.060
      Since the COVID-19 pandemic, felt disconnected from family and friends because of work–0.1710.7000.2410.082
      Since the COVID-19 pandemic, felt overwhelmed by work load or family/work balance–0.1820.6660.2680.041
      Since the COVID-19 pandemic, felt inadequately compensated for work–0.4060.4830.1440.115
      Since the COVID-19 pandemic, felt unappreciated at work–0.6180.3170.1370.163
      Since the COVID-19 pandemic, able to take time off work when needed0.275–0.5320.009–0.143
      Since the pandemic, felt supported by family/friends0.439–0.038–0.040–0.082
      Since the pandemic, felt supported by coworkers/peers0.7780.0660.001–0.007
      Since the pandemic, felt supported by supervisor/leadership0.867–0.077–0.024–0.061
      Since the pandemic, felt supported by organization/agency0.830–0.149–0.072–0.045
      Note: Boldface denotes numbers close to ±1, representing a high factor loading within each respective factor.
      a Scale=1/4 (supported by coworkers) + ¼ (supported by supervisor/leadership) + ¼ (supported by organization/agency) + ¼ (felt unappreciated at work).
      b Scale=1/5 (percentage time on COVID-19) + 1/5 (hours worked in a typical week) + (felt disconnected from family/friends due to work) + (overwhelmed by work load) + (inadequately compensated at work) + (able to take time off work when needed).
      c Scale=stressed owing to civil unrest + stressed owing to racial tensions.
      Table 4 shows the multivariable models for the 4 mental health outcomes using the imputed data. After controlling for confounders such as sociodemographics, work characteristics, support from family/friends, feelings of isolation, death of a loved one, perceived stress due to environment, and worry about the health of family, the association between WPV and the mental health outcomes remained moderate and significant. The dose‒response relationship between the number of WPV events and the likelihood of reporting mental health symptoms also persisted. For example, the proportion of PHWs reporting symptoms of depression was 1.1-fold greater among those experiencing 1 type of WPV, 1.2-fold greater among those experiencing 2 types, and 1.3-fold greater among those experiencing all the 3 types.
      Table 4Multivariable Model of Workplace Violence, Depression, PTSD, Anxiety, and Suicidal Ideation, March 2021–April 2021, U.S.
      VariablesDepression,
      Adjusted for state of residence, sex, marital status, education, and history of self-reported COVID-19 infection.
      Anxiety,
      Adjusted for state of residence, sex, marital status, and education.
      PTSD,
      Adjusted for state of residence, sex, and marital status.
      Suicidal ideation,
      Adjusted for state of residence, sex, and marital status.
      PR (95% CI)PR (95% CI)PR (95% CI)PR (95% CI)
      Any type or combination of WPV1.21 (1.15, 1.27)1.21 (1.15, 1.27)1.31 (1.25, 1.37)1.26 (1.14, 1.38)
      Experienced any 1 type of WPV1.16 (1.09, 1.23)1.16 (1.09, 1.23)1.21 (1.14, 1.27)1.07 (0.95, 1.21)
      Experienced any 2 types of WPV1.21 (1.12, 1.30)1.21 (1.13, 1.30)1.36 (1.28, 1.45)1.28 (1.12, 1.46)
      Experienced all 3 types of WPV1.31 (1.22, 1.41)1.32 (1.23, 1.43)1.47 (1.38, 1.57)1.61 (1.40, 1.85)
      Degree of interaction with the public0.96 (0.93, 0.99)
      Year of public health experience0.94 (0.92, 0.96)0.94 (0.91, 0.97)
      Received mental health services in the previous 4 weeks1.28 (1.21, 1.35)1.35 (1.28, 1.42)1.18 (1.12, 1.24)1.40 (1.27, 1.54)
      Experienced death of loved one since COVID-19 was declared a pandemic1.08 (1.03, 1.14)1.05 (1.00, 1.10)1.08 (1.03, 1.13)
      Felt isolated and alone since COVID-19 was declared a pandemic1.91 (1.79, 2.03)1.96 (1.84, 2.09)1.59 (1.50, 1.68)3.03 (2.61, 3.50)
      Since the start of the pandemic, felt supported by family/friends0.87 (0.85, 0.89)0.91 (0.89, 0.94)0.94 (0.92, 0.97)0.76 (0.72, 0.80)
      Worried about health of family since COVID-19 was declared a pandemic1.25 (1.11, 1.41)1.34 (1.18, 1.52)1.52 (1.34, 1.72)
      Perceived job stress factor1.23 (1.21, 1.25)1.21 (1.18, 1.23)1.24 (1.50, 1.68)1.07 (1.03, 1.11)
      Perceived work support factor0.86 (0.84, 0.89)1.15 (0.85, 0.90)0.95 (0.93, 0.98)0.71 (0.67, 0.75)
      Perceived stress owing to environmental factor1.26 (1.17, 1.35)1.32 (1.23, 1.42)1.51 (1.40, 1.62)1.18 (1.02, 1.35)
      Note: The public health workers included are state, tribal, local, and territorial, and models were based on 25 imputed data sets of n=26,174 each.
      PR, prevalence rate; PTSD, post-traumatic stress disorder; WPV, workplace violence.
      a Adjusted for state of residence, sex, marital status, education, and history of self-reported COVID-19 infection.
      b Adjusted for state of residence, sex, marital status, and education.
      c Adjusted for state of residence, sex, and marital status.

      DISCUSSION

      This study describes the prevalence of WPV among state, tribal, local, and territorial PWHs during the COVID-19 pandemic and its association with mental health. A total of 35% of PHWs experienced at least 1 form or combination of forms of WPV, and that violence was associated with a detrimental impact on PHWs’ mental health. The more WPV the PHW experienced, the more likely they were to report symptoms of depression, anxiety, PTSD, and SI. This association persisted after controlling for potentially confounding variables. PHWs play a pivotal role in PH emergencies, but there is little research on how these emergencies impact their mental health. The current findings complement a recent study that found that over half of PH agencies reported experiencing harassment from the public.
      • Ward JA
      • Stone EM
      • Mui P
      • Resnick B.
      Pandemic-related workplace violence and its impact on public health officials, March 2020–January 2021.
      These findings are also consistent with a wide range of studies showing the associations between WPV and adverse mental health in many occupations.
      • Nyberg A
      • Kecklund G
      • Hanson LM
      • Rajaleid K.
      Workplace violence and health in human service industries: a systematic review of prospective and longitudinal studies.
      • LeBlanc MM
      • Kelloway EK.
      Predictors and outcomes of workplace violence and aggression.
      • Phillips JP.
      Workplace violence against health care workers in the United States.
      However, these studies did not include PHWs or their work environments, which is why more research is needed on the PHW population.
      The psychological impact of infectious disease outbreaks on workers has been previously described.
      • McAlonan GM
      • Lee AM
      • Cheung V
      Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers.
      • Styra R
      • Hawryluck L
      • Mc Geer A
      Surviving SARS and living through COVID-19: healthcare worker mental health outcomes and insights for coping.
      • Lehmann M
      • Bruenahl CA
      • Addo MM
      Acute Ebola virus disease patient treatment and health-related quality of life in health care professionals: a controlled study.
      • Goulia P
      • Mantas C
      • Dimitroula D
      • Mantis D
      • Hyphantis T.
      General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic.
      Workers experienced higher levels of depression, anxiety, and stress disorders during and after infectious disease outbreaks, including Ebola, severe acute respiratory syndrome, and influenza.
      • McAlonan GM
      • Lee AM
      • Cheung V
      Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers.
      • Styra R
      • Hawryluck L
      • Mc Geer A
      Surviving SARS and living through COVID-19: healthcare worker mental health outcomes and insights for coping.
      • Lehmann M
      • Bruenahl CA
      • Addo MM
      Acute Ebola virus disease patient treatment and health-related quality of life in health care professionals: a controlled study.
      • Goulia P
      • Mantas C
      • Dimitroula D
      • Mantis D
      • Hyphantis T.
      General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic.
      In the few studies where WPV was studied concurrent with an outbreak, it was found to add to the heavy burden of workplace stressors faced by workers.
      • Douglas PK
      • Douglas DB
      • Harrigan DC
      • Douglas KM.
      Preparing for pandemic influenza and its aftermath: mental health issues considered.
      • Paladino L
      • Sharpe RP
      • Galwankar SC
      • et al.
      Reflections on the Ebola Public Health Emergency of International Concern, Part 2: The unseen epidemic of posttraumatic stress among health-care personnel and survivors of the 2014–2016 Ebola outbreak.
      • Naushad VA
      • Bierens JJ
      • Nishan KP
      A systematic review of the impact of disaster on the mental health of medical responders.
      There were only a handful of studies conducted on PHWs, which found that they had a high degree of willingness to respond to outbreaks but also felt overworked.
      • Vinck L
      • Isken L
      • Hooiveld M
      • Trompenaars M
      • Ijzermans J
      • Timen A.
      Impact of the 2009 influenza A(H1N1) pandemic on public health workers in the Netherlands.
      • Barnett DJ
      • Balicer RD
      • Thompson CB
      Assessment of local public health workers’ willingness to respond to pandemic influenza through application of the extended parallel process model.
      • Balicer RD
      • Omer SB
      • Barnett DJ
      • Everly Jr., GS
      Survey of local public health workers’ perceptions toward responding to an influenza pandemic.
      Therefore, it is difficult to compare these findings with those of other research because studies have not generally included data on WPV or its impact on mental health. One potential comparison is PH WINS (Public Health Workforce Interests and Needs Survey). PH WINS is the only nationally representative data on emerging issues and demographics of the PH workforce and is collected every 3 years.

      2021 findings. De Beaumont. https://debeaumont.org/programs/ph-wins/. Accessed April 13, 2022.

      In 2021, the survey reported that 50% of PHWs reported 1 symptom of PTSD, 41% felt bullied or threatened, and 32% were considering leaving PH.
      De Beaumont
      Rising stress and burnout in public health.
      In 2021, a journal published several papers on violence against PH officials during the COVID-19 pandemic.
      • Tremmel Freeman L
      Unanticipated pandemic outcomes: the assault on public health [published correction appears in Am J Public Health. 2022;112(10):e4].
      • Yeager VA.
      The politicization of public health and the impact on health officials and the workforce: charting a path forward.
      • Fraser MR.
      Harassment of health officials: a significant threat to the Public's health.
      First, an important step is quantifying and describing the WPV. To do so, Ward et al. recommended establishing a national WPV reporting system.
      • Ward JA
      • Stone EM
      • Mui P
      • Resnick B.
      Pandemic-related workplace violence and its impact on public health officials, March 2020–January 2021.
      Toward this goal, a school of PH-sponsored “We Stand with Public Health Call to Action” Campaign was launched with support from PH partners.
      • Tremmel Freeman L
      Unanticipated pandemic outcomes: the assault on public health [published correction appears in Am J Public Health. 2022;112(10):e4].
      One of the campaign's aims is asking Congress to require state and local reporting of threats against PHWs.
      • Tremmel Freeman L
      Unanticipated pandemic outcomes: the assault on public health [published correction appears in Am J Public Health. 2022;112(10):e4].
      Several approaches to the prevention and mitigation of WPV were suggested, including colleges of PH and national associations providing training for PHWs to respond to conflict as well as investing in the current PH workforce through increased funding and staffing. These are outlined below.
      One recommendation was to train PHWs on responding to political conflict and improve support networks.
      • Ward JA
      • Stone EM
      • Mui P
      • Resnick B.
      Pandemic-related workplace violence and its impact on public health officials, March 2020–January 2021.
      ,
      • Yeager VA.
      The politicization of public health and the impact on health officials and the workforce: charting a path forward.
      This study's results endorse colleague support as a potentially protective factor against adverse mental health outcomes. The Association of State and Territorial Health Officials has a leadership institute that offers training on the navigation of politics.
      • Fraser MR.
      Harassment of health officials: a significant threat to the Public's health.
      Evidence-based trainings on how to mitigate violence, media management, and responding to political conflict could be added to this institute. Because this study also examined city and county PHWs, NACCHO could also consider similar training topics for their constituents. In addition, schools and programs of PH could consider embedding these topics into current courses as part of their larger curriculum.
      While providing PHWs with these vital skills, greater investment in the PH workforce, including funding, increased staffing, and better safety protections, is also needed.
      • Ward JA
      • Stone EM
      • Mui P
      • Resnick B.
      Pandemic-related workplace violence and its impact on public health officials, March 2020–January 2021.
      ,
      • Topazian RJ
      • McGinty EE
      • Han H
      • et al.
      US adults’ beliefs about harassing or threatening public health officials during the COVID-19 pandemic.
      ,
      • Fraser MR.
      Harassment of health officials: a significant threat to the Public's health.
      In an effort toward this, NACCHO Officials sent a letter to U.S. Attorney General Merrick Garland requesting federal protections for PHWs owing to the findings in the report, “Legal Protections for Public Health Officials.”
      • Tremmel Freeman L
      Unanticipated pandemic outcomes: the assault on public health [published correction appears in Am J Public Health. 2022;112(10):e4].
      This report found that 35 states and the District of Columbia had “criminal statutes punishing individuals who impede PH officials’ duties with such behavior,” but 15 states “either do not have a statute protecting government officials in these circumstances or do not have one protecting PH officials.”
      The Network for Public Health Law
      Legal protections for public health officials.
      Increased workplace communication after a WPV incident is also important and may protect the PHW from adverse mental health outcomes.
      Workplace violence prevention course for nurses.
      Occupational Safety and Health Administration (OSHA)
      Guidelines for preventing workplace violence for healthcare and social service workers.
      • Jeong IY
      • Kim JS.
      The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence.
      • Hurrell JJ.
      Critical incident stress debriefing and workplace violence.
      • Fan S
      • An W
      • Zeng L
      Rethinking “zero tolerance”: A moderated mediation model of mental resilience and coping strategies in workplace violence and nurses’ mental health.
      • Dean L
      • Butler A
      • Cuddigan J.
      The impact of workplace violence toward psychiatric mental health nurses: identifying the facilitators and barriers to supportive resources.

      Duan X, Ni X, Shi L, et. al. The impact of workplace violence on job satisfaction, job burnout, and turnover intention: the mediating role of social support. Health Qual Life Outcomes. 2019;17(1):93. https://doi.org/10.1186/s12955-019-1164-3.

      If a WPV event occurs, PHWs should report the event to a designated official at their organization, including the frequency of the violence and other details surrounding the event.
      Workplace violence prevention course for nurses.
      Occupational Safety and Health Administration (OSHA)
      Guidelines for preventing workplace violence for healthcare and social service workers.
      • Jeong IY
      • Kim JS.
      The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence.
      ,
      • Dean L
      • Butler A
      • Cuddigan J.
      The impact of workplace violence toward psychiatric mental health nurses: identifying the facilitators and barriers to supportive resources.

      Duan X, Ni X, Shi L, et. al. The impact of workplace violence on job satisfaction, job burnout, and turnover intention: the mediating role of social support. Health Qual Life Outcomes. 2019;17(1):93. https://doi.org/10.1186/s12955-019-1164-3.

      • Pihl-Thingvad J
      • Elklit A
      • Brandt LPA
      • Andersen LL.
      Workplace violence and development of burnout symptoms: a prospective cohort study on 1823 social educators.
      Supervisors can make informed decisions about changes to work location, tasks, and shifts to reduce the probability of another WPV event. Experiencing multiple WPV events has a cumulative effect on adverse mental health symptoms and can lead to increased turnover,
      De Beaumont
      Rising stress and burnout in public health.
      ,
      • Jeong IY
      • Kim JS.
      The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence.
      ,
      • Dean L
      • Butler A
      • Cuddigan J.
      The impact of workplace violence toward psychiatric mental health nurses: identifying the facilitators and barriers to supportive resources.
      ,
      • Zhao SH
      • Shi Y
      • Sun ZN
      Impact of workplace violence against nurses’ thriving at work, job satisfaction and turnover intention: a cross-sectional study.
      ,

      Caillier JG. The impact of workplace aggression on employee satisfaction with job stress, meaningfulness of work, and turnover intentions. Public Pers Manag. 2021;50(2):159–182. https://doi.org/10.1177/0091026019899976.

      burnout,
      • Pihl-Thingvad J
      • Elklit A
      • Brandt LPA
      • Andersen LL.
      Workplace violence and development of burnout symptoms: a prospective cohort study on 1823 social educators.
      and decreased job satisfaction.

      Duan X, Ni X, Shi L, et. al. The impact of workplace violence on job satisfaction, job burnout, and turnover intention: the mediating role of social support. Health Qual Life Outcomes. 2019;17(1):93. https://doi.org/10.1186/s12955-019-1164-3.

      ,
      • Zhao SH
      • Shi Y
      • Sun ZN
      Impact of workplace violence against nurses’ thriving at work, job satisfaction and turnover intention: a cross-sectional study.
      ,

      Caillier JG. The impact of workplace aggression on employee satisfaction with job stress, meaningfulness of work, and turnover intentions. Public Pers Manag. 2021;50(2):159–182. https://doi.org/10.1177/0091026019899976.

      Most important, supervisors and PH agencies need to contact law enforcement immediately if the PHWs’ life or family is threatened.

      Limitations

      There are limitations to these findings. Although this sample was large, it should be noted that this is a convenience sample and may not be representative of the U.S. PH workforce. In addition, owing to the study design, an accurate response rate cannot be calculated. Because the data were collected retrospectively and were self-reported, the potential for recall bias exists. Participants may have been unwilling to share or had difficulty recalling less serious WPV events.
      • Gonsalves G
      • Staley P.
      Panic, paranoia, and public health—the AIDS epidemic's lessons for Ebola.
      In addition, mental health outcomes were based on screening instruments and reflect symptomology rather than clinical diagnoses. Another limitation was that respondents were reporting on experiences that may have occurred in 2020 but reporting on mental health symptoms over the past 2 weeks. In addition, the authors were unable to collect data on the exact cause of or the perpetrator of the WPV event. Because of the survey design, it is also possible that PHWs completed the survey multiple times. Finally, because this is a cross-sectional survey, a causal relationship between WPV and mental health cannot be determined.

      CONCLUSIONS

      To the best of the authors’ knowledge, this is the first study to document this in the PHW workforce. Public hostilities targeted at the PH workforce are not fully understood; however, any WPV directed at a PHW during a PH emergency is detrimental to them as well as the communities they serve. WPV against PHWs is an alarming outcome of the COVID-19 pandemic. A better understanding of the scope and consequences of WPV as well as understanding of differences across the type of PH agencies; geographic locations; and sociodemographic groups, including race and sex, is needed. Finally, efforts should be made to protect and support the current PH workforce.

      ACKNOWLEDGMENTS

      The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention
      No financial disclosures were reported by the authors of this paper.

      CRediT AUTHOR STATEMENT

      Hope M. Tiesman: Conceptualization, Formal analysis, Methodology, Visualization, Writing - original draft, Writing - review & editing. Scott A. Hendricks: Conceptualization, Data curation, Formal analysis, Software, Validation, Visualization, Writing - original draft, Writing - review & editing. Douglas M. Wiegand: Conceptualization; Writing- original draft, Writing - review & editing. Barbara Lopes-Cardozo: Conceptualization, Methodology, Resources, Writing - review & editing. Carol Y. Rao: Conceptualization, Investigation, Methodology, Resources, Project administration, Supervision, Writing – review & editing. Libby Horter: Data curation, Validation, Writing - review & editing. Charles E. Rose: Conceptualization, Data curation, Formal analysis, Methodology, Investigation, Visualization, Writing – review & editing,. Ramona Byrkit: Conceptualization, Investigation, Methodology, Project administration, Supervision, Writing – review & editing.

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