Understanding Low Utilization of Employee Assistance Programs and Time Off by US Public Health Workers During the COVID-19 Pandemic
新冠肺炎疫情期間美國公共衛生工作者員工協助方案和休假低利用率之研究

Jazmyn T. Moore, MSc, MPH $^{1 -}$ ; Claire Wigington, BSA $^{1, 2}$ ; Jamilla Green, DrPH $^{1}$ ; Libby Horter, MPH $^{1, 3}$ ; Ahoua Kone, MPH $^{1}$ ; Barbara Lopes-Cardozo, MD, MPH $^{1}$ (D); Ramona Byrkit, MPH $^{1}$ ; and Carol Y. Rao, ScD, CIH $^{1 - D}$
賈茲敏·T·摩爾，碩士，公共衛生碩士 $^{1 -}$ ；克萊爾·威京頓，學士 $^{1, 2}$ ；賈蜜拉·格林，公共衛生博士 $^{1}$ ；莉比·霍特，公共衛生碩士 $^{1, 3}$ ；艾霍亞·科內，公共衛生碩士 $^{1}$ ；芭芭拉·洛佩斯-卡多佐，醫學博士，公共衛生碩士 $^{1}$ （D）；拉蒙納·伯基特，公共衛生碩士 $^{1}$ ；卡羅爾·Y·饒，科學博士，工業衛生師 $^{1 - D}$

Abstract 摘要

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.
目的：儘管新冠肺炎疫情期間公共衛生工作者普遍報告了嚴重的心理健康症狀，但他們對雇主提供的資源利用率卻很低。我們的研究目的是瞭解公共衛生工作者獲取雇主資源時所面臨的障礙和阻礙因素。

Methods: Four national public health organizations disseminated a national online survey of public health department employees during March-April 2021; 26174 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.
方法：四個全國性公共衛生組織於 2021 年 3 月至 4 月期間發放全國線上調查問卷，調查公共衛生部門員工；共有 26,174 名公共衛生工作者完成問卷。我們使用主題分析方法，檢視了 5,164 份書面調查回覆，以確定公共衛生工作者未能使用休假和員工協助方案（EAPs）的關鍵原因，並了解他們希望雇主提供的資源。

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 (II.3%). While desired employer-offered resources varied widely, PHWs most frequently listed financial incentives, paid time off, flexible scheduling, and organizational change.
結果：公共衛生工作者未在 COVID-19 疫情期間休假的首要原因包括：財務顧慮（24.4%）、擔心受到評判或報復（20.8%），以及可休假時間數量有限（11.0%）。未使用員工協助方案的主要原因包括：難以取用方案（53.1%）、使用外部服務（21.5%），以及對方案缺乏認知或缺乏使用動機（11.3%）。儘管所需的雇主資源多樣，公共衛生工作者最常列出的是財務獎勵、帶薪休假、彈性排班和組織變革。

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.
結論：組織可以透過以下方式最有效地幫助員工：以允許公共衛生工作者休假的方式安排勞動力、營造正面且支持的組織氛圍、定期評估工作者需求、清楚溝通雇主提供的福利，以及強調使用這些福利的可接受性。

Keywords 關鍵詞

COVID-19, public health workforce, mental health, public health departments
COVID-19、公共衛生人員、心理健康、公共衛生部門

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 250000 public health workers (PHWs) is less well documented.
COVID-19 疫情對心理健康造成深遠影響，全球通報的心理健康狀況症狀（包括焦慮和憂鬱）均有增加。

^{1}

美國的醫療保健和一線工作者回報經歷高度的倦怠、

^{2, 3}

心理困擾、

^{4}

焦慮、

^{3, 5}

創傷後壓力症候群（PTSD）

^{3, 5}

和憂鬱症。

^{3, 5}

疫情對全國約 25 萬名公共衛生工作者（PHWs）的影響尚未充分記錄。

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 26174 PHWs conducted during March-April 2021 suggest that the
公共衛生工作者遭受來自公眾的暴力、騷擾和欺凌，以及來自政治人物的反對和敵意。

^{6, 7}

2021 年 3 月至 4 月間對 26,174 名公共衛生工作者進行的線上調查結果顯示，
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,
通報心理健康症狀的比例高於一般人口。

^{8}

無法休假的公共衛生工作者，相較於有休假的同事，通報憂鬱症狀的可能性是其兩倍，

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 allcause mortality,

^{12}

and enacting equitable sick-leave policies may help reduce gender, racial, and ethnic disparities in communicable diseases and other conditions.

^{13}

焦慮、創傷後壓力症候群和自殺意念。

^{8, 9}

帶薪休假可以降低工作者患上身心健康問題的風險。

^{10 - 13}

這可能有助於預防憂鬱症

^{10}

，並可能提高工作場所安全性；擁有帶薪休假的員工較不可能在出現呼吸道症狀疾病時仍前往工作場所。

^{11}

帶薪病假可以預防各種原因導致的死亡，

^{12}

而制定公平的病假政策可能有助於減少傳染性疾病和其他疾病中的性別、種族和族裔差異。

^{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 COVID19 pandemic.
員工協助方案（EAPs）是由雇主提供的免費或補貼服務，旨在幫助員工管理可能影響工作表現和生產力的生活挑戰和壓力。這些方案通常因各種原因而使用率低，包括污名化和員工缺乏認知。

^{14, 15}

例如，近五分之一的公共衛生工作者在線上調查中表示需要心理健康/諮詢服務但未能獲得。

^{8}

職場健康促進方案通常也有較低的使用率和有限的效果。

^{16, 17}

雇主往往在這些旨在改善員工福祉的方案上投入大量資源。了解阻礙和遏制獲取這些資源的原因，可能有助於提高其使用率和效果，並最終改善公共衛生工作者的健康。我們評估了公共衛生工作者未使用員工協助方案和雇主提供資源的原因，並探討了他們為何在 COVID-19 疫情期間未請假。

Methods 方法

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 26174 PHWs completed the survey. Detailed methods and demographic characteristics are described elsewhere.

^{8}

Briefly, a nonprob-ability-based convenience sample of PHWs in the United States was invited to complete the survey during March 29April 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
四個全國性公共衛生組織（州和區域流行病學委員會、全國縣市衛生官員協會、公共衛生實驗室協會以及州和區域衛生官員協會）向其成員分發了一份關於疫情期間心理健康的自填、線上匿名調查。共有 26,174 名公共衛生工作者完成了調查。詳細方法和人口統計特徵已在其他地方描述。

^{8}

簡單來說，在 2021 年 3 月 29 日至 4 月 16 日期間，邀請了一個非隨機方便抽樣的美國公共衛生工作者完成調查。所有在 2020 年曾在州、部落、地方或區域衛生部門工作過的人都有資格參與。問卷通過標準化問題評估了最近 2 週的心理健康症狀，包括 9 題病人健康問卷中的抑鬱和自殺念頭、

^{18}

2 題廣泛性焦慮量表中的焦慮、

^{19}

以及 6 題事件影響量表中的創傷後壓力症候群症狀。

^{20}

我們詢問了參與者是否能夠自 2020 年 3 月以來請假。對於回答「否」的人，我們進一步詢問了他們無法請假的原因。我們還詢問了他們的雇主是否提供員工協助方案（EAP）；對於那些表示雇主有 EAP 但他們尚未
accessed it since March 2020, we asked why they did not access it. We also asked respondents to select all employeroffered 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.
自 2020 年 3 月以來未曾使用員工協助方案的受訪者，我們詢問了他們未使用的原因。我們也請受訪者選擇如果可用的話，他們會使用的所有雇主提供的資源，並寫下他們感興趣的其他資源。問題格式包括單選、多選和自由文字填寫的回應。我們在頻率分析中排除了未回答的問題。

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 46.102.1.2; 21 CFR part 56; 42 USC §241.d; 5 USC §552a; 44 USC §3501 et seq).
三位研究人員（J.T.M.、C.W.、J.G.）使用歸納式主題分析法分析書面回應。

^{21}

對於每個問題，2 位研究人員進行初步獨立審查並自由編碼。初步資料審查後，研究人員認為關於休假和員工協助方案（EAP）的書面回應只需要一個主要編碼和一個次要編碼，而對於雇主提供的資源問題的回應則可為每個答案分配最多 5 個編碼，因為受訪者列出了多種資源。同樣的 2 位研究人員獨立地重新審查並重新編碼回應。研究人員隨後比較編碼簿，建立並定義每個問題的標準編碼集，並按類別對編碼進行分組。他們根據建立的編碼集重新編碼問題的回應。他們計算編碼間的一致性，方法是在任何討論之前計算兩人之間一致的編碼百分比。然後，第三位研究人員審查了不一致的編碼並做出最終判定。三位研究人員共同確定了更廣泛的類別並提取主題。他們使用 Microsoft Excel 進行分析。這項活動經過疾病控制與預防中心審查，並遵守適用的聯邦法律和中心政策（例如，45 CFR part 46.102.1.2；21 CFR part 56；42 USC §241.d；5 USC §552a；44 USC §3501 et seq）。

Results 研究結果

The number of respondents to each question ranged from 13155 (50.3%) to 22668 (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

\geq 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.
每個問題的回應者人數從 13,155 人（50.3%）至 22,668 人（86.6%）不等。整體而言，團隊分析了 5,164 份書面回應，每個問題的書面回應數量介於 1,151 至 2,618 之間。總計有 4,460 名受訪者針對分析的 3 個問題提供書面回應；634 人針對

\geq 2

問題給出書面回應；957 人僅針對無法請假的原因提供書面回應；2,160 人僅針對未使用員工協助方案（EAP）的原因提供書面回應；另有 709 人僅就雇主提供的感興趣資源撰寫回應。

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
我們發現，在提供這 3 個問題書面回應的公共衛生工作者，其社會人口統計學特徵和職場特徵與整體樣本幾乎沒有差異（表 1）。然而，與整體樣本相比，針對無法請假原因提供書面回應的公共衛生工作者中，有較高比例的人在 COVID-19 疫情應對工作中投入

> 75 %

的時間（54.6%）；在解釋未使用員工協助方案原因的書面回應中，主管的比例較高（

70.5 %

）；以及那些具有較高比例的人……

Table I. 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}

表 I. 公共衛生工作者在 COVID-19 疫情期間（2021 年 3 月至 4 月）關於使用員工協助方案和休假調查的社會人口統計學特徵和職場特徵（

n = 4460

個回應者）

Characteristic (no. of respondents) 特徵（回應者人數）	Overall ( $N = 26174$ ), $%^{b}$ 整體（ $N = 26174$ ）而言， $%^{b}$	Provided written responses, % 已提供書面回應的百分比
Characteristic (no. of respondents) 特徵（回應者人數）		About reasons why unable to take time off ( $n = 1395$ ) 關於無法請假的原因（ $n = 1395$ ）	About reasons why did not use EAP ( $n = 2618$ ) 關於未使用員工協助方案的原因（ $n = 2618$ ）	Listing employeroffered resources they would access if available ( $n = 1151$ ) 列出若可使用會願意使用的雇主提供資源（ $n = 1151$ ）
Age, y ( $n = 21843$ ) 年齡，歲（ $n = 21843$ ）
$\leq 29$	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
$\geq 60$	13.0	9.9	10.4	12.9
Sex/gender ( $n = 23$ 917) 性別（ $n = 23$ 917）
Male 男性	16.3	12.8	9.7	17.2
Female 女性	83.1	86.2	89.3	81.2
Transgender or nonbinary 跨性別或非二元性別	0.6	0.9	1.0	1.6
Race and ethnicity ( $n = 23$ 244) 種族與族裔（ $n = 23$ 244）
Hispanic 西語裔	8.5	9.2	7.2	8.6
Non-Hispanic 非西語裔
AI/AN 美洲原住民	0.7	0.4	0.4	0.8
Asian 亞裔	4.3	4.1	2.5	4.2
Black or African American 黑人或非裔美國人	9.4	8.4	6.3	9.3
NH/PI 原住民/太平洋島民	0.4	0.3	0.1	0.2
White 白人	74.1	74.1	80.7	74.0
Multiple races 多重種族	2.6	3.5	2.8	2.9
Marital status ( $n = 23$ 553) 婚姻狀態（ $n = 23$ 553）
Never married 從未結婚	21.5	25.4	19.5	23.1
Married or unmarried couple 已婚或未婚伴侶	65.1	60.1	66.0	63.5
Divorced, separated, or widowed 離婚、分居或喪偶	13.3	14.5	14.4	13.5
Household size ( $n = 24037$ ) 家庭規模（ $n = 24037$ ）
Lives alone 獨居	14.3	15.9	14.9	16.2
2 or 3 2 或 3	57.2	55.4	56.4	57.5
$\geq 4$	28.5	28.7	28.8	26.3
Household with children ( $n = 24$ 058) 有兒童的家庭（ $n = 24$ 058）
Yes 是	37.1	38.8	41.6	36.0
No 無	62.9	61.2	58.4	64.0
Region ( $n = 25$ 214) 地區（ $n = 25$ 214）
Northeast 東北部	12.2	12.6	12.7	13.4
Midwest 中西部	28.6	28.1	30.6	29.0
South 南部	35.6	36.4	28.5	32.7
West 西部	23.4	22.5	28.2	24.8
Territory/FAS 領地/自由聯繫州	0.2	0.4	0.1	0.2
Public health agency ( $N = 26$ 174) 公共衛生機構（ $N = 26$ 174）
State 州	49.5	50.5	45.3	53.4
Local 地方	49.9	48.9	54.2	45.4
Tribal 部落	0.4	0.4	0.3	1.0
Territorial 境內	0.3	0.2	0.1	0.2
Education, degree ( $n = 23941$ ) 教育程度、學歷（ $n = 23941$ ）
High school to associate's degree 高中至副學士學位	22.5	20.4	15.8	18.3
Bachelor's degree 學士學位	38.3	38.1	36.4	34.9
Master's degree or higher 碩士學位或以上	39.2	41.4	47.8	46.8
No. of years in public health ( $n = 25$ 084) 公共衛生工作年資（ $n = 25$ 084）
<1	13.2	18.1	5.9	11.2
I-4	26.1	28.0	23.1	25.5

| Characteristic (no. of respondents) | Overall ( $\mathbf{N} \boldsymbol{=} \mathbf{2 6} \mathbf{1 7 4}$ ), $\boldsymbol{\%}^{\mathbf{b}}$ | Provided written responses, % | | | | :--- | :--- | :--- | :--- | :--- | | | | About reasons why unable to take time off ( $\mathrm{n}=1395$ ) | About reasons why did not use EAP ( $\mathbf{n} \boldsymbol{=} \mathbf{2 6 1 8}$ ) | Listing employeroffered resources they would access if available ( $\mathbf{n} \boldsymbol{=} \mathbf{1 1 5 1}$ ) | | Age, y ( $\mathrm{n}=21843$ ) | | | | | | $\leq 29$ | 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 | | $\geq 60$ | 13.0 | 9.9 | 10.4 | 12.9 | | Sex/gender ( $\mathrm{n}=23$ 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 ( $\mathrm{n}=23$ 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 ( $\mathrm{n}=23$ 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 ( $\mathrm{n}=24037$ ) | | | | | | Lives alone | 14.3 | 15.9 | 14.9 | 16.2 | | 2 or 3 | 57.2 | 55.4 | 56.4 | 57.5 | | $\geq 4$ | 28.5 | 28.7 | 28.8 | 26.3 | | Household with children ( $\mathrm{n}=24$ 058) | | | | | | Yes | 37.1 | 38.8 | 41.6 | 36.0 | | No | 62.9 | 61.2 | 58.4 | 64.0 | | Region ( $\mathrm{n}=25$ 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 ( $\mathrm{N}=26$ 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 ( $\mathrm{n}=23941$ ) | | | | | | 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 ( $\mathrm{n}=25$ 084) | | | | | | <1 | 13.2 | 18.1 | 5.9 | 11.2 | | I-4 | 26.1 | 28.0 | 23.1 | 25.5 |

Table I. (Continued) 表 I.（續）

Characteristic (no. of respondents) 特徵（受訪者人數）	Overall ( $N = 26174$ ), $%^{b}$ 整體而言（ $N = 26174$ ）， $%^{b}$	Provided written responses, % 提供書面回覆的比例
Characteristic (no. of respondents) 特徵（受訪者人數）		About reasons why unable to take time off ( $n = 1395$ ) 關於無法請假的原因（ $n = 1395$ ）	About reasons why did not use EAP ( $n = 2618$ ) 關於未使用員工協助方案的原因（ $n = 2618$ ）	Listing employeroffered resources they would access if available ( $n = 1151$ ) 列出若有提供的雇主資源他們會使用的項目（ $n = 1151$ ）
5-9	19.4	18.8	24.7	22.8
10-14	12.8	11.3	16.0	13.3
$\geq 15$	28.4	23.9	30.3	27.4
Supervisor ( $n = 25042$ ) 主管（ $n = 25042$ ）
Yes 是	31.8	29.5	42.4	31.7
No 否	68.2	70.5	57.6	68.3
Agency leadership position ( $n = 24778$ ) 機關領導職位 ( $n = 24778$ )
Yes 是	7.1	4.6	9.8	5.8
No 否	92.9	95.4	90.2	94.2
Interaction with the public ( $n = 24461$ ) 與公眾互動 ( $n = 24461$ )
A lot 很多	45.6	51.5	48.4	47.3
Some 一些	28.9	26.6	29.1	28.1
Little to none 很少到幾乎沒有	25.6	21.9	22.5	24.5
COVID-19 response COVID-19 疫情應對
Work, $h / wk$ ( $n = 24477$ ) 工作， $h / wk$ （ $n = 24477$ ）
$\leq 40$	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, % ( $n = 24273$ ) 花費時間，%（ $n = 24273$ ）
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.
縮寫：AI/AN，美洲原住民/阿拉斯加原住民；EAP，員工協助方案；FAS，自由聯繫州；NH/PI，夏威夷原住民/太平洋島民。

^{a}

Respondents to each question are not mutually exclusive; 635 respondents provided written responses to

\geq 2

of the 3 questions analyzed.
每個問題的受訪者並非互斥；635 名受訪者對已分析的 3 個問題中的

\geq 2

提供書面回應。

^{b}

Previously reported via Bryant-Genevier et al.

^{8}

先前已由 Bryant-Genevier 等人報告

^{8}

。
wrote in resources that they would like to see their workplace offer had a master degree or higher (46.8%).
填寫他們希望工作場所提供的資源的人中，有 46.8%持有碩士或以上學位。

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.
在分析的 3 個問題中，提供書面回應的受訪者中，

n = 4460

報告焦慮症狀，

43.6 %

報告憂鬱症狀，

45.1 %

報告創傷後壓力症候群症狀，以及

50.5 %

報告有自殺念頭（補充資料中的 eTable 1）。在提供無法請假原因書面回應的受訪者中，

12.6 %

報告焦慮症狀，

n = 1395

報告憂鬱症狀，

42.9 %

報告創傷後壓力症候群症狀，以及

44.5 %

報告有自殺念頭。在描述為何不使用員工協助方案（EAP）的受訪者中，

49.1 %

報告焦慮症狀，

13.5 %

報告憂鬱症狀，

n = 2618

報告創傷後壓力症候群症狀，以及

47.2 %

報告有自殺念頭。在提供額外雇主提供資源清單的受訪者中，

48.7 %

報告焦慮症狀，

54.2 %

報告憂鬱症狀，

12.6 %

報告創傷後壓力症候群症狀，以及

40.4 %

報告有自殺念頭。

Time Off 請假

Of 22668 respondents,

79.1 % (n = 17920)

reported having PTO for personal and family needs. Of the 8011 respondents who selected

\geq 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 %

.
在 22,668 名受訪者中，

79.1 % (n = 17920)

報告有個人和家庭需求的帶薪休假。在 8,011 名選擇

\geq 1

無法請假原因的受訪者中，1,395 人選擇「其他」並提供書面回應。回應長度為 1-313 字。從 1,395 份書面回應中建立了 8 個類別和 25 個子類別（表 2）。最常見的回應是財務顧慮（

24.4 %, n = 341

）、害怕被評判或遭報復/不被看好（

20.8 %, n = 290

），以及請假限制（

15.3 %, n = 214

）。評分者間信度為

68 %

。

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
在寫入回覆中最常被提及的類別是財務考量，其中包含 3 個編碼：無薪休假、無薪休假會導致財務困難，以及未進一步說明的財務問題。部分公共衛生工作者

(15.3 %, n = 214)

是約聘人員，按小時計酬或沒有帶薪休假。七十

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
表 2. 源自全國性美國公共衛生工作者調查

n = 26

中寫入回覆的類別與子類別 (n = 174)，說明他們在 2020 年 3 月至 2021 年 4 月因應 COVID-19 疫情期間無法休假的原因

Qualitative category 質性類別

No. (%) of qualitative responses citing a reason
提及該原因的質性回覆數 (%)

Description of qualitative responses
定性回應說明

Financial concerns 財務顧慮

341 (24.4)

- 無帶薪休假 - 提及因請假造成的財務困難 - 一般提及財務原因

- 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
擔心被評判或遭報復/不被看好

290 (20.8)

- 對主管核准的顧慮 - 害怕報復或被解僱威脅 - 內部政策禁止請假 - 同事不認同

- Concerns about supervisory approval

- Fear of retaliation or threats of termination

- Internal policy forbidding time off

- Frowned upon by colleagues

Time-off restrictions 請假限制

214 (15.3)

- 因工作身分限制請假（例如，提到是約聘人員或新進員工） - 因先前醫療問題已用盡病假 - 家庭責任（例如，產假、照顧生病的孩子）

- 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 職務涵蓋範圍

153 (11.0)

- 因領導職位或專業技能導致人力不足 - 提及人手短缺 - 限制同時可休假的員工人數

- 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
與工作未能有效區隔

122 (8.7)

- 工作量過大 - 缺乏界限且仍會被聯絡 - 隨時待命

- Workload too great

- Lack of boundaries and will still be contacted while off

- Always on call

Other 其他

109 (7.8)

- 提及為約聘人員但未進一步說明情境 - 能夠請假 - 其他原因

- Mention of being a contractor without further context

- Was able to take time off

- Other reasons

Guilt 內疚

103 (7.4)

- 因擔心給同事增加負擔而感到內疚 - 因疫情嚴重性而感到內疚 - 因其他或未具體說明的原因感到內疚

- Guilt due to fear of overburdening coworkers

- Guilt due to the severity of the pandemic

- Guilt for other or unspecified reasons

Unable to enjoy 無法享受

101 (7.2)

- 無法從事正常活動，如旅行和與朋友家人相處 - 因工作相關壓力無法放鬆 - 無法停止思考工作 - 沒有足夠時間做出改變

- 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

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”).
公共衛生工作者（5.0%）表示，請無薪假會導致經濟困難（例如，「如果我請假，就沒有錢支付帳單，我將流落街頭」）。部分公共衛生工作者（

20.8 %

、

n = 290

）也提到擔心因請假而被評判，或組織不贊成請假（例如，「請假存在污名化。在我目前的部門，這是非常不鼓勵的」）。近十分之一（

7.4 %

、

n = 103

，共 1,395 人）的受訪者描述了內疚感，無論是因為疫情的整體狀況，還是因為增加了必須替班的同事的工作量（例如，「我覺得自己會讓同事失望；他們會不停地工作，而我在休息」）。

Employee Assistance Programs
員工協助方案

Of 13155 PHWs who selected

\geq 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.
在 13,155 名公共衛生工作者中，選擇未使用員工協助方案的原因是：

\geq 1

人認為不需要，

51.4 % (n = 6766)

人不認為它會有幫助，

23.3 % (n = 3064)

人對諮詢品質存有疑慮，

11.4 %

、

(n = 1504)

人提出保密性問題，

10.4 % (n = 1363)

人認為諮詢師無法理解他們的情況。

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 %

.
從 2,618 份描述未使用員工協助方案(EAP)原因的書面回應中，建立了 7 大類別和 20 個子類別（表 3）。回應長度為 1 至 146 字。未使用 EAP 的最常見原因包括：使用存取困難（53.1%、

n = 1390

）、使用外部諮詢服務（

21.5 %, n = 564

）、缺乏使用意識或動機（

EAP (11.3 %, n = 297)

），以及對 EAP 效用的負面看法（

7.7 %, n = 202

）。對此問題的回應之間的評分者一致性為

94 %

。

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:
超過半數的公共衛生工作者（53.1%、

n = 1390

，共 2,618 人）回報了使用雇主提供方案時遇到的問題。此類別中包含數個編碼：

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”).
EAP 難以取得（例如：「很難預約，或提供者不接受新病患，即使是透過 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”).
EAP 僅能透過紀律處分或主管核准使用（例如：「EAP 僅能在主管因工作表現不佳或影響工作的行為問題而轉介時才能使用」）。
The respondent did not have a private location to speak (eg, "I live in an apartment with my family and
受訪者沒有私密的交談空間（例如：「我與家人住在一個公寓裡，且

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
表 3. 美國公共衛生工作者在回應 COVID-19 疫情期間（2020 年 3 月至 2021 年 4 月）未使用員工協助方案（EAP）的原因，摘自全國性問卷調查的書面回應類別與子類別（

n = 2618

）（n = 174）

Qualitative category 質性類別

No. (%) of responses citing a reason
引用該原因的回應數（百分比）

Description of qualitative responses
質性回應描述

Difficulty accessing EAP
難以使用員工協助方案（EAP）

1390 (53.1)

- 難以使用員工協助方案 - 員工協助方案僅能透過紀律處分或主管轉介 - 無私密交談空間 - 沒有時間 - 經濟因素

- 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
使用外部諮詢服務

564 (21.5)

- 與外部諮商師建立關係 - 尋求外部諮商服務

- Established relationship with external counselor

- Sought external counseling service

Lack of awareness or motivation to initiate use of EAP
缺乏使用員工協助方案的意識或動機

297 (11.3)

- 不知悉或忘記員工協助方案福利 - 缺乏動機或未曾考慮聯繫

- Unaware of or forgot about EAP benefit

- Unmotivated or did not think to reach out

Poor perception of EAP usefulness
對員工協助方案的效用評價不佳

202 (7.7)

- 過去諮商體驗不佳或對員工協助方案（EAP）印象不佳 - 不需要員工協助方案或認為無法提供幫助

- Previous poor counseling experience or unfavorable of EAP

- Do not need EAP or do not think it would help

Insufficient or unavailable
資源不足或無法使用

122 (4.7)

- 使用員工協助方案的其他福利 - 員工協助方案對員工不可用或可用資源不足 - 無法以偏好的形式提供（例如，線上或現場）

- Used EAP benefit for something else

- EAP not available to employee or available in insufficient amounts

- Not available in preferred format (eg, virtual or inperson)

Other 其他

75 (2.9)

- 曾接觸員工協助方案 - 其他原因 - 不知道為何未使用

- Accessed EAP

- Other reasons

- Did not know why they did not access

Stigma or judgment concerns
汙名化或評判疑慮

45 (1.7)

- 擔心使用員工協助方案會遭受評判或汙名化 - 擔心工作安全與使用紀錄被記錄在員工檔案中

- Fear of judgment or stigma from using EAP

- Concerns about job security and documentation of use in employee records

Abbreviation: EAP, employee assistance program.
縮寫：EAP，員工協助方案。
would have nowhere to take the calls and have full privacy").
沒有地方可以接電話並保持完全隱私。

The respondent did not have time (eg, “Did not feel I could take the time away from work to take advantage of this benefit”).
受訪者沒有時間（例如，「我感覺無法從工作中抽出時間來利用這項福利」）。
The EAP was inaccessible for financial reasons (eg, “After two sessions, you have to pay and [I] can’t afford counseling”).
基於經濟原因無法使用員工協助方案（例如，「兩次諮詢後，你必須付費，而我無法負擔諮詢費用」）。

Employer-Offered Resources
雇主提供的資源

Of 21354 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 = 16749

), free food for staff (

57.0 %, n = 12168

), self-care retreat (

50.9 %, n = 10872

), 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 %

.
在 21,354 名公共衛生工作者中，回答「如果可用，您會使用哪些雇主提供的資源？」這個多選題時，最常被選擇的資源包括事先安排/排定的休假（

78.4 %, n = 16749

）、免費員工餐（

57.0 %, n = 12168

）、自我照顧的退休活動（

50.9 %, n = 10872

），以及虛擬或面對面的瑜伽或冥想課程（

46.6 %, n = 9942

）。1,151 名公共衛生工作者描述他們感興趣的額外資源的書面回應長度為 1 至 421 個字（表 4）。這個問題的回應間的一致性信度為

85 %

。

Write-in responses to the question about desired employeroffered 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
對於想要雇主提供的資源這個問題，書面回覆的內容相當廣泛；許多受訪者在單一回覆中列出多個項目。將近三分之一的受訪者提到希望獲得補償和時間
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.
包括獎金、額外帶薪休假、強制休假、延長休假選項（如休 sabbatical）和心理健康假。第二大類別是其他（

24.7 %

、

n = 284

），包含許多項目，如托育、食物、動物治療等。部分受訪者（

20.1 %

、

n = 231

）表達了希望有部分或更多遠距工作彈性和彈性排班。約六分之一（

n = 184, 16.0 %

）的人報告希望雇主進行組織改革，如內部討論、增加人力或肯定工作表現。回應有時會相互衝突：有些受訪者明確表示只對參加實體聚會感興趣，而其他人則表示只會參加線上聚會。

Discussion 討論

In a nationwide survey of 26174 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
在一項針對 26,174 名公共衛生工作者的全國性調查中，財務困難、缺乏時間（例如，因工作狀態導致休假有限、沒有時間）以及對污名化和評判的恐懼，是受訪者不休假或不使用員工協助方案的關鍵原因。低薪、高工作量和工作倦怠已被確定為公共衛生機構人員流動的主要驅動因素，

^{22}

我們在分析中也觀察到這些主題。這些發現為缺乏利用率的背景提供了解釋

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
表 4. 從美國公共衛生工作者的全國性調查中衍生的類別和子類別（

n = 1151

）（n = 174），描述如果雇主提供，他們將會使用的額外資源，2021 年 3 月-4 月

Qualitative category 質性類別

No. (%) of responses citing a reason
回應引用原因的數量（%）

Description of qualitative responses
質性回應描述

Compensation and time off
薪酬與休假

331 (28.8)

- 獎金 - 額外帶薪休假 - 強制性休假 - 延長休假/休 sabbatical - 心理健康假

- Bonus

- Additional paid time off

- Mandatory time off

- Extended time away/sabbatical

- Mental health days

Other 其他

284 (24.7)

- 雇主提供或支付托育費用 - 提供食物 - 提供福利 - 可攜寵物上班/辦公室寵物/動物治療 - 工作保障 - 雇主提供的任何福利

- 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
排班彈性

231 (20.1)

- 可在家工作 - 工作日中撥出時間自我照顧 - 排班調整或彈性

- Ability to work from home

- Time in workday allotted for self-care

- Scheduling accommodations or flexibility

Organizational changes 組織變革

184 (16.0)

- 縮短工作週或工作負荷 - 領導層變動 - 內部討論與會議總結 - 肯定工作成果 - 增加人力

- Reduced work week or workload

- Leadership changes

- Internal discussions and debriefs

- Acknowledgment of a good job

- Additional staff

Health and wellness services
健康與福祉服務

111 (9.6)

- 免費或優惠健身房會員 - 現場健身房設施 - 按摩

- Free or reduced gym membership

- On-site gym access

- Massage

Mental health 心理健康

109 (9.5)

- 心理健康支持或諮商 - 網路研討會、課程或靜修 - 種族創傷支持

- Mental health support or counseling

- Webinars, classes, or retreats

- Race-based trauma support

Not interested or unknown
不感興趣或未知

49 (4.3)

- 對雇主提供的資源不感興趣 - 無超出所提供的內容 - 未知

- Not interested in employer-offered resources

- Nothing beyond what is offered

- Unknown

Gatherings and social events
聚會和社交活動

44 (3.8)

- 與同事當面交流 - 與同事視訊交流 - 聖經研讀、禱告聚會或其他宗教聚會

- In-person gatherings with colleagues

- Virtual gatherings with colleagues

- Bible study, prayer group, or other religious gatherings

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}

在公共衛生工作者樣本中，關於福利和支援服務的研究顯示，超過半數的受訪者最近曾經歷至少一種心理健康狀況的症狀。

^{8}

Previously reported data from the same survey provide additional context. Among 22093 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
先前從同一份問卷報告的數據提供了額外背景。在 22,093 名公共衛生工作者中，38.9%（

n = 8586

）表示無法在需要時休假（補充資料中的電子表格 2）。

^{8}

在 8,586 名無法休假的員工中，

64.4 %

認為這會使他們更落後，

60.6 %

認為沒有人能夠代替他們的工作職責，

59.5 %

感到內疚，且

18.2 %

表示雇主不允許他們休假。

^{8}

在提供書面回覆的受訪者中，許多公共衛生工作者強調他們無法休假是因為缺乏替補人員。這項挑戰可以透過改善人力配置，並在緊急應變中仔細關注組織結構，包括在關鍵領域規劃備援，以允許休假。這些發現同時突顯雇主需要強調使用帶薪休假的可接受性。
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.
許多受訪者還表示是新近雇用的員工，因為新進員工的休假限制或帶薪休假未納入薪酬方案而幾乎沒有休假機會。超過五分之一的受訪者（

20.9 %

）沒有帶薪休假。為了減少新進員工的心理健康症狀、職業倦怠和離職率，公共衛生雇主可以考慮擴大帶薪休假和員工協助方案的福利，不論是否為合約工，皆適用於所有工作人員。

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

> $ 50000

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
公共衛生工作者感知到的不足薪酬可能導致財務挑戰、壓力和相關的心理健康症狀。另一項對此調查的分析發現，感覺工作薪酬不足的公共衛生工作者之 PTSD 症狀，幾乎是那些認為薪酬足夠的工作者的兩倍（盛行率比

= 1.85; 95 % CI, 1.78 - 1.93

）。

^{8}

擁有公共衛生碩士學位的公共衛生工作者，其研究所學貸

> $ 50000

和起薪年薪介於 50,000 至 70,000 美元之間。

^{23}

學生貸款債務與負面心理健康和降低的生活滿意度有關，

^{24}

且債務已被證實與壓力和憂鬱症相關。

^{25}

增加薪酬或提供財務協助（例如，學生貸款償還）可能有助於
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.
緩解公共衛生工作者所報告的心理健康症狀。這些福利也可能吸引更多候選人進入該領域並填補勞動力缺口。

^{26}

改善薪酬可能有助於預防一些與感覺薪酬不足和面臨財務挑戰相關的負面心理健康結果。

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 selfcare 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.
許多受訪者渴望得到肯定與感謝；在感到工作上不被重視的調查受訪者中，創傷後壓力症候群（PTSD）症狀幾乎是未感到不被重視的人的兩倍（盛行率比=1.82；95% 信賴區間，1.76-1.90）。

^{8}

正面的組織氛圍與醫療工作者較低的倦怠、憂鬱和焦慮水平有關，

^{27}

這個族群與公共衛生工作者相似且常有重疊。公共衛生領導者可以透過以身作則來幫助改善組織氛圍與文化。雇主可以考慮安排全組織的自我照護休息時間、工作日內不排開會的強制時段，以及組織範圍的強制休假。這些策略中的一些可以低成本或不需成本實施，並可能有助於提振士氣和改善績效。

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 23000 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 14902 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.
與提高員工協助方案（EAP）使用率相關的因素包括描述組織 EAP 運作方式的書面政策、足夠的 EAP 人員配置以及主管培訓。

^{28}

在近 23,000 名公共衛生工作者中，回答 EAP 可用性問題的人當中，幾乎三分之一不知道雇主/工作場所是否提供 EAP。

^{8}

在 14,902 名公共衛生工作者中，

11.7 %

報告在疫情期間使用了 EAP（補充資料中的電子表格 2）。

^{8}

許多參與者回覆表示對 EAP 缺乏認知或不知道如何使用，這表明改變 EAP 資訊的傳遞方式可能會增加使用率。此外，如果組織解釋 EAP 如何確保保密性，員工可能會更傾向於使用這項福利。在本次調查的受訪者中，那些組織提供 EAP 的人，比未提供 EAP 的組織員工更不可能報告焦慮症狀，這凸顯了此類服務的價值。

^{9}

在 COVID-19 疫情期間，上海醫院工作者中進行的一項研究發現，參與者在使用 EAP 後，報告的心理健康狀況有正面改變，強調了這些方案的潛力。

^{29}

對機構 EAP 進行全面評估，以評估可及性、服務品質和保密性，可以幫助公共衛生組織提高所提供服務的使用率。

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.
由於回覆差異很大，為了更好地服務員工並確保滿足他們的需求，雇主應考慮定期進行組織氛圍調查，例如國家職業安全與健康研究所的 WellBQ。

^{30}

為了最好地了解各種政策和方案實施對員工的影響，雇主可以考慮進行實施前後的評估活動。

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.
美國公共衛生長期資金不足，可能是導致參與本次調查的公共衛生工作者（PHWs）感到不滿並出現相關心理健康症狀的原因。

^{31}

這種資金不足情況在疫情期間更加惡化，導致人力短缺、薪資相對較低，以及雇主能提供的福利受限。

^{32}

加強公共衛生人員隊伍的策略，可包括支持公共衛生工作者心理健康與福祉的措施，並以促進公平為優先，改善員工薪酬和福利。

Limitations 研究限制

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 %

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

\geq 1

question reported a higher prevalence of anxiety, depression, PTSD, and suicidal ideation (ranging from

4.2 %

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.
本分析存在若干限制。首先，許多填寫回應篇幅冗長，導致編碼人員間初步協議度較低。儘管審查者針對休假和員工協助方案（EAPs）的問題最多列出 2 個代碼，資源問題則最多列出 5 個代碼，但某些回應可能包含超過已使用代碼數量的資訊。在這些情況下，審查者選擇了提及的主要和次要因素的代碼，這可能導致某些資料被排除。其次，在進行代碼決策打破僵局時，第三位審查者未盲目遮蔽，可能受到前兩位審查者所輸入代碼的影響。儘管如此，可用的回應數量仍允許進行強有力的質性分析，可為組織政策和變革提供參考。第三，僅有

4.4 %

至

10.0 %

的受訪者填寫回應，這些發現可能無法完全反映參與調查的 26,174 名公共衛生工作者的需求。第四，填寫

\geq 1

問題回應的公共衛生工作者報告焦慮、憂鬱、創傷後壓力症候群和自殺念頭的盛行率較高（範圍為

4.2 %

至

13.7 %

），相較於先前發表的整體調查人口，

^{8}

這表明提供質性回應的受訪者可能不具代表性。最後，由於採用便利性抽樣且未納入聯邦公共衛生工作者，這些結果不具全面代表性。

Conclusion 結論

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.
保障公共衛生人員的心理健康是維護國家公共衛生基礎設施的關鍵。我們的研究發現突顯了雇主有機會改善可能提升公共衛生工作者心理和生理健康的福利。隨著公共衛生緊急事件持續發生，降低倦怠並改善公共衛生工作者的心理健康，是提高勞動力韌性和表現的重要策略。

Disclaimer 免責聲明

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
本文章中的發現和結論屬於作者個人觀點，並不一定代表美國疾病管制暨預防中心的官方立場。

Declaration of Conflicting Interests
利益衝突聲明

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
作者就本文之研究、著作及/或出版聲明並無任何潛在利益衝突。

Funding 資助

The authors received no financial support for the research, authorship, and/or publication of this article.
作者未就本文之研究、著作及/或出版獲得任何財務支持。

ORCID iDs

Jazmyn T. Moore, MSc, MPH (D) https://orcid.org/0000-0002-1710-1815
Moore, J. T., 碩士，公共衛生碩士（D） https://orcid.org/0000-0002-1710-1815
Ahoua Kone, MPH (D) https://orcid.org/0000-0002-8698-1940
Kone, A., 公共衛生碩士（D） https://orcid.org/0000-0002-8698-1940
Barbara Lopes-Cardozo, MD, MPH (D) https://orcid.org/0000-0003-0259-655X
Lopes-Cardozo, B., 醫學博士，公共衛生碩士（D） https://orcid.org/0000-0003-0259-655X
Carol Y. Rao, ScD, CIH (D) https://orcid.org/0000-0001-7187-2189
Rao, C. Y., 科學博士，工業衛生證照（D） https://orcid.org/0000-0001-7187-2189

Supplemental Material 補充材料

Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the

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$^{1}$ COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
$^{1}$ 美國疾病管制與預防中心 COVID-19 應變小組，喬治亞州亞特蘭大
$^{2}$ Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
$^{2}$ 橡樹嶺科學教育研究院，田納西州橡樹嶺
$^{3}$ Goldbelt C6, LLC, Chesapeake, VA, USA
$^{3}$ Goldbelt C6, LLC，弗吉尼亞州切薩皮克

Corresponding Author: 通訊作者：

Jazmyn T. Moore, MSc, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30329, USA.
賈茲敏·T·摩爾，碩士，公共衛生碩士，美國疾病控制與預防中心，喬治亞州亞特蘭大市克里夫頓路 1600 號，郵遞區號 30329，美國。
Email: vin2@cdc.gov 電子郵件：vin2@cdc.gov

Understanding Low Utilization of Employee Assistance Programs and Time Off by US Public Health Workers During the COVID-19 Pandemic 新冠肺炎疫情期間美國公共衛生工作者員工協助方案和休假低利用率之研究

Abstract 摘要

Keywords 關鍵詞

Methods 方法

Results 研究結果

Time Off 請假

Employee Assistance Programs員工協助方案

Employer-Offered Resources雇主提供的資源

Discussion 討論

Limitations 研究限制

Conclusion 結論

Disclaimer 免責聲明

Declaration of Conflicting Interests利益衝突聲明

Funding 資助

ORCID iDs

Supplemental Material 補充材料

References 參考文獻

Corresponding Author: 通訊作者：

Understanding Low Utilization of Employee Assistance Programs and Time Off by US Public Health Workers During the COVID-19 Pandemic
新冠肺炎疫情期間美國公共衛生工作者員工協助方案和休假低利用率之研究

Employee Assistance Programs
員工協助方案

Employer-Offered Resources
雇主提供的資源

Declaration of Conflicting Interests
利益衝突聲明