Health worker's mental health during COVID-19: Lessons from, and for, fragile and conflict-affected settings
This article first appeared on the Health Systems Global blog on 24 April 2020
In collaboration with HSG’s Thematic Working Group on Health Systems in Fragile and Conflict Affected States (TWG-FCAS), Haja Wurie (COMAHS/ARISE, Sierra Leone) and Julia Lohmann (LSHTM, UK) reflect on the impact of the current COVID-19 pandemic on the mental health of health workers. The TWG-FCAS will continue these reflections and post materials relevant to COVID-19 in FCAS in the coming weeks on our LinkedIn group and Google group pages.
April 5-11 was World Health Worker Week (#WHWWeek) and 2020 has been designated as Year of the Nurse and the Midwife. In the midst of the COVID-19 pandemic, Dr Haja Wurie (College of Medicine and Allied Health Sciences – COMAHS, Sierra Leone) and Dr Julia Lohmann (London School of Hygiene and Tropical Medicine – LSHMT, UK) reflect on what the pandemic means for the mental health of health workers. This is obviously an issue that affects all settings across the globe. Are there lessons we can learn from research carried out in fragile and conflict affected states (FCAS) on coping strategies and support to health workers? How will health workers ‘used to’ extremely difficult environments be able to cope with the pandemic? What are the key questions for research and for interventions to support them during the COVID-19 epidemic?
COVID-19 and health workers’ mental health
Julia: It is safe to say that one of my most vivid memories of 2020 will be of completely exhausted health workers trying to cope with an unprecedented influx of patients in need of care for COVID-19-related complications. Health workers’ mental health and wellbeing happens to be my area of research after all, as a health systems researcher with a background in psychology. But I am sure many of you can relate – indeed, it is almost inevitable that the COVID-19 crisis will affect the health workforce in many adverse ways. Emerging tangible research evidence cements impressions from the news and social media. Initial studies from China indicate that COVID-19 has taken a severe toll on the mental health of the frontline health workforce, with particular groups being at higher risk. Attention and worries are now increasingly turning to low-and-middle income countries (LMICs) and sub-Saharan Africa. Given the starting point of many LMIC health systems, particularly in FCAS, the COVID-19 impact will likely be particularly severe. What will that mean for the people working in them, particularly for their mental health?
The impact of the Ebola epidemic on health workers’ mental health
Haja: That health workers are the most vulnerable in the face of a disease outbreak was evident during the 2014-16 Ebola Virus Disease (EVD) outbreak, and the ongoing COVID-19 pandemic will not be an exception. Research conducted by the ReBUILD project in Sierra Leone showed that health workers experienced a range of emotions, whilst expected to continue serving. They reported being very frightened of contracting Ebola, as they saw many health workers, relatives and community members die. Some recalled the constant fear of contracting the virus and spreading it to their families and loved ones or being paranoid, always looking for Ebola symptoms. In the meantime, they were expected to continue working, and, more often than not, without the necessary enablers. In addition, health workers also faced stigma and discrimination at the community level. They were asked to vacate their rented properties, not allowed to board public transportation, and accused of injecting patients with the virus.
Health workers’ coping strategies and lessons learned for support
Haja: Several coping strategies reported by health workers during the EVD outbreak were based on their intrinsic motivation or were self-initiated, reflecting similar findings pre-Ebola and in other fragile and conflict-affected settings. These include selfless patriotism – having a strong sense of duty to serve their communities during a national crisis – and having peer and family support – being each other’s keepers when managing patients in terms of infection prevention and control. For example, a WhatsApp group called ‘Ebola Fighters’ was created to provide morale support and encouragement to each other and appeared to be helpful. Many health workers reported that their religious belief helped them cope with seeing patients and colleagues dying from Ebola. Health workers often prayed together before starting work. Other external support strategies included supporting an enabling environment in terms of availability of essential resources such as personal protective equipment (PPE) and the requisite training. Later, psychosocial support was also provided to help them cope with the stigma of being a health worker during an epidemic.
Psychological resilience of health workers: “being used to” doesn’t mean “being ok with”
Julia: Since the 2014-16 Ebola outbreak, “preparedness” and “resilience” have been favourites in the global health community. Yet, many high-income countries were clearly not as well prepared as they could have been, in terms of material and infrastructure, but also in terms on health workers’ psychological resilience. Echoing sentiments expressed in social media over the last weeks, a London-based GP friend of mine recently told me that people dying is not the problem, they are used to that. Rather, it is the avoidable deaths, having to decide who received treatment and who does not, and not being able to protect themselves from infection.
This makes me think that, in a twisted way, the very reasons rendering resource-limited and crisis/conflict-affected health systems particularly vulnerable to COVID-19 might, in fact, put their health workforce at an advantage when it comes to their mental health. Sadly, some of the challenges health workers in high-income countries currently face for the first time are part of daily reality for health workers in many LMICs and particularly in FCAS. They are used to not having sufficient PPE, despite high prevalence of HIV, TB, and other infectious diseases among their patients. They are used to not being able to save patients from avoidable causes. They are used to having to decide over who lives and who dies.
“Being used to” of course doesn’t mean “being ok with”. Research indicates that levels of burnout and other mental health conditions are high among health workers worldwide. However, health workers in resource-limited and FCAS have no choice but to develop strategies to cope with their more than sub-optimal working conditions. This might now put them at an advantage compared to their high-income peers in dealing with the psychological toll the COVID-19 pandemic will inevitably take.
Supporting health workers in FCAS during the COVID-19 pandemic
Haja: As the current pandemic continues to evolve, we must think ahead of the potential mental health impact that COVID-19 will entail for health workers. They will again be expected to serve whilst dealing with the fear of contracting the virus and potentially passing this on to their loved ones, with often inadequate support systems in place. This has serious consequences, not only for the individual, but on their productivity at the frontline and ultimately the overall response.
This is a call for decision-makers to ensure that our health ‘soldiers’ are well equipped in this and future fights – not just in terms of essential resources, but in a holistic manner. This includes prioritising the mental health and psychosocial support of health workers at all levels – including community health workers – and having supportive supervision and problem-solving approaches that respond to the different needs and concerns of health workers, at all levels of the health system.
Julia: We will be soon starting a longitudinal, diary study to investigate health workers’ experiences and their psychosocial wellbeing in selected sites. We want to explore the real-time impact of the COVID-19 epidemic and look into some of the hypotheses we mentioned in this blog post, in particular about the psychological resilience of health workers. The study will begin in Burkina Faso, The Gambia and Senegal, with Wellcome Trust funding, and we are looking into options to extend it to other settings, specifically FCAS, in collaboration with the Rebuild for Resilience (R4R) project, which will build on the work of ReBUILD to further support the health workforce in fragile and shock-prone settings.
Photo credit: United Nations Photo under a Creative Commons license.