By Joanna Raven, Sally Theobald, Kate Hawkins, Sophie Witter and Haja Wurie, members of the Fragile and Conflict Affected States TWG
“Healthcare workers are only human. We experience the same COVID-19-related fear and anxiety as anyone else. This might be fear that we or our friends and family will have to self-isolate or quarantine, or become ill. But there is also the fear of caring for people with COVID-19, some of whom will die. A survey of nearly 1,300 healthcare workers treating people with COVID-19 in hospitals in China showed high rates of depression, distress, anxiety and insomnia.” ~ Miriam Taegtmeyer and Tom Wingfield
‘Invest in mental health’ is the theme set for this year’s mental health day by the World Federation for Mental Health. The impact of COVID-19 has triggered real challenges for mental health and well-being around the world. Narratives of anxiety, fear and distress are commonplace as people struggle with sickness, stigma, loneliness, and isolation, and gender-based violence is on the rise too.
The rallying call of “mental health for all” must include action, support and solidarity for frontline health care workers who face these challenges day in, day out at work, at home and in their communities. In many contexts, health care workers do not have easy access to Personal Protective Equipment (PPE) or psychosocial or mental health support.
Research from the ReBUILD consortium used life histories and other methodologies to understand the challenges faced by health care workers in fragile and shock-prone settings. This includes pre-, during and post-war and other shocks, such as Ebola in Sierra Leone. You can learn more about this and research on psychosocial health of adolescents’ girls in ReBUILD for Resilience World Mental Health Day – resources. COVID-19 brings new challenges for health care workers at all levels that require solidarity and psychosocial support.
Five key messages from our work on health workers in fragile and shock-prone settings
- Health workers are often targeted during shocks and conflict. They face fear of or actual attack, sexual violence, abduction and death. Health workers also witness traumatic events that happen to others, including colleagues, relatives and community members.
- The stigmatising nature of disease outbreaks create particular challenges for health workers. During the Ebola outbreak, they were frequently ostracized by their communities — a social isolation which was not only hard to bear but also a poor reward for their continued service. There was often increased suspicion between health workers. Health workers also experienced isolation from families for fear of passing on the infection, and pressure from relatives to discontinue working. These continue to affect health workers’ daily life.
- There are ongoing everyday stressors for health workers in these settings, which contribute to increased stress and burnout. These include limited supplies, long hours and overload of work, managing complex health issues with little support, and challenges with referrals, irregular payment, and limited support from the health system and community.
- Health workers adopted coping strategies. Self-protection mechanisms included not wearing uniform and changing sleeping places frequently (during conflict). Psychosocial support came from drawing on internalized value systems such as religion and a sense of fatalism and service to country, as well as from community, peer and organizational support.
- However, we found that there are important gaps in the support for health workers in fragile and shock-prone settings. Support strategies should be in place at local, national and international levels, rather than relying on personal sacrifices by staff to keep services functioning.
Interventions to support mental health and wellbeing
In fragile and shock-prone settings – where chronic stressors and crisis situations often collide – there have been a number of trial interventions by communities and health facilities to support health care workers to maintain good mental health. For example, a recent paper in BMJ Global Health describes a series of rapid and longer term strategies that were used during and after the Ebola outbreak in Liberia and Sierra Leone. These include ‘de-stressing zones’ in health facilities to aid the transition between work and home, mandatory rest-periods, Schwarz rounds and the use of trained mental health nurses to support their peers. Informal WhatsApp groups and more professional crisis lines offered the opportunity for dialogue and counselling. Community healing and support groups were developed to deal with the fall out of fear, stigma and discrimination.
In ReBUILD, three new projects will explore health workers’ experiences during COVID-19. In Myanmar, we will identify strategies to maintain routine service delivery during the COVID-19 pandemic in the Yangon region, and how these strategies are affecting health worker wellbeing. In Nepal, a study focuses on how health workforce policies and practices are adapted at the district level to manage and support health workers during the COVID-19 pandemic. In Sierra Leone, Lebanon, Nepal and Myanmar, our focus is on close to community providers, their gendered experiences and how they are supported to fulfil their critical roles in the COVID-19 response.
Health workers are at the epicentre of the COVID-19 pandemic, and yet their interests are often last on the list of priorities. Personal and professional coping strategies which were already stretched to their limits in fragile and shock-prone settings are being tested even further. Pressures from frightened and confused community members, from health staff and their families, and from systems which often fail to provide the necessary guidance, equipment and support for staff.
At the same time, the world has understood – more than ever before, perhaps – how critical their frontline and public health staff are. And the measures which are needed to support them and their mental health are often simple and affordable, such as better communication, more recognition, and protected time to rest. On mental health day, let us remember that there is no person-centred health care system without person-centred health worker support systems.