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Health care providers on the frontlines: A qualitative investigation of the social and emotional impact of delivering health services during Sierra Leone’s Ebola epidemic

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Although research on the epidemiology and ecology of Ebola has expanded since the 2014–15 outbreak in West Africa, less attention has been paid to the mental health implications and the psychosocial context of the disease for providers working in primary health facilities (rather than Ebola-specific treatment units). This study draws on 54 qualitative interviews with 35 providers working in eight peripheral health units of Sierra Leone's Bo and Kenema Districts. Data collection started near the height of the outbreak in December 2014 and lasted 1 month. Providers recounted changes in their professional, personal and social lives as they became de facto first responders in the outbreak. A theme articulated across interviews was Ebola’s destruction of social connectedness and sense of trust within and across health facilities, communities and families. Providers described feeling lonely, ostracized, unloved, afraid, saddened and no longer respected. They also discussed restrictions on behaviors that enhance coping including attending burials and engaging in physical touch (hugging, handshaking, sitting near, or eating with colleagues, patients and family members). Providers described infection prevention measures as necessary but divisive because screening booths and protective equipment inhibited bonding or ‘suffering with’ patients. To mitigate psychiatric morbidities and maladaptive coping mechanisms—and to prevent the spread of Ebola—researchers and program planners must consider the psychosocial context of this disease and mechanisms to enhance psychological first aid to all health providers, including those in peripheral health settings.
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Healthcare providers on the frontlines:
a qualitative investigation of the social and
emotional impact of delivering health services
during Sierra Leone’s Ebola epidemic
Shannon A. McMahon,
1,2
Lara S. Ho,
3,
* Hannah Brown,
4
Laura Miller,
5
Rashid Ansumana
6,7,8
and Caitlin E. Kennedy
2
1
The Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, 69120, Germany,
2
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205,
USA,
3
International Rescue Committee, New York, NY, 10017, USA,
4
Department of Anthropology, Durham
University, Durham, DH1 3LE, UK,
5
International Rescue Committee, Freetown, Sierra Leone,
6
Department of
Parasitology, Faculty of Biological Sciences, Liverpool School of Tropical Medicine, Liverpool, L35QA, UK,
7
Department of Community Health and Clinical Studies, School of Community Health Sciences, Njala University,
Bo, Sierra Leone and
8
Mercy Hospital Research Laboratory, Bo, Sierra Leone
*Corresponding author. 1730 M St NW, Suite 505, Washington, DC 20009. E-mail: lara.ho@rescue.org
Accepted on 10 April 2016
Abstract
Although research on the epidemiology and ecology of Ebola has expanded since the 2014–15 out-
break in West Africa, less attention has been paid to the mental health implications and the psycho-
social context of the disease for providers working in primary health facilities (rather than Ebola-spe-
cific treatment units). This study draws on 54 qualitative interviews with 35 providers working in
eight peripheral health units of Sierra Leone’s Bo and Kenema Districts. Data collection started near
the height of the outbreak in December 2014 and lasted 1 month. Providers recounted changes in
their professional, personal and social lives as they became de facto first responders in the outbreak.
A theme articulated across interviews was Ebola’s destruction of social connectedness and sense of
trust within and across health facilities, communities and families. Providers described feeling lonely,
ostracized, unloved, afraid, saddened and no longer respected. They also discussed restrictions on
behaviors that enhance coping including attending burials and engaging in physical touch (hugging,
handshaking, sitting near, or eating with colleagues, patients and family members). Providers
described infection prevention measures as necessary but divisive because screening booths and
protective equipment inhibited bonding or ‘suffering with’ patients. To mitigate psychiatric morbid-
ities and maladaptive coping mechanisms—and to prevent the spread of Ebola—researchers and
program planners must consider the psychosocial context of this disease and mechanisms to en-
hance psychological first aid to all health providers, including those in peripheral health settings.
Key words: Ebola, frontline health workers, mental health and psychosocial support, qualitative research, Sierra Leone
Introduction
As of 10 January 2016, Sierra Leone reported 14 122 cases (includ-
ing 8704 laboratory-confirmed cases) of Ebola virus disease (Ebola),
the highest number of reported cases amid the ongoing West Africa
outbreak (CDC 2016). During the outbreak, an unprecedented
number of doctors, nurses and healthcare workers have been in-
fected (Fischer et al. 2014;WHO 2014b). The WHO estimated in
April 2015 that 303 health workers in Sierra Leone had been in-
fected with Ebola, and 221 had died (WHO 2015a). In Liberia and
Guinea, health worker fatalities due to Ebola were 188 and 94, re-
spectively (WHO 2015a).
Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine V
CThe Author 2016.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
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Health Policy and Planning, 2016, 1–8
doi: 10.1093/heapol/czw055
Original Manuscript
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A small but growing body of literature from the current epidemic
has emphasized that efforts to address Ebola outbreaks—during, im-
mediately after and in the longer-term—must be more attentive to the
mental health needs and psychosocial context of the disease (Arwady
et al. 2014;Cooper 2015;Hughes 2015;Lee-Kwan et al. 2014). This
sentiment is echoed in recommendations from earlier Ebola outbreaks
in Uganda (Kinsman 2012) and Democratic Republic of Congo (De
Roo et al. 1998) and from outbreaks of yellow fever and cholera in
the 18th and 19th centuries (Honigsbaum 2014).
Existing literature at the nexus of mental health and Ebola focuses
on patients and, to a lesser extent, their families. Those studies high-
light how individuals enduring Ebola often face stigmatization, de-
pression, economic adversity and—in the case of survivors and their
families—survivor’s guilt and non-acceptance upon reintegration into
society (Arwady et al. 2014;De Roo et al. 1998;Lee-Kwan et al.
2014). Stigma has been particularly highlighted throughout history in
relation to illnesses that are life-threatening, difficult to treat and
whose source and transmission mechanism are (at least initially) un-
certain; HIV/AIDS is a historically recent example (Wainberg et al.
2014). The current Ebola outbreak has highlighted stigmatization at
local, regional and global levels. In Sierra Leone specifically, an
August 2014 survey conducted by UNICEF, Catholic Relief Services
and Focus 1000 found that in a random sample of 1413 population-
based respondents, 96% held discriminatory attitudes towards those
who had or were suspected of having Ebola, 76% of respondents said
they would not welcome someone back in their community if they
had recovered from Ebola and 32% said they viewed a recovered
school pupil as a risk to other students (Focus 1000, 2014).
Although challenges—including stigma—relating to the experience
of survivors, their families and healthcare workers in Ebola case man-
agement facilities have been explored, less attention has been paid to
the experiences and needs of those engaged as front-line responders in
primary care facilities where many cases first present (Cooper 2015;
Deng et al. 1978;Hewlett and Hewlett 2005;Hughes 2015;Khan
et al. 1999;Kinsman 2012;Pathmanathan et al. 2014). These individ-
uals are among the most vulnerable to infection and are at an excep-
tionally high risk for being (or having been) stigmatized, ostracized,
attacked, contracting Ebola or forced to bear witness to tremendous
human suffering (Hewlett and Hewlett 2005;Kinsman 2012). In Sierra
Leone, preliminary estimates presented in February 2015 suggest that
at least 65% of healthcare worker infections occurred among providers
working in non-Ebola-specific care facilities (Bennet 2015). Ensuring
the protection of workers in Ebola-specific facilities was prioritized in
the beginning of the outbreak; however, this approach did not account
for the fact that the non-specific clinical presentation of the disease
meant that most Ebola patients seeking care first visited a non-Ebola
healthcare centre. Health care workers in primary health care facilities
and hospitals where therefore particularly vulnerable to contracting
Ebola (Levy et al., 2015).
Given a paucity of research on the psychosocial context of
Ebola, and limited insights drawn from the experiences of providers
– particularly those working in peripheral health facilities – this art-
icle examines how front-line providers in Sierra Leone experienced
and assessed the changes in their professional, personal and social
lives during the protracted Ebola outbreak (Hughes, 2015).
Materials and Methods
Study setting
The study took place in eight peripheral health units (PHU) across
two districts (Bo and Kenema) in Sierra Leone during the height of
the 2014–15 Ebola epidemic. PHUs were government-run and
included Community Health Posts (CHP), Maternal and Child
Health Posts (MCHP) and Community Health Centers (CHC).
Qualified staff ranged from two to five clinical personnel at each fa-
cility. The total catchment population for PHUs included in the
study is 35 738 and 16 240 in Bo and Kenema districts, respectively.
During this period, upwards of 300 new cases were confirmed
weekly (WHO 2014a).
Study design
This analysis draws from 54 qualitative, semi-structured interviews
with 35 providers including community health officers, nurses, ma-
ternal child health aides, community health workers and laboratory
technicians. Communities were primarily Mende, and most lower
tier health professionals identified as Mende. Higher tier health pro-
fessionals were from a variety of ethnic backgrounds, but many
were also Mende speakers. These research activities were conducted
as a part of a larger mixed methods study on improving infection
prevention and control in PHUs in the context of Ebola (2015). At
the outset of the overall study, the research team intended to inter-
view each provider twice to assess possible changes after a workshop
to develop infection prevention and control improvement plans, but
this was not always feasible as providers could be absent, ill or pro-
viding care on the day of the scheduled interview. Interviews typic-
ally lasted 1 hour. This participatory study was not designed to
explore the psychosocial dimensions of Ebola. However, in response
to questions about Ebola case management, impressions of Ebola,
and knowledge or experiences implementing infection prevention
measures, respondents discussed feeling emotionally, socially and
physically distanced from colleagues, families, friends or the broader
community. Following the iterative nature of qualitative research,
this theme was more purposefully explored as interviews
progressed.
Key Messages
This article examines the social and emotional experiences of front-line providers (those not working in Ebola-specific
treatment facilities) as they became de facto first responders in Sierra Leone’s Ebola outbreak.
Frontline healthcare workers described how Ebola weakened a sense of trust within and across health facilities, pro-
viders, communities and households.
Along with changes in their professional lives, communities and homes, providers described a profound sense of stig-
matization, suffering, loneliness, isolation and sadness since the onset of Ebola.
To mitigate psychiatric morbidities and maladaptive coping mechanisms, health systems must consider how to enhance
mental health and psychosocial support for not only providers working in designated Ebola treatment and care facilities
but also those working in facilities that are not specifically for Ebola management.
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Data collection
Data were collected between 15 December 2014 and 30 January
2015. A team of eight data collectors with previous experience in re-
search on behalf of NGOs or community development sectors was
trained for 3 days, including 1 day of piloting and tool refinement.
Four of the data collectors identified as Mende: three as Temne and
one as Fullah. Free and informed consent was obtained from each
respondent prior to the start of interviews. Interviews were audiore-
corded, conducted and transcribed verbatim in Krio or Mende be-
fore being translated into English. Respondent characteristics are
outlined in Table 1.
Data analysis
An initial phase of open, inductive coding on a selection of rich, diverse
and representative transcripts was done by the lead author, as informed
by principles of Grounded Theory (Charmaz 2006). This resulted in
the creation of a codebook that was shared by the lead author and vali-
dated by a senior author (L.H.). The codes were then applied to re-
maining transcripts using Dedoose (Lieber and Weisner 2013). The
lead author routinely provided analytic summaries to the study leads
(L.H. and H.B.) and received feedback that helped to further refine the
analysis and inform higher-level interpretations of the work.
Ethical approval
The study received ethical approval from Institutional Review
Boards of Durham University and the Sierra Leone Ethics and
Scientific Review Committee.
Results
We first present an overview of how providers described ‘living
through Ebola’. We then present experiences at the PHU
1
, commu-
nity, household and individual levels (Table 2).
One theme that respondents consistently articulated was the
manner in which Ebola undermined a sense of trust within and
across health facilities, communities and families. Many providers
described a need to be vigilant and ‘not trust’ others because of the
fear of contracting Ebola, which ‘lives not only in your enemies but
can get you through close relationships ... with your friends, wife,
children and family’. This sentiment applied to anyone with whom a
provider came into contact, from family members to patients to col-
leagues. Providers described needing to constantly ‘observe’ those
around them to watch for strange or infection-compromising behav-
ior. One provider explained that she used to hold lactating mothers’
Table 1. Respondent characteristics
Bo (n¼16) Kenema (n¼19)
Male 5 (31) 10 (53)
Age
<30 4 (25) 4 (21)
30–39 4 (25) 7 (37)
40–49 5 (31) 6 (32)
50 2 (13) 1 (5)
Missing 1 (6) 1 (5)
Job title
Community health assistant 4 (25) 0
Community health officer 1 (6) 2 (11)
Community health worker 1 (6) 0
Maternal child health aide 5 (31) 4 (21)
State enrolled nurse 4 (25) 7 (37)
Laboratory technician 0 1 (5)
Other 1 (6) 4 (21)
Missing 0 1 (5)
Table 2. Provider experiences of social, emotional and physical distancing in the “Time of Ebola”
In health facilities
Changes in facility routines and practices
Facility quarantines; restriction of movement within facilities (including infection prevention screening)
Changes in provider-provider relations
No communal eating; loss of trust among providers
Changes in patient-provider relations
No touching, holding or hugging a grieving patient, maintaining distance from and among patients, isolating ill patients, “turning one’s shoulder” to
patients, denying emergency care until a patient has been screened
In communities
Restrictions or bans against
Communal or public gatherings (for school, burials, meetings, soccer matches and construction projects)
Travel
Entering/exiting communities
Burning of houses or possessions of Ebola patients
At home
Restrictions or bans against
Sitting close to others
Handshaking or hugging
Checking in on neighbors or accepting visitors
Checking on sick family or friends
Children’s movements
Intimate relationships
As individuals
Providers report
Grief, loneliness, suffering and sadness
Feeling stigmatized by family and community
Fearing death
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babies during weigh-ins but since the Ebola outbreak, ‘No one will
take your child because we do not trust you. Providers do not even
trust one another. We nurses do not get close to patients because
there is no trust’. A lack of trust was especially prominent in encoun-
ters with strangers or visitors from another town, and to community
members who had been away a period of time because, as one re-
spondent put it, ‘We cannot allow you to be among us because we
don’t know where you are coming from, if you have fallen sick and
you come to us, we will never know’.
Distancing within facilities
Two facilities included in this study underwent a 21-day quarantine
due to early, compromised contact with a confirmed Ebola case. In
those facilities, providers described being ‘deprived of our movement’
and feeling ostracized, scared and upset. Describing that period, one
respondent said, ‘We did not even have access to even our own chil-
dren. We were lying on the floor for 21 days’. The quarantine induced
panic within the facilities and the broader community; one provider
reported that ‘community members tried to burn this place down’.
Although the quarantine had ended by the time of interviews, pro-
viders described a tense ‘waiting period’ post-quarantine as clients did
not return to the facility for fear of contracting Ebola.
Although facilities included in the study were not under quaran-
tine at the time of the study, providers described how ‘movement’ and
a sense of ‘being free’ was restricted due to the erection of fencing and
screening booths (also called ‘interrogation tables’). Providers under-
stood the necessity of the screening process, but were profoundly
upset by the fact that it prevented them from immediately treating ur-
gent cases. Providers reported that many individuals suffering from
an illness in the post-Ebola period delayed seeking care until their
cases were severe because they viewed facilities as Ebola transmission
points. This meant that more severe cases were presenting at facilities,
including ‘a delivering woman’, ‘patients with bleeding wounds’,
‘shaking children’, ‘shivering brothers and sisters’, ‘dying people’ and
individuals who were so ill that they had difficulty walking. As one
provider said, ‘If we have not done triage, we are not going to take
care of that person even if she is in labor... we have to abandon her
on the street’. Along with these extreme situations, providers also
described imposing necessary but ‘disliked’ measures to physically
separate patients, such as telling them ‘not to cluster’ and to stay an
arms-length distance away from other patients. They also had to stop
women from co-nursing babies.
Providers described how they missed casual interactions with the
community. ‘People used to be happy to come here, to meet us, to
say thanks. The place was open ... Now the hospital is fenced off’.
Another provider said, ‘Nobody comes to ... say hello anymore’.
Still another presented this comparison: ‘Children used to come here
and hug us. Now they run away from us... they call us the devil’. In
one facility, providers described how they used to be ‘blessed’ with a
heavy caseload including ‘people who came from far away, even
though they had nearby facilities’. Given restrictions on travel, and
bans against allowing strangers into a community or one’s home,
providers said they could no longer ‘open our hands to you if you
are not from this community’.
Strained relationships between providers
Relationships between providers were also described as strained.
When asked to discuss life in the months since the outbreak began,
one provider said she felt that ‘although we are in this together,
there is a distance between us’. Another said she and her colleagues
felt constant anxiety due to the concern that ‘you make one little
mistake’ and you may infect yourself, your colleagues or your fam-
ily. Providers said they no longer touched one another, or gathered
to converse or eat; that they were instructed to observe and ‘watch
over’ one another for infection-compromising behavior; and that
previous feelings of trust and confidence had been replaced by the
sentiment that ‘it is every man for him or herself’ and ‘an infection
to one ... can be an infection to all’. Some lower grade health work-
ers, such as porters, reported that senior health workers monopo-
lized the use of protective material such as gumboots, leaving them
unprotected in their work. In an extreme case, a nurse described
how a colleague survived Ebola, but upon returning home and learn-
ing that his wife and children had died, he ‘became paralyzed’ and
‘lost his mind’. The nurse said her only option was to call an ambu-
lance to take her colleague back to the Ebola treatment unit as facil-
ity providers were ‘scared to get near him’ or touch him.
Strained patient–provider relationships
Among the most painful adjustments providers described since the
onset of the Ebola outbreak related to patient–provider relation-
ships. Providers described ‘preaching and living the don’t-touch
practice’ and knowing that ‘too much sympathy will lead to Ebola
infection’, but they nevertheless missed touching their patients, hold-
ing or hugging a grieving patient, assisting lactating mothers with
their babies, sitting face-to-face or ‘being near’ patients, and rushing
to assist individuals presenting with an emergency. Providers felt
bad that infection prevention equipment ‘dehumanized’ them in the
face of patients, and that ‘thermometer guns’ (used to take tempera-
tures at screening booths) initially terrified many community mem-
bers. One provider used the phrase ‘turning one’s shoulder’ to
describe how she felt while interacting with patients.
I feel bad because I am a medical person, and this disease is pre-
venting us from touching patients.... I am an MCH [maternal
child health] Aide and I always carry out deliveries and immun-
ization ...I must touch my patients.
This stood in contrast to previous facility practices wherein pro-
viders ‘were open, welcoming’, ‘would check patients with our bare
hands’, and would ‘suffer alongside’ patients. One provider felt she
was no longer connected to her patients: ‘It used to be that patients
would just come to the center without being screened, and we would
allow that patient to enter. Whether the patient came with a conta-
gious disease or not all of us will just suffer through it’.
In extreme (and rare) instances, respondents described how pa-
tients cursed, slapped and attacked providers because they heard
rumors of providers ‘injecting Ebola’ and ‘selling bodies’ as a means
for personal financial gain.
Distancing within communities
Along with drastic changes in their professional lives, providers also
described changes within their communities. One provider said,
‘nothing is working any more’ and another described how Ebola
was ‘wiping away’ the progress Sierra Leone had made in the post-
war period. Providers described how it could be traumatizing for a
community to watch as an Ebola victim’s personal possessions were
burned, leaving ‘nothing but walls’. Providers said protracted school
closures were becoming problematic as children were left with little
to occupy their days; one provider feared that his ‘bored’ daughter
would ‘get into trouble’—possibly even become pregnant—if
schools were not re-opened soon. Providers said they missed attend-
ing burials and visiting their sick families. Travel bans were
described as necessary (‘because Ebola is everywhere in the
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country’). Nevertheless, bans prevented providers from visiting sick,
dying or grieving family members, which was especially discomfort-
ing given that providers were often called upon to assist ailing
relatives.
Three people have died in my hometown. I’ve not gone there to
pay a visit. I have decided not to attend any burial because if I
do, when I come back whether it’s Ebola or not anything that
happens to me even if it’s just a slight headache they will say I
went to the village to attend a burial.
One provider described missing soccer and his favorite team,
Manchester United: ‘Watching soccer (at the community television)
was my hobby.... I am really unhappy because I no longer see my
players when they are playing’. Along with community television
cancellations, broader public meetings and celebrations were also
cancelled as well as building projects (including a hospital expansion
project and a latrine construction). One exception was religious ser-
vices, which were permitted to continue.
Distancing at home - within and across households
Similar restrictions on movement and interactions were also experi-
enced in the context of interactions at home and with neighbors.
Providers said they avoided hugging or handshaking, ‘even if it is
your sister whom you have not seen for a long time’ or your ‘son
who is visiting’. Providers described telling members of their house-
hold to ‘stop going to another person’s compound’, and they dis-
cussed how they tried in vain to restrict their children’s movement.
One provider said she imposed limits on the distance her child was
allowed to be from their home, but he routinely disobeyed her
orders. Another said she forced her children to sit inside. Still an-
other described how her child no longer had friends because neigh-
bors ‘quietly stigmatized’ the children of health providers.
In instances where providers could not prevent visitors from
coming to their homes, they described setting up washing stations
and requiring that guests remove their shoes. More often though
they discouraged such home visits or confined visitors to designated
areas of their property.
Providers also described the impact of Ebola on intimate rela-
tionships. One provider said that since a man she had been dating
was away for several weeks, she knew she could not ‘allow him
(near me) until I know his status’. Other providers said they had
learned to ‘avoid sexual intercourse. There were so many love rela-
tionships that have stopped because of Ebola’.
Personal perceptions and experiences of distancing
The changes described in their professional lives, communities and
households affected how providers felt about themselves and their
social surroundings. Providers described ‘suffering’, ‘loneliness’,
being ‘isolated’ and feeling ‘full of sadness’ since the onset of Ebola.
Many said they were in the midst of grieving the deaths of wives,
husbands, sisters, children, colleagues and friends. One provider
said she was ‘bleeding in my heart for all of my colleagues’ who had
died. Another stated, ‘We have a saying that there is nothing that
can break a family, but this sickness will cut an entire family. It des-
troys everything’.
Providers said they yearned for ‘the way things were before
Ebola’. They felt that they were ‘not trusted’, ‘not loved’, and ‘not
respected by the community’, that they had ‘fewer friends’, and that
people wanted to ‘keep a distance’ from them. Providers said they
heard neighbors ‘whispering things’ about them and were viewed
with suspicion. One provider used the phrase ‘killing my spirit’ to
describe how the community’s perception of her made her feel. She
said she had tried to address this problem by saying:
If you are scared of me, it makes me feel bad. And what if I feel
bad and get angry and decide not to go to the center again? What
if all the health workers sit down and refrain from treating Ebola
patients? Who will do that job? People have come from other
countries to help us fight Ebola. If we sit in our own country and
say we will not take part in that fight how will the disease go?
Several providers noted their families stopped coming near them
or talking to them due to fear. Many of their families urged them to
stop working at health facilities. Several providers said they did, at
some point, leave their posts, which was a demoralizing and guilt-
inducing decision. One provider felt lonely at the end of the work-
day because she went home and had to ‘sit alone and isolate myself’
from her family. Another provider said he felt that he ‘owns the
Ebola’ because his family told him, ‘You, the health workers, cur-
rently we are afraid of you because you possess the disease’. Another
provider said she felt distrusted by her family. She shared the follow-
ing account from a conversation with her mother:
As for my mother I do not go to her, nor does she come to me.
When she needs something, I send it to her... Even the last time
we were talking, I was just making a joke and I said that I want
to pay her a visit and she kept saying, ‘If you come right now, we
will quarantine you for 21 days before we allow you to mix with
us’ and then I told her, ‘It’s just a joke. I don’t even have plans to
go’.
Finally, providers described fearing their own mortality. ‘I have
begun to imagine my own death, how sad my family would be with-
out me’, said one. They described losing their appetite, having trou-
ble sleeping, and ‘living in fear’.
Discussion
This article documents the experiences of front-line providers work-
ing in primary healthcare settings during the recent Ebola outbreak
in Sierra Leone. Such providers have received relatively little atten-
tion compared with those working in Ebola treatment units or
Ebola patients and their families despite their critical role in the epi-
demic response. Amid the Ebola outbreak, the Sierra Leonean
Ministry of Health and Sanitation recognized the risk to peripheral
health providers and prioritized improvements to infection preven-
tion measures across the country’s 1200 PHUs (Levy et al., 2015).
The timely deployment of equipment coupled with the continued
operation of >95% of these facilities at the height of the epidemic
reflects an impressive commitment across multiple levels of the
health system (Levy et al. 2015). Nevertheless, this study has high-
lighted providers’ concurrent need for support and guidance on how
to cope with the stress, horror, danger, grief and human misery that
enveloped them in their role as de facto first responders in the Ebola
crisis (WHO, World Vision, UNICEF 2014). Like providers in
Ebola treatment units, our respondents internalized the suffering
they experienced as witnesses to sudden, horrifying deaths from
Ebola (Padickakudi et al. 2015). The ways in which providers know
that wearing protective equipment is necessary, but makes them feel
inhuman or uncaring has also been discussed in relation to this and
other outbreaks (Borchert et al. 2007;Cooper 2015). Despite facing
these significant stressors, providers commendably continued to
work out of a sense of dedication to their jobs, their patients and
their communities.
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Ethnic cleavages between healthcare providers and communities
experiencing epidemics have been identified in other settings as
exacerbating effective epidemic management (Bolten 2014). In our
study neither ethnic difference nor the gender of health workers
emerged as a significant points of tension. We found that the pri-
mary cause of unease and distrust was being a health worker. This
experience was shared across all tiers of health workers, and by
para-health professionals (such as porters). Providers in our study
described feeling stigmatized by people to whom they had previously
been very close, including friends, their own family members, fellow
health professionals and the broader community. Previous research
on Ebola outbreaks has emphasized that many of the measures
introduced by affected communities such as increasing distance and
avoiding contact can aid disease control (Hewlett and Amola 2003;
Hewlett and Hewlett 2007). However, the effect of these measures
upon health workers was distressing. Health workers were accus-
tomed to working in stressful and traumatic situations, without
proper resources, sometimes without pay, and dealing with a range
of dangerous infectious diseases. However, many had worked and
lived among the communities whom they served for many years and
spoke movingly of radical transformation in interpersonal relations
that they experienced during the Ebola outbreak. Despite this, they
remained committed to their efforts as health professionals. Similar
feelings of stigma have been reported by providers in previous Ebola
outbreaks in Uganda, Republic of Congo and Democratic Republic
of Congo (Hewlett and Hewlett 2005;Kinsman 2012). In Sierra
Leone, our findings suggest that initial conspiracy beliefs that as-
signed discrediting attributes to providers were not sustained later in
the epidemic. Rather, the protracted stigma described by providers
appeared to be linked to fears of Ebola transmission and nosocomial
infection. However, as the epidemic evolves, more pointed research
into the nature of stigma and the potential emergence of courtesy
stigma, or stigma by association, may merit further investigation
across types of health facilities and types of providers (Phillips and
Benoit 2013).
Psychological literature has highlighted that individuals affected
by Ebola may feel compounded grief as their ability to cope is con-
strained; individuals such as those in this study cannot engage in rit-
uals that facilitate grieving (such as burials) or practices that
demonstrate bonding (such as physical touch) (WHO, World
Vision, UNICEF 2014). In an effort to mitigate psychiatric morbid-
ities and maladaptive coping mechanisms, and to prevent the spread
of Ebola, we urge research on ways to provide psychosocial support
(through messaging, media and health system supports) to providers
across various strata of the healthcare system—not only to those
working in Ebola treatment units (Hughes 2015). This should in-
clude attention to indigenous strategies developed by health workers
and members of the communities whom they serve, which have been
introduced to mitigate the effects of these experiences and to im-
prove relations with service users. The WHO’s provisional psycho-
logical guidance emphasizes the importance of psychological first
aid, or ‘human, supportive and practical help’, to those suffering in
an Ebola crisis (WHO, World Vision, UNICEF 2014). The guidance
states that individuals need to feel safe, listened to, comforted and
capable of accessing support to help themselves and their commun-
ities during and immediately after an Ebola outbreak (WHO, World
Vision, UNICEF 2014).
Such recommendations need to be articulated through the spe-
cific needs and experiences of affected communities. As a starting
point for formative research, we urge engaging with providers and
community members to identify and pilot interventions that are
deemed feasible and culturally acceptable in order to mitigate
distress. Such interventions could draw from existing mental health
literature that emphasizes the provision of counseling for providers
(particularly those who are placed under quarantine); mandatory
rest periods for health workers (coupled with supportive supervi-
sion) and the designation of a mental health professional who can
work with providers in the months after an acute or critical incident
to assist in healing (Hughes 2015;IASC 2010). In 2015, the WHO
issued guidelines to assist non-specialist, first-line providers in their
efforts to address mental health needs amid humanitarian emergen-
cies (WHO 2015b). Although these guidelines emphasize measures
that providers can undertake to meet patient needs, the process of
creating an atmosphere that promotes mental health and provides
tools for managing stress, grief and depression may help to empower
providers (WHO 2015b). We are encouraged by Sierra Leone’s
launch of a mental health policy and strategic plan, and hope that
this will bolster an expansion of efforts to address mental healthcare
needs (WHO 2012). According to a 2012 WHO report, Sierra
Leone has severe shortages in human resources for mental health;
the ratio of psychiatrists, psychiatric nurses, neurologists and social
workers is 0.02, 0.04, 0.02 and 0.06, respectively, per 1000 people
(Alemu et al. 2012). The report stated that there are no neurosur-
geons or psychologists in the country (Alemu et al. 2012). Related to
Ebola prevention specifically, further efforts to make personal pro-
tective equipment more humanizing, such as by adding pictures of
providers’ faces to the front of their suits (Aizenman 2015) or having
providers don equipment in the community, rather than arriving
fully dressed (Raabe et al. 2010), may also enhance patient–provider
bonding (Aizenman 2015;Hughes 2015).
Although we applaud recent calls to improve the overall health
system (Kieny et al. 2014) and to address critical shortfalls in human
resources for health, our research demonstrates that the psychoso-
cial needs of existing health workers merit immediate attention.
Although emotional and social support—as well as acute psycho-
logical care—are often neglected amid disease outbreaks, the im-
portance of mental health was poignantly documented in an account
of an Ebola treatment unit’s suspension of services in Monrovia,
Liberia (one of two functioning units at the time) due to a provider’s
psychotic episode (Cooper 2015).
Limitations
In this article, we present qualitative data on the experiences of
front-line Sierra Leonean primary healthcare providers during the
recent Ebola outbreak. Such providers play a critical role in out-
break responses yet have received relatively little attention in the
academic literature. We conducted interviews during the height of
the 2014–15 outbreak, allowing for a timely analysis. Nonetheless,
our findings must be considered in light of limitations. In terms of
transferability, we interviewed providers from eight health facilities
in two predominantly Mende districts in the south and east of the
country, and our results cannot necessarily be generalized to pro-
viders in other settings or other outbreaks. The themes discussed in
this article emerged from a broader study on infection control. As
we did not design the study to specifically consider the psychosocial
effects of the epidemic on health workers, there are limitations in
the scope of our material. Areas that merit further consideration in-
clude how experiences of this epidemic compared with other forms
of stress experienced by health workers, and how characteristics of
the outbreak such as caseload and epidemic curve affect provider ex-
perience. Similarly, although ethnicity, gender, age and professional
6Health Policy and Planning, 2016, Vol. 0, No. 0
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position did not emerge as factors that compelled community unease
towards providers, we did not probe specifically for these variables.
Conclusion
Ebola has torn at the fabric of Sierra Leonean society. It has high-
lighted the vulnerability of a fragile health system and revealed under-
lying tensions in this post-conflict setting. Literature related to Ebola
generally, and to the current epidemic in West Africa, emphasizes the
epidemiology of the disease, including clinical manifestations. We
argue that efforts to address this and other stigmatizing diseases must
explicitly incorporate an examination of the social landscape of the
disease and its mental health consequences. These efforts must extend
their focus to include front-line healthcare workers.
In this and future epidemics, responses must consider that front-
line healthcare providers are among the earliest to be affected by an
outbreak and they may be subjected to intense and protracted fear
and stigmatization by the very communities in which they live and
treat patients. Community engagement and sensitization should not
only address knowledge dissemination related to transmission but
also incorporate modules that are attentive to the psychosocial needs
of providers and their communities. This would involve explicitly
promoting non-discrimination and non-stigmatization towards
health providers, victims and victims’ families (De Roo et al. 1998)
and providing special support to providers. In much of west Africa,
access to mental health and psychosocial service is limited whereas
infectious disease epidemics remain relatively common, which high-
lights a need to address issues such as those presented in this study.
Note
1. In Sierra Leone, it is common practice to use the word “hospital”
when referring to any health facility. We have retained the term
hospital when used by respondents, but highlight that this word-
ing is in reference to peripheral health units, which provide first-
line, primary health care.
Acknowledgements
The authors would like to acknowledge the support of the International
Rescue Committee staff in Sierra Leone, New York, and London, who made
this research possible. We would like to thank our co-investigators Dr.
Matthias Borchert, Dr. Thomas Kratz, Mr. Ruwan Ratnayake and Dr. Foday
Sahr for their contribution to the larger study from which this analysis is
drawn. We would like to thank Annie Bonz of IRC for her insights regarding
mental health interventions. In addition, we appreciate the dedication of our
research team in Sierra Leone: Fatmata Bah, Mohamed Conteh, Mohamed
Kabbah, Aminata Kamara, Hassan Koroma, Mohamed Koroma, Henry
Saidu, and Alfred Tamba. Finally, we would like to thank the healthcare pro-
viders in this study and across Sierra Leone, who have continued to provide
essential health services during this most challenging ‘time of Ebola’.
Funding
This work was supported by the Research for Health in Humanitarian Crises
(R2HC) Programme, managed by ELRHA [SCUK – Accountable Grant No.
13488]. The Research for Health in Humanitarian Crises (R2HC) program
aims to improve health outcomes by strengthening the evidence base for pub-
lic health interventions in humanitarian crises. Visit www.elrha.org/work/
r2hc for more information. The £8 million R2HC program is funded equally
by the Wellcome Trust and DFID, with Enhancing Learning and Research for
Humanitarian Assistance (ELRHA) overseeing the program’s execution and
management.
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