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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,
Lara S. Ho,
* Hannah Brown,
Laura Miller,
Rashid Ansumana
and Caitlin E. Kennedy
The Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, 69120, Germany,
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205,
International Rescue Committee, New York, NY, 10017, USA,
Department of Anthropology, Durham
University, Durham, DH1 3LE, UK,
International Rescue Committee, Freetown, Sierra Leone,
Department of
Parasitology, Faculty of Biological Sciences, Liverpool School of Tropical Medicine, Liverpool, L35QA, UK,
Department of Community Health and Clinical Studies, School of Community Health Sciences, Njala University,
Bo, Sierra Leone and
Mercy Hospital Research Laboratory, Bo, Sierra Leone
*Corresponding author. 1730 M St NW, Suite 505, Washington, DC 20009. E-mail:
Accepted on 10 April 2016
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
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 (, which permits
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Health Policy and Planning, 2016, 1–8
doi: 10.1093/heapol/czw055
Original Manuscript
Health Policy and Planning Advance Access published June 8, 2016
by guest on June 11, 2016 from
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
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.
We first present an overview of how providers described ‘living
through Ebola’. We then present experiences at the PHU
, 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)
<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)
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
Health Policy and Planning, 2016, Vol. 0, No. 0 3
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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
4Health Policy and Planning, 2016, Vol. 0, No. 0
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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
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
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’.
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.
Health Policy and Planning, 2016, Vol. 0, No. 0 5
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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).
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
by guest on June 11, 2016 from
position did not emerge as factors that compelled community unease
towards providers, we did not probe specifically for these variables.
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.
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.
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’.
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
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
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... PHCWs and their family members reported stigma from their own family and society as they were believed to be at high risk of contracting COVID-19. High percentages of health care workers also reported social stigmatisation during the 2003 SARS outbreak in Singapore and the Ebola epidemic in Sierra Leone [26,27]. Our findings are consistent with previous research [28,29] that social stigmatization during the COVID-19 pandemic has a significant impact on the psychological state of HCWs. ...
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Background Primary healthcare workers (PHCWs) are at the frontline of dealing with viral pandemics. They may experience significant psychological stresses, which have hitherto not been examined in depth. We aimed to explore the impact of the COVID-19 pandemic on the psychological health and wellbeing of frontline PHCWs in Malaysia. Method We purposively recruited PHCWs with diverse backgrounds in Klang Valley, Malaysia. Using longitudinal qualitative methods, we conducted two sequential semi-structured telephone interviews, 3 to 4 weeks apart, to capture different stages of the pandemic. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Result Twenty-one PHCWs participated yielding a total of forty-two interviews. Themes clustered around stressors associated with work, home, and leisure activities, emotional changes, and modifying factors. In the first interviews, COVID-19 had just started in Malaysia. Participants expressed fear about the actual and perceived personal risk of COVID-19 infection. Most were worried about transmitting COVID-19 to their family members. Some felt stigmatized because of this perceived risk of infection. By the second interviews, participants felt safer, but instead focused on the need to keep other people safe. Participants’ emotions were influenced by their perceived risk of contracting COVID-19 infection. Internal factors such as religion enabled them to manage their concerns and develop personal coping strategies. Support from family members, colleagues, and employers promoted wellbeing during the pandemic. Training sessions, daily roll calls, and psychological support services were important in maintaining their psychological health and wellbeing. Many participants were hopeful and believed normalcy would return by the end of 2020. Conclusion PHCW’s psychological health and wellbeing evolved throughout the early stages of the pandemic and were influenced by their perceived risk of contracting the disease and personal belief structures. Clear updates on the disease and strategies for keeping safe at work and socially are essential to maintaining PHCWs’ psychological health and wellbeing.
... In any biological disaster, fear and stigmatization are heightened, and healthcare workers may be particularly vulnerable to the latter. Many healthcare workers in the recent Ebola and SARS epidemics experienced overwhelming stigmatization, loneliness and even loss of trust within their own communities [21,22]. During the SARS epidemic in Singapore in early 2000 for example, one nurse in a lift was told that her presence in the lift was spreading the virus to others; and another was scolded by fellow passengers for making trains "dirty". ...
Aims: This study psychological impact of COVID-19 on Frontline Healthcare Workers (FHW) in the Northern Regions of Ghana in their pursuit of the frontline duties during the COVID-19 pandemic. The study also evaluated the determinants of psychological factors influencing the burden levels among FHW. Study Design: Frontline healthcare workers (FHW) were recruited in this study through the online survey method of data collection. Place and Duration of Study: The study was carried out in five Regions of Ghana, namely Northern, Savannah, North East, Upper East and Upper West region. Data collection spanned a period of four weeks. Methodology: A total of 120 frontline health personnel working out in five Regions of Ghana (Northern, Savannah, North East, Upper East and Upper West region) participated in the study. The study was conducted with the diagnostic survey method, using Zarit burden interview scale and a questionnaire of our authorship. Results: The results revealed that 85% of FHW experienced more than average amount of burden whiles 60% of them suffered severe burden of care levels in pursuit of their duties for COVID-19 patients. The results from chi-square test of association between caregivers’ socio-demographic characteristics and severity of burden revealed that gender, marital status, educational qualification and caring for own children were significantly associated with caregiver burden level (P – value < 0.05). Factor analysis results identified seven psychological factors that underlies caregivers of COVID-19 and they were labeled as consequences of care giving on the caregiver; exhaustion and uncertainty; patient’s dependence; moral-guilt; helplessness; compensation and overwhelmed with care giving, which are consistent with prior studies. A multiple regression model results further affirmed that these seven psychological factors were significantly (P – value < 0.05) influencing the burden levels of FHW. Conclusion: The ability of policy makers to address these experiences of FHW will have positive consequences on the overall containment of the pandemic.
... Medical care had to be provided with inadequate personal protective equipment, limited resources and poor information-sharing. (5) We also learn from previous pandemics of the potential for significant psychosocial impact on HCWs, from fear for themselves and family, perceived alienation and isolation, to some diagnosed with post-traumatic stress disorder. (6,7) Despite the challenges, reports of high levels of morale, (6) motivation and the commitment to provide good medical care were also evident. (8) Even before the pandemic, high burnout amongst physicians and prehospital providers was reported. ...
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In March 2020, the World Health Organisation declared COVID-19 a global pandemic. Shortly after the first case of COVID-19 was reported in South Africa, the Western Cape province experienced a rapid growth in the number of cases, establishing it as the epicentre of the disease in South Africa. The aim of this study was to explore emergency care personnel’s lived experiences and their perceptions thereof within the context of the COVID-19 pandemic in the Western Cape province. This study followed a longitudinal hermeneutic phenomenological approach. The convenience sample included prehospital and emergency centre medical personnel. Data were collected over a 4-month period using both one-on-one interviews and participant recorded voice recordings. Data were analysed following Ricoeur’s theory of interpretation. Four themes were generated during the data analysis: 1) In the beginning, waiting for the unknown; 2) Next, change and adaptation in the workplace; 3) My COVID-19 feelings; 4) Support and connection. Participants discussed the uncertainty associated with responding to an unknown threat and a need to keep up with constant change in an overburdened work environment. Results showed high levels of uncertainty, restriction, fear, anxiety, and exhaustion. Despite these difficulties, participants demonstrated resilience and commitment to caring for patients. A need for support was also highlighted. Results indicated that change, over time, resulted in adaptation to a new way of practising and keeping safe. Healthcare workers experienced intersecting consequences as frontline healthcare workers and members of the public, all of which impacted their well-being. The importance of compassion and encouragement as forms of support was highlighted in the study. Robust and sustained support structures in a time of change, low mood, and exhaustion are essential.
... In several trials, CHW training and education improved disease prevention, control, and vaccination rates. Through adequate training and education, CHWs can handle anxiety, build confidence in providing care, solve problems, and improve their communication and leadership abilities [97][98][99]. ...
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The COVID-19 global pandemic requires, not only an adequate supply of, but public adherence to safe and effective vaccinations. This study analyzes the human and economic resources and political and public attitudinal factors that influence widely varying country-level coronavirus vaccination rates. Using data on up to 95 countries, we found that countries’ strength of community health training and research (CHTR), education index, globalization, and vaccine supply are associated with a greater COVID-19 vaccination rate. In a separate analysis, certain political factors, and public attitudes (perceived government effectiveness, government fiscal decentralization, trust in science, and parliamentary voter turnout) predicted vaccination rates. Perceived corruption and actual freedoms (political rights and civil liberties) related to vaccination rates in prior studies were not significantly predictive when controlling for the above factors. The results confirm our prior findings on the importance of CHTR resources for increasing COVID-19 vaccination rates. They also suggest that to motivate vaccine adherence countries need, not only an adequate vaccine supply (which depends on a country having either its own resources or effective global political, social, and economic connections) and community health workforce training and research, but also a population that trusts in science, and is actively engaged in the political process.
... 10 Most health institutions showed overwork in responding to the pandemic so this will increase concern that COVID-19 will disrupt health service delivery especially those for maternal and new born , a lot of pregnant women don't follow up their ANC schedule either due to fear from the infection or due to curfew and stay at home policies so the citizens were unable to reach primary health care centers. Layla T, Amall Y SMJ A focused antenatal care model was used for routine antenatal care in times of pandemic in order to decrease risk of diseases transmission between pregnant women and medical staff , now in COVID-19 pandemic this model is in use especially for low risk, uncomplicated pregnancies to minimize the risk of cross infection 11,12 . it recommend a four antenatal care visits instead of eight , first between 8 and 12 weeks, then between 24 and 26 weeks, third at 32 weeks and the last one between 36 and 38 weeks . ...
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Background: COVID 19 pandemic result in great thread to the public health and by the measures taken to limit viral transmission , a lot of maternal healthcare services had been disrupted .Our research aimed to assess the impact of COVID-19 on access to maternal health services in Basrah city .method : This is a descriptive retrospective records based study implemented during the period from 1 st of March 2019 to 31 st of August 2019 (pre-COVID19) compared to same months of 2020 (intra-COVID 19). All pregnant women who attended to six chosen primary health care centers in Basrah were included in the study. Results: Comparing 2019 maternal health services indicators with those from 2020, there is reduction about 22% in women in first antenatal visits and 33% in antenatal visits more than one less than four ,49% in visits equal and more than four , postnatal visits by 16% and tetanus toxoid doses by 17%. The greatest reduction occurred in March 2020 then these services utilization surged in July 2020 and decreased again in August .Conclusion:Our results demonstrate negative effects of COVID-19 on maternal health access and a deficient health information system in Basrah.
... Historically, healthcare workers' discrimination and mental health concerns are no different from other health crises in the past. This includes neglecting behavior and rejection [9] ; and social and emotional impact [10] during the 2012 MERS-CoV and 2014 Ebola epidemic, respectively. During the early part of the COVID-19 pandemic, numerous reports of ill-treatment of individuals from the local and global settings were documented. ...
Background At the core of a global health crisis, healthcare workers are tasked to perform crucial and life-threatening roles. Despite the heavy-laden responsibilities amid COVID-19 pandemic, these workers are subjected to various forms of stigma and discrimination. Objectives The primary intent of this paper is to investigate the existence of discrimination among healthcare workers during COVID-19 pandemic in the Philippines. Further, it aims to test the following hypotheses: (1) Discrimination experiences among Filipino healthcare workers are dependent on certain demographic characteristics; and (2) Discrimination experiences vary significantly according to the type of healthcare workers. Methods This exploratory study used a two-part survey questionnaire consisting of the baseline data of the respondents and an 8-point Likert-type scale to identify the different forms of discrimination experienced by Filipino healthcare workers. Data yielded by the instruments were descriptively (frequency, mean and percentage) and inferentially (Pearson R, Kendall tau, t-test, and One-Way Analysis of Variance) treated. Results Among the Filipino healthcare workers, the Radiologic Technologists experienced the most forms of discriminatory acts, followed by Nurses and Medical Technologists. Those who work in high-risk duty assignments experienced the most discriminatory incidents such as insulting gestures and physical/social loathing, social media bashing and offensive jokes. Conclusion The discrimination experienced by Filipino healthcare workers is a valuable platform for health policy interventions at the local and global levels to safeguard the physical, social and psychological well-being of healthcare workers, especially in battling the COVID-19 pandemic.
... This led to reduced antenatal visits and screening of pregnancy related complications as well as institutional deliveries (12). The health institutions were strained in responding to Covid-19 pandemic as well as many health facilities were converted to covid dedicated hospitals which led to disruption of maternal and newborn health-services delivery, particularly in resource-limited countries (13). The Government of Nepal implemented nationwide lockdown came into effect from 24 th March 2020 for preventing spread of corona virus (14). ...
Background: Covid-19 pandemic affected maternal health directly by causing respiratory disease in pregnant women as well as indirectly by affecting health care delivery and caused sharp increase in maternal mortality. Aim: This study aimed to assess causes and contributing factors for maternal mortality during six months of Covid-19 lockdown. Methodology: This was a retrospective review of all maternal mortalities over the period of six months (23rd March - 22nd September 2020) after implementation of lockdown. Information regarding demographic variables, obstetric characteristics, referral, diagnosis, cause of death and any delay present were obtained from the patient records. The data were analyzed using SPSS 11.5 and descriptive statistics was used. Results: There were 19 maternal deaths, of which one was due to accidental cause. The MMR was 419 per 100,000 live births. Mean age was 29.16 ± 9.53 years with age ranging from 16 to 49 years, 44.4% women never had antenatal check-up, mean POG at presentation was 29.7 ± 9.7 weeks. Four patients died during early pregnancy (two (11.1%) due to abortion related complications and two molar pregnancies) and six (33.3%) expired during antenatal period. Three most common causes for maternal mortality were sepsis (27.8%), hypertensive disorder (22.2%) and obstetric hemorrhage (16.7%). Covid pneumonia caused one (5.6%) mortality. Main contributory cause was anemia (50%). Major delay was in providing appropriate care timely. Conclusion: Maternal mortality was very high during lockdown and the leading cause was sepsis contributed by anemia in most cases. Delays in screening high-risk pregnancies as well as delay in appropriate treatment were responsible factors.
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Background The coronavirus 2019 (COVID-19) pandemic has caused a worldwide health crisis. In Tunisia, this large-scale health crisis urgently triggered the restructuring and reorganization of health services to support Emergency Departments, intensive care units, and continuing medical care units. Concerns about the mental health, psychological adjustment, and recovery of health care workers treating and caring for are now emerging. The objective was to assess the psychological impact of the Covid-19 pandemic on health care workers' work, psychological outcomes, and return to work. Methods Our study is a retrospective monocentric clinical trial. It is performed between June and July 2022 using a self-administered questionnaire to assess: (i) the impact on their work; (ii) the psychological consequences of the Covid-19 epidemic for health care workers. Results We collected 140 responses from 73 nurses (34.76%), 23 public health physicians (10.95%), 15 health technicians (7.14%), 13 residents (6.19%), 7 interns (3.33%), 5 workers (2.38%), and 4 medical specialists (1.90%). The HAD score for depression favoured certain symptomatology in most cases (n = 72, 51.43%) and certain symptomatology in most cases (n = 73, 52.14%) for anxiety. Conclusions The Covid-19 pandemic has brought about changes in the work organization and an overall increase in the workload for health care personnel.
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Background Health officials have called for more information about the mental or psychological consequences of COVID-19 on individuals, especially in the US general population where COVID rates are remarkably high. Aims This exploratory study aimed to understand stress, loneliness and substance abuse among the US general population during the COVID-19 pandemic. Methods A cross-sectional study comprising 1,203 respondents to a controlled-access, web-based survey was conducted. Results Study results reveal statistically significant differences in stress (p<0.001), loneliness (p<0.001), and substance (ab)use (p<0.001), especially illicit (non-prescription) drug use, between those with COVID-19 or related symptoms and those without. Effect size estimates indicate small to moderate effects, ranging from 0.178 to 0.276, consistent with prior studies based on past outbreaks. Conclusions Findings have significant implications for mental health practitioners, community organizations, and federal agencies in terms of policy, practice, and future research.
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In early 2020, the first wave of the COVID-19 pandemic hit India, generating one of the highest rates of infection and death in the world. Meanwhile, healthcare workers experienced stigma and discrimination due to their association with COVID-19 patients. This study analyzed healthcare workers’ experience of courtesy stigma in India, the communication strategies they used to manage stigma, and the impact on their mental health. A cross-sectional survey of 150 healthcare workers in India showed that almost 50% experienced discrimination due to their association with COVID-19 patients. Using Confirmatory Factor Analysis and Structural Equation Modeling, this study found that experience of discrimination was associated with perceived courtesy stigma. Two stigma management strategies (reducing offensiveness and passive acceptance) mediated the relationship between perceived courtesy stigma and perceived stress and depression. Participants also reported engaging in stigma management strategies of bonding with other healthcare professionals and passive acceptance of the stigma more than reducing stigma and displaying/disclosing stigma. We conclude that perhaps due to depletion of cognitive and emotional resources, healthcare workers engaged more in social support (bonding) and passive stigma acceptance strategies to alleviate the stress associated with providing COVID-19 patient care. Practical and theoretical implications are further discussed.
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Armed conflicts and natural disasters impact negatively on the mental health and well-being of affected populations in the short- and long-term and affect the care of people with pre-existing mental health conditions. This paper outlines specific actions for mental health and psychosocial support by the health sector in the preparedness, response and recovery phases of emergencies. Broad recommendations for ministries of health are to: (1) embed mental health and psychosocial support in national health and emergency preparedness plans; (2) put in place national guidelines, standards and supporting tools for the provision of mental health and psychosocial support during emergencies; (3) strengthen the capacity of health professionals to identify and manage priority mental disorders during emergencies; and (4) utilize opportunities generated by the emergency response to contribute to development of sustainable mental health-care services.
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Stigma by association, also referred to as "courtesy stigma," involves public disapproval evoked as a consequence of associating with stigmatized persons. While a small number of sociological studies have shown how stigma by association limits the social support and social opportunities available to family members, there is a paucity of research examining this phenomenon among the large network of persons who provide health and social services to stigmatized groups. This paper presents results from a primarily qualitative study of the workplace experiences of a purposive sample of staff from an organization providing services to sex workers. The findings suggest that stigma by association has an impact on staff health because it shapes both the workplace environment as well as staff perceptions of others' support. At the same time, it is evident that some staff, owing to their more advantaged social location, are better able to manage courtesy stigma than others.
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As of December 6, 2014, Sierra Leone reported 6,317 laboratory-confirmed cases of Ebola virus disease (Ebola), the highest number of reported cases in the current West Africa epidemic. The Sierra Leone Ministry of Health and Sanitation reported that as of December 6, 2014, there were 1,181 persons who had survived and were discharged. Survivors from previous Ebola outbreaks have reported major barriers to resuming normal lives after release from treatment, such as emotional distress, health issues, loss of possessions, and difficulty regaining their livelihoods. In August 2014, a knowledge, attitude, and practice survey regarding the Ebola outbreak in Sierra Leone, administered by a consortium of partners that included the Ministry of Health and Sanitation, UNICEF, CDC, and a local nongovernmental organization, Focus 1000, found that 96% of the general population respondents reported some discriminatory attitude towards persons with suspected or known Ebola. Access to increased psychosocial support, provision of goods, and family and community reunification programs might reduce these barriers. Survivors also have unique potential to contribute to the Ebola response, particularly because survivors might have some immunity to the same virus strain. In previous outbreaks, survivors served as burial team members, contact tracers, and community educators promoting messages that seeking treatment improves the chances for survival and that persons who survived Ebola can help their communities. As caregivers in Ebola treatment units, survivors have encouraged patients to stay hydrated and eat and inspired them to believe that they, too, can survive. Survivors regaining livelihood through participation in the response might offset the stigma associated with Ebola.
The grounded theory approach to doing qualitative research in nursing has become very popular in recent years. I confess to never really having understood Glaser and Strauss' original book: The Discovery of Grounded Theory. Since they wrote it, they have fallen out over what grounded theory might be and both produced their own versions of it. I welcomed, then, Kathy Charmaz's excellent and practical guide.
A large outbreak of haemorrhagic fever (subsequently named Ebola haemorrhagic fever) occurred in southern Sudan between June and November 1976. There was a total of 284 cases; 67 in the source town of Nzara, 213 in Maridi, 3 in Tembura, and 1 in Juba. The outbreak in Nzara appears to have originated in the workers of a cotton factory. The disease in Maridi was amplified by transmission in a large, active hospital. Transmission of the disease required close contact with an acute case and was usually associated with the act of nursing a patient. The incubation period was between 7 and 14 days. Although the link was not well established, it appears that Nzara could have been the source of infection for a similar outbreak in the Bumba Zone of Zaire. In this outbreak Ebola haemorrhagic fever was a unique clinical disease with a high mortality rate (53% overall) and a prolonged recovery period in those who survived. Beginning with an influenza-like syndrome, including fever, headache, and joint and muscle pains, the disease soon caused diarrhoea (81%), vomiting (59%), chest pain (83%), pain and dryness of the throat (63%), and rash (52%). Haemorrhagic manifestations were common (71%), being present in half of the recovered cases and in almost all the fatal cases. Two post mortems were carried out on patients in November 1976. The histopathological findings resembled those of an acute viral infection and although the features were characteristic they were not exclusively diagnostic. They closely resembled the features described in Marburg virus infection, with focal eosinophilic necrosis in the liver and destruction of lymphocytes and their replacement by plasma cells. One case had evidence of renal tubular necrosis. Two strains of Ebola virus were isolated from acute phase sera collected from acutely ill patients in Maridi hospital during the investigation in November 1976. Antibodies to Ebola virus were detected by immunofluorescence in 42 of 48 patients in Maridi who had been diagnosed clinically, but in only 6 of 31 patients in Nzara. The possibility of the indirect immunofluorescent test not being sufficiently sensitive is discussed. Of Maridi case contacts, in hospital and in the local community, 19% had antibodies. Very few of them gave any history of illness, indicating that Ebola virus can cause mild or even subclinical infections. Of the cloth room workers in the Nzara cotton factory, 37% appeared to have been infected, suggesting that the factory may have been the prime source of infection.
Sierra Leone is currently going through the worst Ebola epidemic on record, creating anxiety and anxiety related, somatic symptoms. Additionally, increased psychiatric morbidity could be expected as a result of the adverse social and psychological consequences of the epidemic, exposing the country's weak, poorly resourced mental health services and highlighting the need for psychosocial interventions and development of psychiatric interventions. Countrywide, there are 20 psychiatric nurses and 150 community health workers trained in the mental health Gap Action Programme and Psychological First Aid. However, in order to strengthen their capacity to deliver psychosocial and psychiatric interventions and to create a potential resource for psychiatric interventions during a major humanitarian crisis, ongoing training and supervision will be essential.
A group of UK trainees find themselves face-to-face with one of the most catastrophic health crises in recent times.
The Ebola virus disease outbreak occurring in West Africa has resulted in at least 199 cases of Ebola in Sierra Leonean health care workers, many as a result of transmission occurring in health facilities. The Ministry of Health and Sanitation of Sierra Leone recognized that improvements in infection prevention and control (IPC) were necessary at all levels of health care delivery. To this end, the U.S. Centers for Disease Control and Prevention, United Nations Children's Fund, and multiple nongovernmental organizations implemented a national IPC training program in 1,200 peripheral health units (PHUs) in Sierra Leone. A tiered training of trainers program was used. Trainers conducted multiday trainings at PHUs and coordinated the delivery of personal protective equipment (gloves, gowns, masks, boots) and infection control supplies (chlorine, buckets, disposable rags, etc) to all PHU staff. Under the ongoing project, 4,264 health workers have already been trained, and 98% of PHUs have received their first shipment of supplies. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
This personal reflection is based on the author's experiences, a native Liberian, in her country at the beginning of the 2014 Ebola epidemic. It includes her account of events as Ebola cases and related deaths began to rise and the response appeared inadequate. Examples are presented where a robust psychosocial and mental health response was critically required, but most often lacking. This reflection focuses on the points where the author's personal and the professional life met as she co-led the psychosocial pillar of the national response team on Ebola. It also explores the challenges of leading the mental health and psychosocial component of a complex emergency within a fragile, post conflict state, where the medical and infectious disease component of the response often takes precedence. Additionally, the author's internal struggle that occurred when she was forced to evacuate at the outbreak's peak is explored.