COVID-19 Webinar 2: Supporting frontline workers
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health have launched a series of weekly webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair: Shekhar Saxena, Harvard University, USA
Co-Organiser: Ananda Gallappatti, MHPSS.net, Sri Lanka
Speakers:
Aiysha Malik: WHO, Geneva, Switzerland
Beatriz Rodriguez Vega: University Hospital of La Paz, Madrid, Spain
Mohammad Elshazly: UNHCR Egypt, Cox’s Bazaar (Bangladesh)
Eliza Cheung: Hong Kong Red Cross, China
Ananda Gallappatti, MHPSS: Thank you to all who have joined the webinar, we are excited for this session particularly given the numbers of people who we have seen seeking information from our website on this topic. In the first three weeks of the pandemic the most downloaded document (over 100,000 views) was the early guidance on support for frontline staff. Now the most viewed document is the adaptation of this guidance, addressing mental health needs.
Shekhar Saxena, Harvard: Welcome. Whilst most of us are being asked to stay at home there is a certain population that is expected to go to work, to work additional hours, day and night. These are the health care providers, who are at the frontline of the health response. Front line responders include doctors, nurses, technicians, ambulance providers and primary health care providers.
Key factors impacting their mental health include:
Fear of infection which is very valid (death rates among health care staff is many times the general population)
Working overtime with inadequate time for rest and sleep; and in situations that are extremely demanding, not supported enough by the authorities and without sufficient Personal Protection Equipment (PPE) and infrastructure
Sometimes contradictory and confusing instructions that regularly change
At times a lack of food and transport, childcare, and housing
Lack of timely information and feedback on their performance (which they need to be motivated to do their work well)
What can we do? A report on, “Understanding and Addressing Sources of Anxiety Among Health Care Professionals During COVID19 Pandemic Response,” based on interviews with health care professionals summarised their needs as, Protect me, Hear me, Support me, Care for me.
Aiysha Malik, WHO: The health of health workers is a key focus for the WHO including advocating to ensure support for their mental health. Health workers are already a group that experience poor mental health – it is a rewarding yet challenging occupation - and the mental health of health care workers, as with any other workers, affects how well they can work. Poor or declining mental health in this group of workers can lead to poor quality of health care and potential accidents, therefore protecting mental health is a life quality measure for both health workers and their patients.
Policy makers need to invest in mental health now, and prepare for the longer term. We need healthy health workers both now and after the pandemic. WHO's growing emphasis is on the protection of health workers as a paramount, cross cutting issue. There has been an important focus on Infection Prevention and Control (IPC), but protection involves many fields including occupational health and human resources.
WHO will be releasing a new stress management tool for anyone to use shortly. WHO recommends using practical work based approaches that target the whole system - health managers, supervisors and peers all play a vital role. These approaches include rotation and buddy systems as well as other ways to promote team cohesion.
WHO will be developing training that integrates occupational and mental health for use by health workers including the mental health workforce. The role of mental health staff can be broader than providing care to patients; it can be providing care to managers, peer support etc. Health workers struggle with a sense of stigma as well as concerns about confidentiality. These are important barriers to them seeking support for their mental health that need to be addressed and need to be considered when addressing the needs of health workers. Moreover, health workers are not homogenous and work in different settings. Early studies from China suggest mental health outcomes may vary between different groups of health workers. WHO is encouraging countries to learn from the experiences of one another as this webinar is promoting.
What approaches have been put in place and to what extent have they been successful?
Beatriz Rodriguez Vega, University Hospital of La Paz: Frequently managers see selfcare not as a necessity but a luxury and this creates shame around asking for help, as well as increased fear and anxiety. Frontline workers are frequently in a heightened state of mind; rushing and in action mode and the nature of their work makes it very difficult to make time for breaks during their work.
We developed a 5-10 minute mental health intervention, which can help care for health workers (and all kinds of workers) and teach strategies for self care. This was presented as training - not therapy - and so was more acceptable to them. The sessions helped identify those who may need more mental health support. When presenting the intervention to a new team it was presented on the basis of the need for self care.
Mohammad Elshazly, UNHCR: The refugee populations in Cox’s Bazaar have already experienced a great deal of stress. And health care workers there have already worked to respond to a number of epidemics including a cholera outbreak. Currently health care is provided through primary health care; there is very little secondary care, so that needs to be strengthened now before COVID-19 becomes a serious health issue in the camps and the surrounding area. In the Cox’s Bazaar response - typically for resources involving international staff - there is more attention paid to expat staff then local staff. There is a severe lack of PPE.
To address the mental health of frontline responders we recommend pre-assignment orientation for workers including discussion of the risks and how to respond, and to address the mental health and psychosocial (MHPSS) needs of responders and those that they work with. During the assignment we promote self help guides. Post-assignment we encourage support: sometimes psychological stress can continue for 3-6 months after assignment.
In Egypt there is a dedicated MHPSS task force who aim to support the mental health of care workers. This task force of course has more resources than the refugee camps in Bangladesh and is being organised now to provide adequate support for the health system.
Shekhar Saxena, Harvard: Sometimes the countries that are poorer but have a long experience of facing humanitarian disasters can be better prepared than richer countries who have not experienced something akin to that.
Eliza Cheung, ICRC: Eliza works at the Hong Kong branch of the Red Cross and is also part of IFRC MHPSS reference center. As Hong Kong faced the outbreak earlier this year, the community has developed mental health materials for health workers as well as providing services directly to the public, including psychological first aid. These materials have been distributed to hospitals, medical associations, trade unions, lab technicians and other allied health professionals, as their work could also involve exposing themselves to risk of infection. These materials are now being distributed and translated into other languages for a number of Red Cross and Red Crescent national societies across the world.
The most relevant messages for health workers on the front line have been as follows: “You are also a human being and need to take good care of yourself as a way to be responsible to others. You should understand your role and make time to make a decision.” This messaging is designed to help alleviate their burden of their internal struggles with their mental health. A hotline and other support for self care has been proven to be useful, but we have also learnt that frontline workers cannot just survive using self care, they also need support from others. They may not always want to talk to the hotline or mental health professionals, and usually the care they want the most is from family or friends and employers.
At the start of the COVID-19 outbreak, due to the experience of the 2003 SARS outbreak there was a sense of panic and concern due to lack of PPE etc. Now 2-3 months later health workers acknowledge the COVID-19 response is not a sprint but a marathon and they are adjusting to a new way of life. We need to help them adjust to the lack of equipment and insufficient staffing and help them find ways to cope. One main worry they have is afraid of infecting families and this is something to address on an ongoing basis.
Questions
Shekhar Saxena, Harvard University: Aiysha, looking at the imminent launch of the WHO’s stress reduction programme, to what extent is this evidence based?
Aiysha Malik, WHO: I believe this is to be discussed in the next webinar, but the programme is strongly based on evidence. There are plans to develop a digital version.
Shekhar Saxena, Harvard University: Did hospital authorities welcome Beatriz’s MHPSS programmes?
Beatriz Rodriguez Vega, University of La Paz: We had already worked with them during the Ebola crisis 5 years before and we worked in a similar way then so they did welcome it. So far more than 500 workers have participated in at least one session. There have been no adverse effects reported and most rate the intervention a 9 out of 10 in utility.
Shekhar Saxena, Harvard University: Has it been easy for Eliza and team to work with the government sector to safeguard the MHPSS of staff?
Eliza Cheung, Hong Kong Red Cross: It is important to work with the government. In some contexts the government took the initiative and leadership e.g. on contact tracing etc. The Red Cross movement has been able to involve its staff in MHPSS but also families and therefore spread the impact of its work.
Shekhar Saxena, Harvard University: To what extent has it been easy to insert the MHPSS of providers into the plans the Egyptian government is making now for COVID-19?
Mohammad Elshazly, UNHCR: The attention to mental health and that of health workers has been placed as a top priority and the Minister of Health and the top leaders are speaking frankly about the need to dedicate more resources. It is a good opportunity to scale up MHPSS during this time for workers and also for the wider population.
Shekhar Saxena, Harvard University: In conclusion, although this is a public health disaster, the response to COVID-19 could be used as an opportunity to think more about the mental health and wellbeing of the general population, and the health care staff who are at the frontline of the response.
Ananda Gallappatti, MHPSS.net: Thank you to Shekhar, Aiysha, Mohammed, Beatrix and Eliza for taking your time to take part in this session. The next webinar will be on mental health and Covid-19 research, you can sign up here.
