research topic about health workers

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Research hotspots and trends in healthcare workers' resilience: A bibliometric and visualized analysis

Affiliations.

• 1 Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.
• 2 Department of Traditional Chinese Medicine, The First College of Clinical Medical Science, Three Gorges University/Yichang Central People's Hospital, Yichang City, Hubei Province, China.
• 3 Philippine Women's University School of Nursing, Manila, Philippines.
• 4 Department of Emergency and Critical Care Medicine, The First College of Clinical Medical Science, Three Gorges University/Yichang Central People's Hospital, Yichang, Hubei Province, China.
• 5 The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China.
• PMID: 39170181
• PMCID: PMC11336405
• DOI: 10.1016/j.heliyon.2024.e35107

Background: The resilience of healthcare workers has gained increasing attention, yet comprehensive studies focusing on recent trends and developments are scarce. We conducted an extensive bibliometric analysis from inception to 2023 to address this gap.

Methods: Publications on healthcare workers' resilience were extracted from the Web of Science Core Collection database. Bibliometric analysis was conducted with CiteSpace, VOSviewer, and Scimago Graphica, focusing on annual publications, country/region, institution, journal, author, keyword analysis, and reference co-citation analysis related to resilience in healthcare workers.

Results: The analysis included 750 documents, revealing a general upward trend in publications across 67 countries/regions, 1,251 institutions, and 3,166 authors. The USA and China emerged as the top contributors, with 192 and 168 publications, respectively. Based on keyword analysis and reference co-citation analysis, the focus areas include the Resilience Scale, the impact of the COVID-19 pandemic on HCWs and their resilience, and nurse resilience.

Conclusion: This study highlights the growing interest in healthcare workers' resilience by using bibliometric and visualization techniques for effective analysis. This paper will enhance scholars' understanding of the dynamic evolution of healthcare workers' resilience and identify emerging research topics.

Keywords: Bibliometric; CiteSpace; Healthcare workers; Resilience; VOSviewer.

© 2024 Published by Elsevier Ltd.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Flow chart for including and…

Flow chart for including and excluding documents. Other document types include Early Access,…

Annual evolution of publications and…

Annual evolution of publications and citations output for HCWs' resilience.

Distribution of research on resilience…

Distribution of research on resilience in HCWs worldwide.

International cooperation networks between countries.…

International cooperation networks between countries. These countries are marked with varying colors, and…

The dual-map overlay of journals…

The dual-map overlay of journals concerning HCWs' resilience. The citing and cited journals…

(a) Co-occurrence visualization map of…

(a) Co-occurrence visualization map of keywords; (b) Co-occurrence overlay map of keywords over…

Top 38 references with the…

Top 38 references with the strongest citation bursts. The red bar represents that…

• Prasad K., et al. Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: a national cross-sectional survey study. EClinicalMedicine. 2021;35 - PMC - PubMed
• Phillips J.P. Workplace violence against health care workers in the United States. N. Engl. J. Med. 2016;374(17):1661–1669. - PubMed
• Rotenstein L.S., et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320(11):1131–1150. - PMC - PubMed
• Timofeiov-Tudose I.G., Măirean C. Workplace humour, compassion, and professional quality of life among medical staff. Eur. J. Psychotraumatol. 2023;14(1) - PMC - PubMed
• Werke E.B., Weret Z.S. Occupational stress and associated factors among nurses working at public hospitals of Addis Ababa, Ethiopia, 2022; A hospital based cross-sectional study. Front. Public Health. 2023;11 - PMC - PubMed

Publication types

• Search in MeSH

Related information

Linkout - more resources, full text sources.

• Elsevier Science
• PubMed Central

Miscellaneous

• NCI CPTAC Assay Portal

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

The health of the healthcare workers

• Indian Journal of Occupational and Environmental Medicine 20(2):71
• CC BY-NC-SA 3.0

• St. John's National Academy of Health Sciences

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations
• Ayşe Göksu ÖZÜDOĞRU

• Jacqueline Pangani
• Benson Munyenyembe

• BMC PUBLIC HEALTH

• Mohamad Rabani Abdul Wahab

• Tran Thi Hong Le
• Le Chi Nhan
• Ha Bao Tran
• SOC SCI MED

• Beverley M. Essue

• Zakaria Ahmed Abd El Fattah Ammar
• Le Minh Cong
• Nguyen Van Tuong
• Pham Thi Bich Ngoc
• Joanna Zawiejska
• V Sudharani
• P. Shashikala Reddy
• G. Jyothi Lakshmi
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

Fact sheets

• Facts in pictures

Publications

• Questions and answers

Tools and toolkits

• Endometriosis
• Excessive heat
• Mental disorders
• Polycystic ovary syndrome
• All countries
• Eastern Mediterranean
• South-East Asia
• Western Pacific
• Data by country
• Country presence 
• Country strengthening 
• Country cooperation strategies 
• News releases
• Feature stories
• Press conferences
• Commentaries
• Photo library
• Afghanistan
• Cholera 
• Coronavirus disease (COVID-19)
• Greater Horn of Africa
• Israel and occupied Palestinian territory
• Disease Outbreak News
• Situation reports
• Weekly Epidemiological Record
• Surveillance
• Health emergency appeal
• International Health Regulations
• Independent Oversight and Advisory Committee
• Classifications
• Data collections
• Global Health Observatory
• Global Health Estimates
• Mortality Database
• Sustainable Development Goals
• Health Inequality Monitor
• Global Progress
• World Health Statistics
• Partnerships
• Committees and advisory groups
• Collaborating centres
• Technical teams
• Organizational structure
• Initiatives
• General Programme of Work
• WHO Academy
• Investment in WHO
• WHO Foundation
• External audit
• Financial statements
• Internal audit and investigations 
• Programme Budget
• Results reports
• Governing bodies
• World Health Assembly
• Executive Board
• Member States Portal
• Fact sheets /

Occupational health: health workers

• About 54% of health workers in low- and middle-income countries have latent tuberculosis, which is 25 times higher than the general population.
• Between 44% and 83% of nurses in clinical settings in Africa have chronic lower back pain, compared to 18% among office workers.
• Globally, 63% of health workers report experiencing any form of violence at the workplace.
• During the coronavirus disease (COVID-19) pandemic, 23% of front-line healthcare workers worldwide suffered depression and anxiety and 39% suffered insomnia. Furthermore, medical professions are at higher risk of suicide in all parts of the world.
• Unsafe working conditions resulting in occupational illness, injuries and absenteeism constitute a significant financial cost for the health sector (estimated at up to 2% of health spending).
• However, so far only 26 out of the 195 Member States of WHO have in place policy instruments and national programmes for managing occupational health and safety of health workers.

Health workers are all people engaged in work actions whose primary intent is to improve health, including doctors, nurses, midwives, public health professionals, laboratory technicians, health technicians, medical and non-medical technicians, personal care workers, community health workers, healers and traditional medicine practitioners. The term also includes health management and support workers such as cleaners, drivers, hospital administrators, district health managers and social workers, and other occupational groups in health-related activities as defined by the International Standard Classification of Occupations (ISCO-08).

Health workers are the backbone of any functioning health system. While contributing to the enjoyment of the right to health for all, health workers should also enjoy the right to healthy and safe working conditions to maintain their own health.

Health workers face a range of occupational risks associated with infections, unsafe patient handling, hazardous chemicals, radiation, heat and noise, psychosocial hazards, violence and harassment, injuries, inadequate provision of safe water, sanitation and hygiene.

The protection of health and safety of health workers should be part of the core business of the health sector: to protect and restore health without causing harm to patients and workers.

Safeguarding the health, safety and well-being of health workers can prevent diseases and injuries caused by work, while improving the quality and safety of care, human resources for health and environmental sustainability in the health sector. 

Safeguarding the health, safety and well-being of health workers  

The protection of health and safety of health workers contributes to improving the productivity, job satisfaction and retention of health workers. It also facilitates the regulatory compliance of health facilities with national laws and regulations on occupational health and safety, bearing in mind the specific working conditions and occupational hazards in the sector. Unsafe working conditions resulting in occupational illness, injuries and absenteeism represent a significant financial cost for the health sector. For instance, in 2017 the annual costs of occupational illnesses and injuries in the health care and social services sector in Great Britain were the highest among all sectors, estimated at the equivalent of US$ 3.38 billion (1) .

Globally, improving health, safety and well-being of health workers lowers the costs of occupational harm (estimated at up to 2% of health spending) and contributes to minimizing patient harm (estimated at up to 12% of health spending) (2) . Furthermore, implementing key interventions to protect the health and safety of health workers contributes to increasing the resilience of health services in the face of outbreaks and public health emergencies and contribute to strengthening the performance of health systems through: 1) preventing occupational diseases and injuries; and 2) protecting and promoting the health, safety and well-being of health workers, thereby improving the quality and safety of patient care, health workforce management and environmental sustainability.

Policy actions

Only one third of countries have some national policy instrument to protect health, safety and well-being of health workers. Based on the experience of such countries, the following policy interventions have been demonstrated to be beneficial in the protection of health workers:  

• introducing new and updating existing regulations, standards and codes of good practices for protecting health and safety of health workers;
• making the protection of health and safety of health workers an integral part of the management of health care at all levels; 
• creating mechanisms and building capacities for management of occupational health and safety in the healthcare sector at the national, sub-national and facility levels;
• expanding the coverage of health workers with competent occupational health services, including for risk assessment and management, health surveillance, vaccination and psycho-social support; and
• establishing collaboration with organizations of employers and health workers for improving working conditions.

Responsibilities and rights

While employers have the overall responsibility for ensuring that all necessary preventive and protective measures are taken to minimize occupational risks, health workers have the responsibility to cooperate with the management and participate in the measures for protecting their health, safety and well-being.

Health workers have the right to remove themselves from a work situation that they have reasonable justification to believe presents an imminent and serious danger to their lives or health. When a staff member exercises this right, he or she shall be protected from any undue consequences. 

WHO response

In 2022, with resolution WHA74.14 on protecting, safeguarding and investing in the health and care workforce , the World Health Assembly called upon Member States “to take the necessary steps to safeguard and protect health and care workers at all levels”. The global patient safety action plan 2021–2030, adopted by the 74 th World Health Assembly, includes action on health worker safety as priority for patient safety. 

WHO’s work on protecting the health, safety and well-being of health workers includes:

• development of norms and standards for prevention of occupational risks in the health sector;
• advocacy and networking for strengthening the protection of health, safety and well-being of health workers; and
• supporting countries to develop and implement occupational health programmes for health workers at the national, subnational and health facility levels. 

WHO and ILO have jointly issued a guide on the development and implementation of occupational health and safety programmes for health workers  and work with international partners to build capacities for its implementation in countries.

WHO also provides guidelines and recommendations about prevention and management of occupational hazards in the health care sector .

• Costs to Britain of workplace fatalities and self-reported injuries and ill health, 2017/18. [Internet]. Health and Safety Executive; 2019. Available from: https://www.hse.gov.uk/statistics/pdf/cost-to-britain.pdf
• Bienassis De K, Slawomirski L, Klazinga N. The economics of patient safety Part IV: Safety in the workplace: Occupational safety as the bedrock of resilient health systems, OECD Health Working Papers, No. 130. [Internet]. Paris: OECD Publishing; 2021. Available from: https://econpapers.repec.org/RePEc:oec:elsaad:130-en

WHO's work on occupational health

Occupational hazards in the health sector

Caring for those who care: Guide for the development and implementation of occupational health and safety programmes for health workers

Caring for those who care: national programmes for occupational health for health workers. World Health Organization/International Labour Organization policy brief

Protection of health and safety of health workers: checklist for health care facilities

Interim guidance on occupational health for health workers in COVID-19

ILO/WHO toolkit on work improvement in healthcare facilities – a trainers guide and action manual

Protecting health and safety of health workers

Online training courses

Occupational health and safety for health workers in the context of COVID-19

Rapid Response Teams Essentials Online Learning Programme. Module 8: Responder well-being and ethics in emergency preparedness and response

PERSPECTIVE article

Prioritizing the mental health and well-being of healthcare workers: an urgent global public health priority.

• 1 Independent Researcher, Oslo, Norway
• 2 Department of Global Health and Social Medicine and Harvard Medical School, Boston, MA, United States
• 3 Mental Health Foundation, London, United Kingdom
• 4 Department of Global Health and Population, School of Public Health, Harvard University, Boston, MA, United States
• 5 21HealthStreet, London, United Kingdom
• 6 Faculty of Health Sciences, School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
• 7 Danish Committtee for Health Education, Copenhagen, Denmark

The COVID-19 pandemic has had an unprecedented impact on health systems in most countries, and in particular, on the mental health and well-being of health workers on the frontlines of pandemic response efforts. The purpose of this article is to provide an evidence-based overview of the adverse mental health impacts on healthcare workers during times of crisis and other challenging working conditions and to highlight the importance of prioritizing and protecting the mental health and well-being of the healthcare workforce, particularly in the context of the COVID-19 pandemic. First, we provide a broad overview of the elevated risk of stress, burnout, moral injury, depression, trauma, and other mental health challenges among healthcare workers. Second, we consider how public health emergencies exacerbate these concerns, as reflected in emerging research on the negative mental health impacts of the COVID-19 pandemic on healthcare workers. Further, we consider potential approaches for overcoming these threats to mental health by exploring the value of practicing self-care strategies, and implementing evidence based interventions and organizational measures to help protect and support the mental health and well-being of the healthcare workforce. Lastly, we highlight systemic changes to empower healthcare workers and protect their mental health and well-being in the long run, and propose policy recommendations to guide healthcare leaders and health systems in this endeavor. This paper acknowledges the stressors, burdens, and psychological needs of the healthcare workforce across health systems and disciplines, and calls for renewed efforts to mitigate these challenges among those working on the frontlines during public health emergencies such as the COVID-19 pandemic.

Introduction

With the emergence of the coronavirus disease (COVID-19) pandemic in late 2019, and the World Health Organization declaring it a global pandemic on 11th March 2020, health systems in many countries have been at times overwhelmed and stretched past their limits in terms of capacity and resources while striving toward continued delivery of quality care. The challenges for health systems, further complicated by the emergence of new more infectious variants of the virus, are likely to persist—even though infection rates have decreased in many parts of the world and the vaccine roll out progresses at a rapid pace at the time of writing this article—because we are now facing a second and equally serious pandemic of mental health challenges. The threats to mental health run deep within communities and are far reaching, affecting the millions of individuals who have been traumatized during national or regional lockdowns, left vulnerable to substance use or loneliness, those who have lost loved ones to the virus or face heightened anxieties of getting sick, or among those facing the dire economic consequences of the pandemic ( 1 – 3 ). In this challenging recovery phase of the pandemic, the mental health needs of healthcare workers and those on the frontlines of the pandemic response cannot be overlooked.

During recent years, the mental health needs of healthcare providers have been gaining attention as a major public health concern and threat to quality care delivery. Healthcare professionals are exposed to multiple stress factors within their work, which may influence their physical, mental, and emotional well-being in negative ways ( 4 – 6 ). The World Health Organization estimates a projected shortfall of 18 million health workers by 2030, mostly in low- and lower-middle income countries. However, countries at all levels of socioeconomic development face, to varying degrees, difficulties in the education, employment, deployment, retention, and performance of their workforce ( 7 ). The COVID-19 pandemic is likely to exacerbate these issues among healthcare workers across the globe. In this article we reflect on the mental health impacts on healthcare professionals during times of crisis and other challenging working conditions against a backdrop of the current COVID-19 pandemic. First, we provide a broad overview of the elevated risk of stress, burnout, moral injury, and mental health challenges experienced among health workers. Next, we consider how public health emergencies, such as pandemics, can exacerbate these concerns and pose additional challenges to reaching and supporting health workers. Further, we consider promising approaches for protecting and promoting the mental health of health workers through self-care and other evidence-based interventions. Lastly, we highlight the need for organizational measures, policies, and systemic changes needed to address these challenges and empower healthcare workers going forwards.

Stress, Burnout, and Mental Health Challenges Among Healthcare Workers

Numerous factors contribute to elevated stress among healthcare workers, including heavy workloads, long shifts, a high pace, lack of physical or psychological safety, chronicity of care, moral conflicts, perceived job security, and workplace related bullying or lack of social support. The resulting psychological distress can lead to burnout, depression, anxiety disorders, sleeping disorders, and other illnesses ( 5 , 6 , 8 , 9 ). Work related stress can have a negative impact on health care providers' professionalism, quality of care delivery, efficiency, and overall quality of life. Therefore, it is critical to identify and mitigate these work-related risk factors to protect the mental health and well-being of healthcare workers.

Working in a stressful or challenging environment for long periods with little recovery time is a risk factor for burnout. Burnout is defined as an occupational phenomenon in ICD-11: “Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: (1) feelings of energy depletion or exhaustion; (2) increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and (3) reduced professional efficacy. Burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life” ( 10 ). Maslach et al. describe burnout as that point at which important, meaningful, and challenging work becomes unpleasant, unfulfilling, and meaningless. Energy turns into exhaustion, involvement (also referred to as engagement) becomes cynicism and efficacy is replaced by ineffectiveness ( 11 ).

A study investigating burnout and work-life integration in physicians between 2011 and 2017 in the US, found that about 44% of physicians reported at least one symptom of burnout in 2017 compared with about 54% in 2014 and about 45% in 2011 ( 12 ). This indicates some fluctuation in physician burnout in the years before the COVID-19 pandemic, yet the levels of burnout among physicians remained significant. Even when adjusting for age, sex, relationship status, and hours worked per week, physicians were found to be at increased risk for burnout and less likely to be satisfied with work-life integration compared with other working US adults ( 12 ). Studies have shown that physicians in clinical practice can be at risk for burnout as a result of both work and structural issues. Work related risk factors include work overload (e.g., large patient volumes, insufficient resources, or feeling poorly managed), lack of control over one's work environment, having to spend time on tasks inconsistent with one's career goals and high levels of work-home interference ( 4 , 13 ). Structural issues predisposing physicians to burnout include being female, working in a solo practice, being early in one's career, lacking a sense of personal control over events, and attributing success to chance instead of personal accomplishments ( 14 , 15 ). Also, in many low and middle income countries the ratio between healthcare workers and the overall population is a major issue which adds to healthcare workers' work burden, stress, and burnout. Additionally, many frontline health workers in lower income countries are predominantly women, and are therefore typically at the bottom of health system hierarchies, leaving them with limited autonomy and at elevated risk of burnout ( 16 ).

Burnout in healthcare workers can also have adverse impacts on patient care. Several cross-sectional studies have linked burnout to suboptimal patient care practices [e.g., ( 17 – 20 )]—as well as with a doubled risk of medical error and a 17% increased odds of being named in a medical malpractice suit ( 21 ). Self-perceived major medical errors were also associated with worsening burnout, depressive symptoms, and a decrease in quality of life. This suggests a bidirectional relationship between medical errors and distress ( 22 ). Burnout has also been shown to contribute to a higher risk of motor vehicle accidents (even after adjusting for fatigue) among physicians ( 23 ). Other consequences of burnout include absenteeism, low organizational commitment, increased turnover of skilled staff, and greater patient dissatisfaction ( 11 ).

Ethical dilemmas [e.g., ( 24 , 25 )] and moral injury [e.g., ( 26 , 27 )] are other issues that healthcare workers are faced with while providing care within challenging healthcare contexts. Moral injury is defined as the psychological distress that results from actions, or their absence, that violate someone's moral or ethical code ( 28 ). The concept of moral injury describes the ambivalence and guilt felt when one's decisions or actions are not in accordance with one's own moral values. It has been characterized as an invisible epidemic among healthcare providers ( 29 ). Examples might include where a healthcare worker has to make the difficult decision as to who will get oxygen or be put on a ventilator and who will not if there are a finite number of life saving oxygen points or ventilators available.

Moral injury is not a mental illness, but those who do develop moral damage are likely to see themselves negatively, question their actions and experience feelings of guilt and shame ( 30 ). These negative thoughts may contribute to the development of mental illness issues like depression, suicidal ideation and post-traumatic stress disorder (PTSD), as well as thoughts about leaving one's profession ( 31 – 35 ). We could expect increased cases of moral injury when dealing with a health crisis or challenging and stressful working environments; where important decisions—perhaps concerning life and death—are required to be made fast and where the ability to follow optimal care protocols is reduced. Feelings of individual or unclear responsibility is likely to be another risk factor in this context.

The concept of vicarious traumatization , also defined as secondary traumatic stress, has also been gaining increased attention during the last decades ( 36 ). This condition is associated with different psychological abnormalities derived from the sympathy of healthcare workers toward people who are experiencing primary trauma. Common symptoms associated with vicarious traumatization are loss of appetite, fatigue, irritability, inattention, numbness, sleep disorders, fear, and despair. Frequently, these symptoms are accompanied by trauma responses and interpersonal conflicts. However, the symptoms often remain at subclinical levels ( 37 , 38 ).

Further, studies have indicated that healthcare practitioners are likely to suffer in silence due to the perceived stigma associated with experiencing “stress” and “mental illness,” as well as fear of getting their medical license withdrawn ( 39 ). The stigma accociated with mental health issues has inward-facing impacts for health professionals' willingness to seek help or disclose a mental health problem, which can result in an over-reliance on self-treatment, low peer support—including ostracization and judgment from co-workers if disclosure does occur—and increased risk of suicide ( 40 ). A systematic review and meta-analysis of various studies which have been conducted across the world showed high suicide rates among medical professionals across countires, especially among women ( 41 ). It also showed that some medical specialties might be at higher risk; such as anesthesiologists, psychiatrists, general practitioners, and general surgeons. There was an overall rate of 1.0% suicide attempts and 17% suicidal ideation among physicians ( 41 ). Further, mental health problems, stress, compassion fatigue, and burnout at work are leading causes of healthcare workers thinking about leaving their profession around the world ( 42 – 45 ). When healthcare workers quit, or when they are tragically lost to suicide, they take many years of invaluable training and experience with them. Beyond the individual health workers and their immediate families, this has devastating consequences to their co-workers and to entire health systems, while creating further challenges to meeting the needs of diverse patient groups.

Overall, according to the World Medical Association “physicians in many countries are experiencing great frustration in practicing their profession, whether because of limited resources, government and/or corporate micro-management of healthcare delivery, sensationalist media reports of medical errors and unethical physician conduct, or challenges to their authority and skills by patients and other health care providers” ( 46 ). Other subgroups of healthcare workers face similar frustrations and challenges.

Mental Health of Healthcare Workers in Times of Pandemics and Crisis

During the COVID-19 pandemic, which has been the cause of more than 2.85 million deaths worldwide to date (5th April, 2021) and rising, many healthcare workers, both within medical care and the mental health sector, have been experiencing challenges in adapting quickly to changes in patient volume, mounting demands, clinical roles, new technologies, and ways of working. They have also faced quite high risk of infection together with limitations in protective equipment, as well as managing the anxieties of patients and facing uncertainty in how to effectively treat and respond to complex manifestations of the virus. Perhaps left with no other choice than to adapt as best as they can to ensure the continuation of their obligations and services, many health workers have experienced elevated psychological distress, burnout, and increased risk of mental illness ( 47 ). The recovery phase had hardly begun in many countries around the world, when they were faced with a “second wave” or even a “third wave” of the pandemic—and there will probably be several more waves to come as new variants emerge and as we are assessing immunity following vaccination. This means that healthcare providers need to prepare for a continuation of challenging working conditions for quite some time to come. Based on such working conditions and being deployed on the frontlines in the pandemic response, it is perhaps no surprise that issues related to mental health among healthcare workers have drawn interest since the early days of the COVID-19 pandemic ( 9 , 34 , 48 ). Recent surveys, reviews and meta-analyses are pointing to early evidence suggesting that a considerable proportion of healthcare workers have experienced stress, anxiety, depression, and sleep disturbances during the pandemic, raising concerns about risks to mental health ( 5 , 49 , 50 ). Specifically, a recent systematic review and meta-analysis conducted by Li et al. ( 51 ) across 65 studies, involving 97,333 health care workers in 21 countries, has identified a high prevalence of moderate depression (21.7%), anxiety (22.1%), and PTSD (21.5%) among healthcare workers during the COVID-19 pandemic. Further, a review evaluated seven studies on COVID-19 related traumatic stress, where five assessed traumatic stress response, one assessed acute stress symptoms and one focused on vicarious traumatization. The findings in all the included studies highlighted the presence of trauma-related stress, with a prevalence ranging from 7.4 to 35%, particularly among women, nurses, frontline workers and in workers who experienced physical symptoms ( 52 ). A survey by Li et al. ( 38 ), utilizing a mobile phone app-based questionnaire, found evidence of vicarious traumatization in the general public ( n = 214), frontline nurses ( n = 234), and non-frontline nurses ( n = 292) aiding in COVID-19 control during the outbreak in China in February 2020. Another survey conducted among physicians ( n = 2,334) in the US in August 2020 found that 58 percent of physicians reported to often have feelings of burnout, compared to 40 percent in 2018. Further, nearly 1 in 4 physicians (22 percent) reported to know a physician who has committed suicide, while 26 percent know a physician who has considered suicide. Furthermore, 18 percent of physicians reported to have increased their use of medications, alcohol, or illicit drugs as a result of COVID-19's effects on their practice or employment situation ( 53 ).

Vizheh et al. ( 9 ) conducted a systematic review of 11 studies assessing health workers' psychological well-being during the COVID-19 pandemic. These studies showed that various factors were associated with mental pressures experienced by the healthcare workers. Working in areas with a high incidence of infection was significantly associated with higher stress and psychological disturbance. Further, sex-aggregated case data collated by the UN show that more than 70% of COVID-19 infections in healthcare workers in the USA, Italy and Spain are in women ( 54 ). In an analysis of the results from a survey investigating how gender and race affect the ways in which health professionals experience the pandemic in Brazil, Lotta et al. ( 55 ) found that this rate can partly be explained by the absence of necessary resources provided to these healthcare workers: women, and black women in particular, have less access to personal protective equipment and training. Furter, they argue that female healthcare workers worldwide are also facing the downstream effects of their work, including mental health issues, increased physical violence, alternative arrangements for their families so as to not expose them to risk, and physical exhaustion ( 56 ).

These types of issues and concerns may be further exacerbated in difficult work environments, such as in impoverished settings and in low-income or middle-income countries where access to personal protective equipment may be severely limited ( 3 , 57 ). A scoping review was conducted of 51 studies relevant to mental health conditions among healthcare workers during COVID-19, with a focus on low and middle income countries. Symptoms of depression, anxiety, psychological trauma, insomnia and poor sleep quality, workplace burnout and fatigue, and distress were the main adverse mental health outcomes found across these studies. Further, females, younger-aged, frontline workers, and non-physician workers were found to be affected more than other subgroups ( 58 ). In a factor analysis study conducted in the early phases of the pandemic, 140 healthcare workers of a tertiary care hospital in India were assessed for perceived stress and insomnia. The factor analysis yielded four factors which were identified as (1) Insomnia, (2) Stress-related Anxiety, (3) Stress-related Irritability, and (4) Stress-related Hopelessness. These four factors explained 62.2% of the variance. Doctors were found to have the highest level of anxiety among all healthcare workers. Both doctors and nurses perceived a greater level of overload related irritability than the other healthcare workers. Compared to doctors and nurses, other healthcare workers were more likely to experience insomnia ( 59 ).

The increased negative mental health impact on healthcare providers during times of health crises is not a new concern. Prior reviews have reported on the dire consequences of public health emergencies for frontline health workers, with the most severe impacts often observed in lower-income countries where health systems are fragmented and where there are few protections in place for frontline health workers ( 16 ). Several months after the peak of the 2003 SARS outbreak in Hong Kong, healthcare workers reported high levels of ongoing mental distress ( 60 ). Studies conducted at the time of the SARS outbreak have also shown that emergency department staff are at higher risk of developing posttraumatic stress disorder (PTSD). Healthcare workers who volunteered in West Africa during the 2013–2016 Ebola epidemic reported symptoms of isolation, depression, stigmatization, interpersonal difficulties, and extreme stress after they returned home ( 61 ). About 64% of medical staff working during the initial stages of the MERS outbreak reported PTSD-like symptoms. Staff who performed MERS-related tasks showed the highest risk for post-traumatic stress disorder symptoms even after time had elapsed. The risk increased even after home quarantine ( 62 ).

Prior research has reported that disasters have significant adverse effects on the mental well-being of medical responders. Nurses have been found to report higher levels of adverse outcomes, like depression and PTSD, than physicians. Lack of social support and communication, maladaptive coping, and lack of training are important risk factors for developing negative psychological outcomes across different types of disasters ( 63 ). Moreover, studies related to emergency situations and disasters, show that long shifts over a longer period of time and risk of personal injury or contamination is associated with an increased risk of sleep disturbances, harmful alcohol use, anxiety, depression, and PTSD among first responders ( 64 – 66 ). These conditions can be broadly similar to those frontline workers are faced with while working with patients with COVID-19 and wearing limited personal protective equipment. These individuals have been putting their own health and safety at risk for long periods of time, striving to help as many people as they can—while working long hours within stressful environments. Sadly, the COVID-19 pandemic is likely to increase healthcare professionals' mental health issues and suicide rates, especially in low-resource settings and countries with few or limited protective measures in place. In the coming months and years, when the “fight or flight” phase of the crisis is over—we will start to see all the different mental health impacts much more clearly. Should history repeat itself, the negative health impacts of COVID-19 on frontline health workers and all types of healthcare professionals are likely to continue for years or even decades to come ( 67 ).

While evaluating the emerging research on the mental health impacts of the pandemic, it is important to note that some of the conducted surveys are using screeners which are focused on the immediate effects and which only pick up “diagnostically valid” issues or disorders. However, mental well-being is not just an absence of a mental disorder. Chronic stress, fatigue, fear or guilt of transmitting the infection to loved ones, overwork, self-blame, fear of infection and mortality, lack of breaks or leaves and inflexibility in work schedules can all adversely affect the mental health of healthcare workers—whether they fulfill a set of criterion of a disorder, or not.

Several larger research projects are now in place on national level around the world (e.g., in Norway led by the Norwegian Institute of Public Health) to collect data on both short term and long term mental health impacts on frontline workers and other healthcare staff during the COVID-19 response. As data from such studies starts to emerge, along with the collection of invaluable first-person accounts and qualitative data, the total picture of the COVID-19 related and long-term mental health impacts on healthcare staff will get clearer.

The Importance of Practicing Self-Care

Most health care professionals are trained to put patients first. Self-care is not always prioritized among clinicians, as they may fear judgment from others or feel selfish at the thought of attending their own needs. Practicing self-care could however be imperative to coping with the obligations, workload, and demands of their profession, and help health professionals gain a better balance or integration between their work and their spare time—as well as help protect their health, well-being, and satisfaction with both their work and overall life.

Research has indicated that effective self-care practices involves self-awareness, self-compassion, the practice of altruism and the implementation of a variety of strategies across physical, social and inner self-care domains ( 68 – 70 ). In a national study of Australian nurses and doctors within palliative care units, 100% of those using a self-care plan reported it to be an effective strategy, while 70% of those not currently using a self-care plan indicated they would consider developing a self-care plan if they were supported to do so ( 70 ).

Two recent reviews ( 71 , 72 ) point to the importance of balancing one's personal needs and the needs of others and recommend self-care as the first line of defense for healthcare workers to manage COVID-19 patient care demands, the longevity of the crisis, and its disruption of normal life routines. In this regard, these reviews highlight the importance of using supportive tools and techniques to combat mental health issues and compassion fatigue among healthcare workers. Some of the suggested preventive self-care strategies include spiritual practices and relaxation techniques, using e-mental health services and enhancing interpersonal skills. Other evidence-based self-care strategies include prioritizing close relationships such as those with family, maintaining a healthy lifestyle by ensuring adequate sleep, regular exercise, and time for vacations, fostering recreational activities and hobbies, and practicing mindfulness and meditation ( 73 ).

Practicing self-care is important for all healthcare workers, especially during times of crisis, uncertainty and higher demands. This can be done by frequently checking in with and being aware of one's own emotional level and stress level, taking breaks whenever possible, practicing healthy daily routines like eating healthy food, exercising, or taking walks in nature, getting enough sleep, and allowing emotional processing whenever possible and through the means preferred—whether it is through relaxation, mindfulness and meditation exercises, journaling, taking a run, dancing, engaging in arts or creative work, spending time in nature, calling a friend, or crying in solitude. Allowing emotional expression on a continuous basis—as opposed to repressing emotions—helps build emotional resilience and mental well-being in the long run ( 74 ). The beneficial effects of appropriate self-care for healthcare workers include improved physical, mental, and emotional well-being ( 75 ), as well as being able to provide care for their patients in a more sustainable way with greater compassion, sensitivity, effectiveness, and empathy ( 76 ). Practicing self-care can also help healthcare workers create some structure and predictability amidst chaos and uncertainty and make them able to manage high levels of stress in more constructive ways. A qualitative study based on semi-structured interviews with 172 physicians working in COVID-designated centers across India, found support for resilience as a learned and evolving process: Most of the participants mentioned resilience as a continuum developed through experiencing and facing an unprecedented crisis, aided by social support and past encounters with stress. The results suggested that the consistent living through hardships and adversities of the COVID-19 crisis with responsible risk-taking, helped pave the way for problem-solving, personal efficiency and coping in the physicians ( 77 ). Empathy, optimism, and self-efficacy can also improve personal health-risk perception, which is vital for psychological resilience during pandemics ( 77 , 78 ).

The recovery phase is when the healthcare workers will have more time for reflection, contemplation and rumination around the experiences they have been through during a crisis. It is essential for their recovery that they have professional support and appropriate mental health and self-care tools—and knowledge about how to use them—during this phase. Especially when the time of recovery is short, and interrupted with new waves of virus outbreaks or other challenging crises. It's also essential that healthcare providers focus on their strengths, instead of engaging in self-critical thinking about things they could have done better. To avoid accumulation of stress during times of crisis or other challenging working conditions, healthcare workers should try to prioritize and simplify tasks; focus on one task at a time whenever possible; set healthy boundaries; communicate in a self-assertive way; and seek support for important clinical decisions. For some, practicing self-care and being able to debrief with colleagues will be enough, while for others who might be traumatized or who experience high levels or stress, anxiety or depression, stronger measures, and opportunities for professional support over time will be needed.

Proactive Prevention Measures and Interventions

Short-term mood boosters have been widely practiced during the COVID-19 pandemic. These have included free lunches or snacks during the working day, or clapping, posters, and songs thanking “healthcare heroes” for their efforts. While this may offer temporary acknowledgment, it can also seem like a distraction or excuse from attending to the serious challenges frontline workers and other health professionals face in regards to protecting their own health and well-being at work ( 79 ). In fact, repeatedly referring to healthcare workers as “heroes” may actually act as a barrier to them seeking help (i.e., heroes help others; they don't need help). Healthcare workers need to be seen as fellow human beings who are not invincible and whose resilience also has limits. Instead of superficial or temporary appraisal and reward, we need to invest in and accelerate protective and preventive measures to reduce the burden on healthcare workers on a more permanent basis. This should also involve leveraging existing evidence-based interventions for alleviating psychological distress in public health emergencies.

As we have seen, healthcare providers who have worked on the frontline, humanitarian aid workers, lay providers, as well as mental health professionals providing psychological first-aid and mental health care for those affected during these times of crisis, are all exposed to, and can be expected to experience significant negative health impacts like post-traumatic stress, anxiety, insomnia, and depression. As mentioned, we also know that physicians and other healthcare providers may be hesitant to seek mental healthcare, often due to concerns about confidentiality and its potential impact on their careers ( 39 ).

For too long, the responsibility has been on the individual healthcare worker to recognize and manage their own stress, burnout or depression, with few avenues or tools made available for them to successfully do so. COVID-19 has clearly demonstrated the need to invest in protecting the mental health of the healthcare workforce. Based on the current situation and working conditions for healthcare practitioners, as well as earlier research findings on the negative mental health impacts from emergency situations and the difficult and stressful working conditions in general, it should be of highest priority to prevent a parallel pandemic of mental health issues among the healthcare workforce in the times to come.

Thus, it is imperative to provide necessary mental health support for healthcare staff during these times. Healthcare workers across the medical and mental health sector should be offered psychological first aid during times of crisis, heavy workload, or challenging working conditions, as well as long-term support through accessible mental health support programs (e.g., resilience, self-care, or mindfulness courses). For instance, there are brief psychological interventions that have proven to be effective in managing stress in humanitarian emergencies. The World Health Organization's Self-Help Plus (SH+) stress management intervention ( 80 ) may be ideal for addressing the elevated psychological stress and risks of burnout and mental distress among healthcare workers responding to the COVID-19 pandemic. SH+ is based on acceptance and commitment therapy (ACT), which can reduce symptoms of depression and anxiety ( 81 ), and combines elements of cognitive behavioral therapy (CBT) including psychoeducation, mindfulness exercises, and promoting psychological flexibility where individuals learn new ways to open up to and cope with difficult thoughts and feelings consistent with their own values, rather than avoiding these thoughts ( 82 ). One key feature of SH+ is the broad focus on reducing psychological distress associated with adversity and difficult life experiences ( 80 ), which increases scalability by not requiring use of diagnostic procedures or targeting specific syndromes. It is important to recognize that even though health workers during the pandemic are experiencing high rates of distress, this does not mean they have a diagnosable mental disorder, emphasizing the need for early intervention and self-help in alleviating stress. SH+ has demonstrated effectiveness in significantly reducing psychological stress among women in humanitarian settings in Uganda, as reflected in a cluster-randomized trial with 14 villages enrolling 694 participants ( 83 ).

The use of telemedicine centers, platforms, and solutions is a promising strategy to provide more effective care for patients, while reducing the workload and taking off pressure on healthcare workers. During the COVID-19 outbreak in China there have been positive experiences with using remote consultations to connect medical experts in a telemedicine center with frontline health workers in the Hubei province (and other less developed areas) to share medical images, record data, and test results. A telemedicine platform was also set up where medical workers could share their opinions and experiences with each other in order to achieve more suitable treatment methods. The platform was also used to provide psychological counseling for frontline doctors through videoconferencing to help them cope with stress and anxiety. This was found to greatly reduce the pressure on frontline medical staff. Other potential benefits with this approach are reduced needs for face-to-face consultations, protection of experts from exposure to viruses and saved costs ( 84 ). Thus, telemedicine approaches can help prevent work overload, burnout, and mitigate negative mental health impacts in healthcare workers in real time.

Mindfulness practice and stress management approaches are two additional health interventions with evidence of efficacy and measurable outcomes for reducing burnout and promoting resilience in clinicians ( 85 , 86 ). Maunder et al. ( 87 ) found that computer-assisted resilience training in healthcare workers appeared to be of significant benefit under pandemic conditions. Peer-to-peer support groups and buddy teams are other helpful interventions that could give healthcare workers a possibility to debrief their experiences with others with similar experiences ( 30 ). The use of reflective practice groups or “reflective rounds” (e.g., Balint, Schwartz) have a growing evidence base in helping clinicians manage stressful encounters and in reducing the impact of burnout. For example, eight face-to-face reflective rounds were arranged for staff in Southampton Children's Hospital in the UK, from September 2017 to February 2020 with a further virtual round in July 2020 during the COVID-19 pandemic. Each round was facilitated by a clinical psychologist and consultant. For each round, up to three volunteer panelists from different staff groups were invited to share their personal experiences on a pre-selected subject to the large group. The group would then contribute to the discussion by offering their own reflections. Feedback on this practice was received from 202 participants. The results showed that the majority (98%) would recommend the rounds to colleagues with 64 participants (32%) rating the rounds as “exceptional” and 91 (45%) as “excellent.” The virtual round received similar positive feedback ( 88 ).

Such evidence-based prevention measures and interventions will help protect and strengthen the mental health and resilience of healthcare workers in the long run, and make them better prepared to manage and thrive in their work during challenging circumstances. It will also help facilitate their personal and professional development on an ongoing basis.

Workplace Culture and Leadership

Unfortunately, no measures to prevent burnout or other mental health issues will be effective unless attention is paid to enhancing a positive work environment, defined as one “that attracts individuals into the health profession, encourages them to remain in the health workforce and enables them to perform effectively to facilitate better adaptation” ( 89 ). Healthcare leaders and decision makers should seek to lead by example and work toward reducing the stigma associated with mental health issues among healthcare staff, and foster a work culture of transparency, trust, respect, openness, equality, empathy, and support. Healthcare leaders should especially be mindful of promoting a culture of inclusion, collaboration, and support, instead of comparison and competition.

It is crucial that healthcare leaders and decision makers step up and take long-term responsibility when it comes to highlighting the importance of protecting the mental health of the healthcare workforce on an ongoing basis. Normalizing discussions about mental health among physicians and other healthcare workers can help reduce some of this stigma, while establishing long term screening and prevention programs will be critical to monitoring early signs and preventing burnout, PTSD and other mental health issues on a continuous basis. Since the risk of moral injury can be high when faced with a heavy workload, stressful environments, limited equipment or difficult choices, especially during times of public health emergencies, it is a topic worth more attention and interventions from the leadership of health and care organizations. Managers can help staff make sense of morally challenging decisions and their psychological response to these difficult decisions by being straightforward and honest about possible ethical dilemmas. Also, support from colleagues and line managers helps to protect the mental health of healthcare workers in these regards ( 90 ).

A study involving a total of 214 healthcare workers in Turkey found that in order to raise the psychological resilience of healthcare professionals working during the COVID-19 pandemic their quality of sleep, positive emotions, and life satisfaction need to be enhanced. The study also concludes that in order to enhance positive emotions and weaken negative emotions of healthcare professionals, the workers' needs ought to be prioritized in any practice ( 91 ). Rieckert et al. ( 92 ) conducted a scoping review of 73 papers focusing on the impact of COVID-19-like working conditions on the physical and/or mental health of healthcare professionals in a hospital setting, as well as on interventions, measures and policies to preserve physical and/or mental health. The review was supplemented with expert interviews to validate the findings. The results showed that recommendations fostering resilience prior to the outbreak included optimal provision of education and training, resilience training, and interventions to create a feeling of being prepared. Recommendations during the outbreak consisted of (1) enhancing resilience by proper provision of information, psychosocial support, and treatment (e.g., create enabling conditions such as forming a psychosocial support team), monitoring the health status of professionals and using various forms and content of psychosocial support (e.g., encouraging peer support, sharing, and celebrating successes), (2) tasks and responsibilities, in which attention should be paid to kind of tasks, task mix, and responsibilities as well as the intensity and weight of these tasks and (3) work patterns and working conditions.

In line with such findings, healthcare staff should be given the opportunities to express their needs and the means to have these needs met. Further, turning personalized self-care plans and approaches to build resilience into standard organizational cultural practice is important in assisting with overcoming barriers and prioritizing self-care among healthcare workers. At an organizational level, time to and ventures of practicing self-care should be recognized as a needed and essential part, both in terms of preventing mental health issues and building resilience and for increasing motivation, job satisfaction, patient safety, and quality of care. The self-care, resilience, and workplace policy interventions which are promoted on an organizational level could involve mandatory breaks (including power naps, taking walks, access to silent rooms, etc), use of mini-breaks before every meeting, policies to have all meetings to start on the hour and other approaches to improving the workplace environment.

Also, a limit on the length of work shifts should be put in place, and there should be opportunities to enroll in professional mental health support programs and to engage in peer-to-peer support groups, reflective rounds, or buddy teams to debrief their experiences on a regular basis. Furthermore, hospitals and other care facilities should establish adequate parental and sick leave policies that do not burden a healthcare provider's colleagues. Departments should schedule in protected time for personal doctor, therapist, and dentist appointments. Other aspects of policy change likely to have a positive impact on the well-being of healthcare professionals is in relation to non-punitive responses to medical errors ( 93 ) and a trauma-informed approach to stress in the workplace. In addition to common challenges and needs which are necessary to address within the healthcare workforce as a whole, the reviewed literature has also pointed toward heterogeneous needs among healthcare workers based on specific challenges, predispositions, socio-economic factors, gender, race, and other factors. It is important that healthcare leaders and decision makers are aware of such differences in needs, and that their policies and interventions help reduce the extra burdens on those who are most vulnerable to experience adverse mental health impacts as a result of their working conditions.

Essentially, protecting the mental health and the professional and personal development of healthcare staff, should be a high priority not only in times of crisis, but on an ongoing basis. A recent report from the National Academy of Medicine in the US (2019) recommended that medical societies, state licensing boards, specialty certification boards and medical education and health care delivery organizations all need to take concrete steps to reduce the stigma for clinicians of seeking help for psychological distress and make assistance more easily available. These recommendations are even more relevant during the COVID-19 pandemic.

Towards a Systemic Shift

A survey conducted by the World Health Organization on the impact of COVID-19 on mental, neurological, and substance use services in 130 countries, clearly indicates that mental health systems have been compromised at a time when they are likely to be needed the most ( 94 ). Healthcare systems should be reimagined to reduce the increasing burden on healthcare professionals, and promote their health, well-being and thus their ability to provide care and achieve optimal outcomes. We need healthcare systems that are driven by the needs of patients and healthcare providers; and not by demands of increased efficiency and economic interests only. This change should be reflected by policies, professional guidelines or other means of self-regulation.

A recent policy brief by United Nations on COVID-19 and the need for action on mental health suggests that the implementation of the following systemic actions by national decision-makers will help minimize and address the mental health consequences of the pandemic in general: (1) Apply a whole-of-society approach to promote, protect and care for mental health, (2) ensure widespread availability of emergency mental health and psychosocial support, and (3) support recovery from COVID-19 by building mental health services for the future ( 95 ).

Furthermore, involving both healthcare providers and patients in evaluations and improvements of healthcare services, so called co-production ( 96 , 97 ), can help share power ( 98 ) and provide valuable insights on both individual and organizational level. Exercising the principles of co-production, healthcare workers should be involved in the process of decision making, development, implementation, testing, and evaluation of interventions and efforts aimed at preventing psychological distress and mental health issues and improving their health, well-being, and job satisfaction in the long run. Further, including feedback from both patients and healthcare providers about perceived quality of care and working conditions, may also result in other important organizational benefits like financial support for improvements from higher management bodies such as the hospital's medical staff and Board of Directors. Such input can then be used as an instrument to gain legitimacy and set necessary improvements in motion ( 99 ). Exercising the concept of co-production within healthcare systems, could therefore help improve both the quality of care and the working conditions and well-being for overworked health care providers.

Similarly, it is important to address stigmatization within healthcare facilities as a systemic issue and keep those who fear or are being burdened by stigmatization at the center of any response to stigma. This includes working to empower people or groups experiencing stigma (including patients, caregivers, and healthcare workers), for example, by building skills and efficacy to address internalized stigma and cope with and challenge stigma, as well as building partnerships with gatekeepers and opinion leaders for change ( 100 ). Focused social and organizational support and understanding of the distress faced by healthcare workers during times of crisis and in general, can help reduce the stigma and improve social connections while reducing barriers to utilization of mental health interventions aimed at supporting healthcare workers. This has been termed an “epidemic of empathy” and has the potential of bringing together science and humanism in a way that might be beneficial even after cessation of the pandemic ( 77 , 101 ).

Finally, there is a need for prioritizing and promoting global collaboration on research, including longitudinal and qualitative studies, on the mental health impacts on healthcare workers during the pandemic and in the post-pandemic aftermath. The voices and first-person accounts of frontline workers and other healthcare staff who have served during the COVID-19 pandemic across the globe will bring invaluable contributions to the field and help foster needed systemic changes, rather than relying on quantitative studies and mere statistics or survey studies alone.

Implementing and promoting such systemic changes will be especially important in low and middle-income countries, where the vast majority of the world's population reside; yet, access to effective mental health care services remains severely constrained. It is in these lower resource settings where advances in the delivery of mental health care will be especially impactful at a population level, by advocating for the inclusion of these services as part of efforts to achieve universal health coverage, and more specifically, by recognizing the needs of healthcare providers delivering mental health services to vulnerable population groups across diverse settings.

Policy Recommendations

Based on the findings in the reviewed research and the points raised in our discussion, we propose the following policy recommendations:

• Enact national and local evidence based interventions and programs to support frontline healthcare workers health and well-being in a long-term perspective. Leverage the necessary expertise of health, wellness and behavioral science experts to guide the implementation of these solutions and ensure clear evaluation design, analysis, and iteration to inform continual evaluation and improvement.

• Share and distribute these resources across the organization, network of partners, patients, and others.

• Create national knowledge-bases (information, tools, and resources) designed to improve the resilience and well-being needs of workers and their leaders in times of crisis, recovery, and rebuilding.

• Ensure adequate staffing levels in healthcare systems and fair pay for workers.

• Encourage help-seeking and ensure available mental health resources for frontline health workers in distress.

• Condemn and combat the stigmatization of frontline healthcare workers. Increase efforts to de-stigmatize mental health across society.

• Ensure a wider and more actionable dialogue about mental health in the workplace.

• Engage frontline healthcare workers in the political decision-making processes and in co-creating new policy development.

• Reallocate research funds to explore paths for future preparedness for frontline healthcare workers.

• Consider the opportunity for digital technology and other innovative approaches to ensure access to effective training and ongoing support and guidance among frontline workers and in the overall healthcare workforce.

Conclusions

Healthcare workers across health systems and disciplines are facing significant stressors, burdens, and mental health challenges as a result of their work. This is especially the case for those who work on the frontlines during public health emergencies—with further challenges faced by those who work in impoverished and low-resource settings or in settings where stigmatization is high. The COVID-19 pandemic has acutely reminded us of the important and invaluable work that frontline workers and other healthcare professionals do on a daily basis in challenging circumstances, and has exposed the limitations of healthcare systems around the world. Before the memory of the pandemic response starts to fade, appropriate evidence-based measures and interventions must be put in place and actioned to protect the mental health and well-being of the healthcare workforce—not only during public health crises, but on a day-to-day basis. The measures and policy recommendations outlined in this article are a few of the many meaningful interventions that can reduce the risk of healthcare providers incurring ongoing, long-term psychological damage in the wake of COVID-19 and beyond.

Healthcare workers should be respected for the vital work they do to keep populations healthy, meaning we have a duty to find ways to meet their psychological needs and improve their welfare. The authors are hopeful that the acknowledgment and appreciation of the healthcare workforce will continue and become more permanent in the times to come. Empathy, transparency, open disclosure, and effective and supportive communication will solidify the partnership and collaboration between healthcare leaders, healthcare providers and patients as well as other stakeholders. This will then in turn provide the foundation of a healthcare system that revolves around the improvement of experiences and well-being outcomes of all involved.

World leaders and other decision makers need to fully realize the crucial importance and value of investing in the mental health and well-being of the healthcare workforce, on individual, organizational, and societal level. As well as the personal, economical, and societal benefits of doing so. Let us learn from our past and thank our essential healthcare workers by demanding and promoting real reforms within our healthcare systems. We cannot afford the cost of failing in this aim.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author Contributions

LS conceived the main conceptual ideas, drafted the manuscript, and performed the main literature review as well as subsequent editing and corrections. JN contributed with a critical review, helped drafting the introduction section, and contributed with additions, literature citations, and edits to the different sub sections of the manuscript. AK contributed with a critical review, literature citations, and edits in different sub sections of the manuscript. SS contributed with a critical review, literature citations, and edits in specific sub sections of the manuscript. MWQ provided early support for the main conceptual ideas and contributed with literature citations and input for different sub sections of the manuscript. CG contributed with literature citations and edits to specific sections of the manuscript. LM contributed with comments and suggestions to specific sub sections of the manuscript. All authors contributed to the article and approved the submitted version.

Conflict of Interest

MWQ was affiliated with the company 21HealthStreet.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1. Boursier V, Gioia F, Musetti A, Schimmenti A. Facing loneliness and anxiety during the COVID-19 isolation: the role of excessive social media use in a sample of italian adults. Front Psychiatry. (2020) 11:586222. doi: 10.3389/fpsyt.2020.586222

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Horigian VE, Schmidt RD, Feaster DJ. Loneliness, mental health, and substance use among US young adults during COVID-19. J Psychoactive Drugs. (2020) 53:1–9. doi: 10.1080/02791072.2020.1836435

3. Kola L, Kohrt BA, Hanlon C, Naslund JA, Sikander S, Balaji M, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry. (2021). doi: 10.1016/S2215-0366(21)00025-0. [Epub Ahead of Print].

4. Hayashino Y, Utsugi-Ozaki M, Feldman MD, Fukuhara S. Hope modified the association between distress and incidence of self-perceived medical errors among practicing physicians: prospective cohort study. PLoS ONE. (2012) 7:e35585. doi: 10.1371/journal.pone.0035585

5. Khanal P, Devkota N, Dahal M, Paudel K, Joshi D. Mental health impacts among health workers during COVID-19 in a low resource setting: a cross-sectional survey from Nepal. Globalization Health. (2020) 16:89. doi: 10.1186/s12992-020-00621-z

6. Muller AE, Hafstad EV, Himmels J, Smedslund G, Flottorp S, Stensland SØ, et al. The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review. Psychiatry Res. (2020) 293:113441. doi: 10.1016/j.psychres.2020.113441

7. World Health Organization. Working for Health and Growth: Investing in the Health Workforce—Report of the High-Level Commission on Health Employment and Economic Growth . (2016). Retrieved from: http://apps.who.int/iris/bitstream/10665/250047/1/9789241511308-eng (accessed March 10, 2021).

Google Scholar

8. Woo T, Ho R, Tang A, Tam W. Global prevalence of burnout symptoms among nurses: a systematic review and meta-analysis. J Psychiatric Res. (2020) 123:9–20. doi: 10.1016/j.jpsychires.2019.12.015

9. Vizheh M, Qorbani M, Arzaghi SM, Muhidin S, Javanmard Z, Esmaeili M. The mental health of healthcare workers in the COVID-19 pandemic: a systematic review. J Diabet Metab Disord. (2020) 19:1–12. doi: 10.1007/s40200-020-00643-9

10. World Health Organization. International Classification of Diseases for Mortality and Morbidity Statistics (11th Revision) . (2018). Retrieved from: https://icd.who.int/browse11/l-m/en (accessed March 10, 2021).

11. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. (2001) 52:397–422. doi: 10.1146/annurev.psych.52.1.397

CrossRef Full Text | Google Scholar

12. Shanafelt TD, West CP, Sinsky C, Trockel M, Tutty M, Satele DV, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proce. (2019) 94:1681–94. doi: 10.1016/j.mayocp.2018.10.023

13. Linzer M, Rosenberg M, McMurray JE, Glassroth J. Respecting the lifecycle: rational workforce planning for a section of general internal medicine. Am J Med. (2002) 113:443–8. doi: 10.1016/S0002-9343(02)01308-6

14. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer . (1995) 71:1263–9. doi: 10.1038/bjc.1995.244

15. Swetz KM, Harrington SE, Matsuyama RK, Shanafelt TD, Lyckholm LJ. Strategies for avoiding burnout in hospice and palliative medicine: peer advice for physicians on achieving longevity and fulfillment. J Palliat Med. (2009) 12:773–7. doi: 10.1089/jpm.2009.0050

16. Deng D, Naslund JA. Psychological Impact of COVID-19 Pandemic on Frontline Health Workers in Low- and Middle-Income Countries . Cambridge, MA: Harvard public health review. (2020). Available online at: http://harvardpublichealthreview.org/wp-content/uploads/2020/10/Deng-and-Naslund-2020-28.pdf (accessed March 10, 2021).

PubMed Abstract | Google Scholar

17. Firth-Cozens J, Greenhalgh J. Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med. (1997) 44:1017–22. doi: 10.1016/S0277-9536(96)00227-4

18. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. (2002) 136:358–67. doi: 10.7326/0003-4819-136-5-200203050-00008

19. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev. (2007) 32:203–12. doi: 10.1097/01.HMR.0000281626.28363.59

20. De Hert S. Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies. Local Reg Anesth. (2020) 13:171–83. doi: 10.2147/LRA.S240564

21. Balch CM, Oreskovich MR, Dyrbye LN, Colaiano JM, Satele DV, Sloan JA, et al. Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg. (2011) 213:657–67. doi: 10.1016/j.jamcollsurg.2011.08.005

22. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. (2018) 283:516–29. doi: 10.1111/joim.12752

23. West CP, Tan AD, Shanafelt TD. Association of resident fatigue and distress with occupational blood and body fluid exposures and motor vehicle incidents. Mayo Clinic Proc. (2012) 87:1138–44. doi: 10.1016/j.mayocp.2012.07.021

24. Menon V, Padhy SK. Ethical dilemmas faced by health care workers during COVID-19 pandemic: issues, implications and suggestions. Asian J Psychiatry. (2020) 51:102116. doi: 10.1016/j.ajp.2020.102116

25. Baines P, Draper H, Chiumento A, Fovargue S, Frith L. COVID-19 and beyond: the ethical challenges of resetting health services during and after public health emergencies. J Med Ethics. (2020) 46:715–6. doi: 10.1136/medethics-2020-106965

26. Williamson V, Murphy D, Greenberg N. COVID-19 and experiences of moral injury in front-line key workers. Occup Med. (2020) 70:317–9. doi: 10.1093/occmed/kqaa052

27. Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA. A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma. (2020) 12:S138–40. doi: 10.1037/tra0000698

28. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. (2009) 29:695–706. doi: 10.1016/j.cpr.2009.07.003

29. Dean W, Talbot SG, Caplan A. Clarifying the language of clinician distress. JAMA . (2020) 323:923–4. doi: 10.1001/jama.2019.21576

30. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ. (2020) 368:m1211. doi: 10.1136/bmj.m1211

31. Williamson V, Stevelink S, Greenberg N. Occupational moral injury and mental health: systematic review and meta-analysis. Br J Psychiatry. (2018) 212:339–46. doi: 10.1192/bjp.2018.55

32. Johnson SU, Ebrahimi OV, Hoffart A. PTSD symptoms among health workers and public service providers during the COVID-19 outbreak. PLoS ONE. (2020) 15:e0241032. doi: 10.1371/journal.pone.0241032

33. Carmassi C, Foghi C, Dell'Oste V, Cordone A, Bertelloni CA, Bui E, et al. PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: what can we expect after the COVID-19 pandemic. Psychiatry Res. (2020) 292:113312. doi: 10.1016/j.psychres.2020.113312

34. Chew N, Lee G, Tan B, Jing M, Goh Y, Ngiam N, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav Immun. (2020) 88:559–65. doi: 10.1016/j.bbi.2020.04.049

35. Zhang H, Shi Y, Jing P, Zhan P, Fang Y, Wang F. Posttraumatic stress disorder symptoms in healthcare workers after the peak of the COVID-19 outbreak: a survey of a large tertiary care hospital in Wuhan. Psychiatry Res. (2020) 294:113541. doi: 10.1016/j.psychres.2020.113541

36. Kim J, Chesworth B, Franchino-Olsen H, Macy RJ. A scoping review of vicarious trauma interventions for service providers working with people who have experienced traumatic events. Trauma Violence Abuse . (2021). doi: 10.1177/1524838021991310

37. Sabin-Farrell R, Turpin G. Vicarious traumatization: implications for the mental health of health workers? Clin Psychol Rev. (2003) 23:449–80. doi: 10.1016/S0272-7358(03)00030-8

38. Li Z, Ge J, Yang M, Feng J, Qiao M, Jiang R, et al. Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control. Brain Behav Immun. (2020) 88:916–9. doi: 10.1016/j.bbi.2020.03.007

39. Mehta SS, Matthew BA, Edwards L. Suffering in silence: mental health stigma and physicians' licensing fears. Am J Psychiatry . (2018) 13:2–4. doi: 10.1176/appi.ajp-rj.2018.131101

40. Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: barriers to access and care and evidence-based solutions. Healthcare Manage Forum. (2017) 30:111–6. doi: 10.1177/0840470416679413

41. Dutheil F, Aubert C, Pereira B, Dambrun M, Moustafa F, Mermillod M, et al. Suicide among physicians and health-care workers: a systematic review and meta-analysis. PLoS ONE. (2019) 14:e0226361. doi: 10.1371/journal.pone.0226361

42. Hämmig O. Explaining burnout and the intention to leave the profession among health professionals – a cross-sectional study in a hospital setting in Switzerland. BMC Health Serv Res. (2018) 18:785. doi: 10.1186/s12913-018-3556-1

43. Smart D, English A, James J, Wilson M, Daratha KB, Childers B, et al. Compassion fatigue and satisfaction: a cross-sectional survey among US healthcare workers. Nurs Health Sci. (2014) 16:3–10. doi: 10.1111/nhs.12068

44. Nooney JG, Unruh L, Yore MM. Should I stay or should I go? Career change and labor force separation among registered nurses in the U.S. Soc Sci Med . (2010) 70:1874–81. doi: 10.1016/j.socscimed.2010.02.037

45. Yehya A, Sankaranarayanan A, Alkhal A, Alnoimi H, Almeer N, Khan A, et al. Job satisfaction and stress among healthcare workers in public hospitals in Qatar. Arch Environ Occup Health . (2020) 75:10–7. doi: 10.1080/19338244.2018.1531817

46. Williams JR. Medical Ethics Manual, 2nd edition . Ferney-Voltaire Cedex: Ethics Unit of the World Medical Association (2009).

47. Yang L, Yin J, Wang D, Rahman A, Li X. Urgent need to develop evidence-based self-help interventions for mental health of healthcare workers in COVID-19 pandemic. Psychol Med . (2020). 1–2. doi: 10.1017/S0033291720001385

48. Gold JA. Covid-19: adverse mental health outcomes for healthcare workers. BMJ. (2020) 369:m1815. doi: 10.1136/bmj.m1815

49. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. (2020) 88:901–7. doi: 10.1016/j.bbi.2020.05.026

50. Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z, et al. Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry. (2020) 11:306. doi: 10.2139/ssrn.3542175

51. Li Y, Scherer N, Felix L, Kuper H. Prevalence of depression, anxiety and posttraumatic stress disorder in health care workers during the COVID-19 pandemic: a systematic review and meta-analysis. PLoS ONE. (2021) 16:e0246454. doi: 10.1371/journal.pone.0246454

52. Benfante A, Di Tella M, Romeo A, Castelli L. Traumatic stress in healthcare workers during COVID-19. pandemic: a review of the immediate impact Front Psychol . (2020) 11:569935. doi: 10.3389/fpsyg.2020.569935

53. Physicians Foundation. 2020 Survey of America's Physicians, COVID-19 Impact Edition, Part Two of Three: COVID-19's Impact on Physician Wellbeing . (2020). Retrieved from: https://physiciansfoundation.org/physician-and-patient-surveys/the-physicians-foundation-2020-physician-survey-part-2/ (accessed April 5, 2021).

54. UN Women. COVID-19: Emerging Gender Data and Why it Matters . (2020). Retrieved from: https://data.unwomen.org/resources/covid-19-emerging-gender-data-and-why-it-matters (accessed April 5, 2021).

55. Lotta G, Fernandez M, Magri G, de Campos Mello CA, Tavares DDLC, Haddad JP, et al. COVID-19 Pandemic and Health Professionals: Gender and Race on the Front Line (2020). Available online at: https://www.genderandcovid-19.org/resources/covid-19-pandemic-and-health-professionals-gender-and-race-on-the-front-line/ (accessed March 5, 2021).

56. Lotta G, Fernandez M, Pimenta D, Wenham C. Gender, race, and health workers in the COVID-19 pandemic. Lancet. (2021) 397:1264. doi: 10.1016/S0140-6736(21)00530-4

57. Ballard M, Bancroft E, Nesbit J, Johnson A, Holeman I, Foth J, et al. Prioritising the role of community health workers in the COVID-19 response. BMJ Global Health. (2020) 5:e002550. doi: 10.1136/bmjgh-2020-002550

58. Moitra M, Rahman M, Collins PY, Gohar F, Weaver M, Kinuthia J, et al. Mental health consequences for healthcare workers during the COVID-19 pandemic: a scoping review to draw lessons for LMICs. Front Psychiatry. (2021) 12:602614. doi: 10.3389/fpsyt.2021.602614

59. Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol. (2021) 12:611314. doi: 10.3389/fpsyg.2021.611314

60. Wong TW, Yau JK, Chan CL, Kwong RS, Ho SM, Lau CC, et al. The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope. Eur J Emerg Med. (2005) 12:13–8. doi: 10.1097/00063110-200502000-00005

61. Gershon R, Dernehl LA, Nwankwo E, Zhi Q, Qureshi K. Experiences and psychosocial impact of West Africa Ebola Deployment on US Health Care Volunteers. PLoS Currents. (2016) 8:ecurrents.outbreaks.c7afaae124e35d2da39ee7e07291b6b5. doi: 10.1371/currents.outbreaks.c7afaae124e35d2da39ee7e07291b6b5

62. Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry. (2018) 87:123–7. doi: 10.1016/j.comppsych.2018.10.003

63. Naushad VA, Bierens JJ, Nishan KP, Firjeeth CP, Mohammad OH, Maliyakkal AM, et al. A systematic review of the impact of disaster on the mental health of medical responders. Prehospital Disaster Med. (2019) 34:632–43. doi: 10.1017/S1049023X19004874

64. Chatzea VE, Sifaki-Pistolla D, Vlachaki SA, Melidoniotis E, Pistolla G. PTSD. burnout and well-being among rescue workers: seeking to understand the impact of the European refugee crisis on rescuers. Psychiatry Res. (2018) 262:446–51. doi: 10.1016/j.psychres.2017.09.022

65. Brooks SK, Dunn R, Amlôt R, Rubin GJ, Greenberg N. Social and occupational factors associated with psychological wellbeing among occupational groups affected by disaster: a systematic review. J Mental Health. (2017) 26:373–84. doi: 10.1080/09638237.2017.1294732

66. Jones S, Nagel C, McSweeney J, Curran G. Prevalence and correlates of psychiatric symptoms among first responders in a Southern State. Arch Psychiatr Nurs. (2018) 32:828–35. doi: 10.1016/j.apnu.2018.06.007

67. Jun J, Tucker S, Melnyk BM. Clinician mental health and well-being during global healthcare crises: evidence learned from prior epidemics for COVID-19 pandemic. Worldviews Evidence-Based Nurs. (2020) 17:182–4. doi: 10.1111/wvn.12439

68. Callahan K, Christman G, Maltby L. Battling burnout: strategies for promoting physician wellness. Adv Pediatr. (2018) 65:1–7. doi: 10.1016/j.yapd.2018.03.001

69. Adams M, Chase J, Doyle C, Mills J. Self-care planning supports clinical care: putting total care into practice. Prog Palliat Care. (2020) 28:305–7. doi: 10.1080/09699260.2020.1799815

70. Mills J, Ramachenderan J, Chapman M, Greenland R, Agar M. Prioritising workforce wellbeing and resilience: what COVID-19 is reminding us about self-care and staff support. Palliat Med. (2020) 34:1137–9. doi: 10.1177/0269216320947966

71. Waris Nawaz M, Imtiaz S, Kausar E. Self-care of frontline health care workers: during COVID-19 pandemic. Psychiatria Danubina. (2020) 32:557–62. doi: 10.24869/psyd.2020.557

72. Heath C, Sommerfield A, von Ungern-Sternberg BS. Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: a narrative review. Anaesthesia. (2020) 75:1364–71. doi: 10.1111/anae.15180

73. Sanchez-Reilly S, Morrison LJ, Carey E, Bernacki R, O'Neill L, Kapo J, et al. Caring for oneself to care for others: physicians and their self-care. J Support Oncol. (2013) 11:75–81. doi: 10.12788/j.suponc.0003

74. Butler EA, Lee TL, Gross JJ. Emotion regulation and culture: are the social consequences of emotion suppression culture-specific? Emotion. (2007) 7:30–48. doi: 10.1037/1528-3542.7.1.30

75. Mills J, Chapman M. Compassion and self-compassion in medicine: self-care for the caregiver. Austr Med J. (2016) 9:87–91. doi: 10.21767/AMJ.2016.2583

76. Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: “Being connected. a key to my survival”. JAMA . (2009) 301:1155–64, E1. doi: 10.1001/jama.2009.352

77. Banerjee D, Sathyanarayana Rao TS, Kallivayalil RA, Javed A. Psychosocial framework of resilience: navigating needs and adversities during the pandemic, a qualitative exploration in the indian frontline physicians. Front Psychol. (2021) 12:622132. doi: 10.3389/fpsyg.2021.622132

78. Commodari E, La Rosa VL, Coniglio MA. Health risk perceptions in the era of the new coronavirus: are the Italian people ready for a novel virus? A cross-sectional study on perceived personal and comparative susceptibility for infectious diseases. Public Health. (2020) 187:8–14. doi: 10.1016/j.puhe.2020.07.036

79. Wood H, Skeggs B. Clap for carers? From care gratitude to care justice. Europ J Cultural Studies. (2020) 23:641–7. doi: 10.1177/1367549420928362

80. Epping-Jordan JE, Harris R, Brown FL, Carswell K, Foley C, García-Moreno C, et al. Self-Help Plus (SH+): a new WHO stress management package. World Psychiatry. (2016) 15:295. doi: 10.1002/wps.20355

81. A-tjak JG, Davis ML, Morina N, Powers MB, Smits JA, Emmelkamp PM. A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychother Psychosom. (2015) 84:30–6. doi: 10.1159/000365764

82. Hayes SC, Pistorello J, Levin ME. Acceptance and commitment therapy as a unified model of behavior change. Couns Psychol. (2012) 40:976–1002. doi: 10.1177/0011000012460836

83. Tol WA, Leku MR, Lakin DP, Carswell K, Augustinavicius J, Adaku A, et al. Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial. Lancet Global Health. (2020) 8:e254–63. doi: 10.1016/S2214-109X(19)30504-2

84. Wang Y, Li B, Liu L. Telemedicine experience in China: our response to the pandemic and current challenges. Front Public Health. (2020) 8:549669. doi: 10.3389/fpubh.2020.549669

85. Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med. (2012) 43:119–28. doi: 10.2190/PM.43.2.b

86. Mahmoud NN, Rothenberger D. From burnout to well-being: a focus on resilience. Clin Colon Rectal Surg. (2019) 32:415–23. doi: 10.1055/s-0039-1692710

87. Maunder RG, Lancee WJ, Mae R, Vincent L, Peladeau N, Beduz MA, et al. Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training. BMC Health Serv Res. (2010) 10:72. doi: 10.1186/1472-6963-10-72

88. Baker J, Savage A, Pendleton S, Bate JM. Implementation of multidisciplinary reflective rounds within a children's hospital before and during the COVID-19 pandemic. J Paediatr Child Health . (2021). doi: 10.1111/jpc.15386

89. Wiskow C, Albreht T, de Pietro C. “How to Create an Attractive and Supportive Working Environment for Health Professionals.” Health Systems and Policy Analysis (2010). Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0018/124416/e94293.pdf (accessed March 10, 2021).

90. Grobler C. COVID-19: mental health and clinical equipoise in the face of moral injury. South African J Bioethics Law. (2020) 13:21–2. doi: 10.7196/SAJBL.2020.v13i1.00724

91. Bozdaǧ F, Ergün N. Psychological resilience of healthcare professionals during COVID-19 pandemic. Psychol Rep. (2020) 33294120965477. doi: 10.1177/0033294120965477

92. Rieckert A, Schuit E, Bleijenberg N, ten Cate D, de Lange W, de Man-van Ginkel JM, et al. How can we build and maintain the resilience of our health care professionals during COVID-19? Recommendations based on a scoping review. BMJ Open. (2021) 11:e043718. doi: 10.1136/bmjopen-2020-043718

93. Tigard DW. Taking the blame: appropriate responses to medical error. J Med Ethics. (2019) 45:101–5. doi: 10.1136/medethics-2017-104687

94. World Health Organization. The impact of COVID-19 on Mental, Neurological and Substance Use Services: Results of a Rapid Assessment . (2020). Retrieved from: https://www.who.int/publications/i/item/978924012455 (accessed March 10, 2021).

95. United Nations. Policy Brief: COVID-19 and the Need for Action on Mental Health . (2020). Retrieved from: https://unsdg.un.org/resources/policy-brief-covid-19-and-need-action-mental-health (accessed March 10, 2021).

96. Verschuere B, Brandsen T, Pesthoff V. Co-production: the state of the art in research and the future agenda. Voluntas. (2012) 23:1083–101. doi: 10.1007/s11266-012-9307-8

97. Farr MC. Understanding participation and power within collaborative processes: Jointly involving staff and citizens in changing public services . PhD thesis, University of Bath, United Kingdom (2012).

98. Turk E, Durrance-Bagale A, Han E, Bell S, Rajan S, Lota M, et al. International experiences with co-production and people centredness offer lessons for covid-19 responses. BMJ. (2021) 372:m4752. doi: 10.1136/bmj.m4752

99. Vennik FD, Van De Bovenkamp HM, Putters K, Grit KJ. Co-production in healthcare: rhetoric and practice. Int Rev Admin Sci. (2016) 82:150–68. doi: 10.1177/0020852315570553

100. Nyblade L, Stockton MA, Giger K, Bond V, Ekstrand ML, Lean RM, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. (2019) 17:25. doi: 10.1186/s12916-019-1256-2

101. Barello S, Graffigna G. Caring for health professionals in the COVID-19 pandemic emergency: toward an “Epidemic of Empathy” in healthcare. Front Psychol. (2020) 11:1431. doi: 10.3389/fpsyg.2020.01431

Keywords: mental health, healthcare workers, COVID-19, public health emergencies, burnout, self-care, psychological interventions, healthcare policies

Citation: Søvold LE, Naslund JA, Kousoulis AA, Saxena S, Qoronfleh MW, Grobler C and Münter L (2021) Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority. Front. Public Health 9:679397. doi: 10.3389/fpubh.2021.679397

Received: 11 March 2021; Accepted: 12 April 2021; Published: 07 May 2021.

Reviewed by:

Copyright © 2021 Søvold, Naslund, Kousoulis, Saxena, Qoronfleh, Grobler and Münter. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Lene E. Søvold, lene.sovold@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Research Topics & Ideas: Public Health

50 Topic Ideas To Kickstart Your Research Project

If you’re just starting out exploring public health and/or epidemiology-related topics for your dissertation, thesis or research project, you’ve come to the right place. In this post, we’ll help kickstart your research by providing a hearty list of research ideas , including examples from recent studies in public health and epidemiology.

PS – This is just the start…

We know it’s exciting to run through a list of research topics, but please keep in mind that this list is just a starting point . These topic ideas provided here are intentionally broad and generic , so keep in mind that you will need to develop them further. Nevertheless, they should inspire some ideas for your project.

To develop a suitable research topic, you’ll need to identify a clear and convincing research gap , and a viable plan to fill that gap. If this sounds foreign to you, check out our free research topic webinar that explores how to find and refine a high-quality research topic, from scratch. Alternatively, consider our 1-on-1 coaching service .

Public Health-Related Research Topics

• Evaluating the impact of community-based obesity prevention programs in urban areas.
• Analyzing the effectiveness of public smoking bans on respiratory health outcomes.
• Investigating the role of health education in reducing the prevalence of HIV/AIDS in sub-Saharan Africa.
• The impact of air pollution on asthma rates in industrial cities.
• Evaluating the effectiveness of school nutrition programs on childhood obesity rates.
• The role of public health policies in addressing mental health stigma.
• Analyzing the impact of clean water access on infectious disease rates in rural communities.
• The effectiveness of needle exchange programs in reducing the spread of hepatitis C.
• Investigating the impact of social determinants on maternal and child health in low-income neighborhoods.
• The role of digital health interventions in managing chronic diseases.
• Analyzing the effectiveness of workplace wellness programs on employee health and productivity.
• The impact of urban green spaces on community mental health.
• Evaluating the effectiveness of vaccination campaigns in preventing outbreaks of infectious diseases.
• The role of public health initiatives in reducing alcohol-related harm.
• Analyzing the impact of aging populations on healthcare systems.
• Analyzing the impact of urbanization on mental health disorders in metropolitan areas.
• The effectiveness of telemedicine services in improving healthcare access in remote regions.
• Investigating the health impacts of electronic waste recycling practices.
• The role of health literacy in managing non-communicable diseases in aging populations.
• Evaluating the public health response to opioid addiction in rural communities.
• Analyzing the relationship between housing quality and respiratory illnesses.
• The effectiveness of community engagement in improving reproductive health services.
• Investigating the health effects of long-term exposure to low-level environmental radiation.
• The role of public health campaigns in reducing the prevalence of tobacco use among teenagers.
• Analyzing the impact of food deserts on nutritional outcomes in urban communities.

Epidemiology Research Ideas (Continued)

• Investigating the epidemiology of antibiotic-resistant infections in hospital settings.
• The impact of climate change on the spread of vector-borne diseases.
• Evaluating the factors contributing to the rise in type 2 diabetes prevalence.
• Analyzing the epidemiology of mental health disorders in conflict zones.
• The role of epidemiological surveillance in pandemic preparedness and response.
• Investigating the link between environmental exposures and the incidence of childhood cancers.
• The impact of dietary patterns on the prevalence of cardiovascular diseases.
• Evaluating the effectiveness of intervention strategies in controlling obesity epidemics.
• Analyzing the spread and control of zoonotic diseases in rural communities.
• The role of genetic factors in the epidemiology of autoimmune diseases.
• Investigating the socio-economic disparities in cancer incidence and outcomes.
• The impact of urbanization on the epidemiology of infectious diseases.
• Evaluating the public health consequences of occupational exposures to hazardous substances.
• Analyzing the trends and determinants of mental health disorders among adolescents.
• The role of lifestyle factors in the epidemiology of neurodegenerative diseases.
• Investigating the patterns of mental health service utilization during economic recessions.
• The epidemiology of sports-related concussions in youth athletics.
• Evaluating the effectiveness of public health interventions in reducing the spread of tuberculosis in high-risk populations.
• Analyzing the geographic distribution of Lyme disease in relation to climate change.
• The role of international travel in the spread of emerging infectious diseases.
• Investigating the demographic predictors of chronic kidney disease in population-based studies.
• The epidemiological impact of air pollution on asthma and other respiratory conditions.
• Evaluating the long-term health effects of exposure to endocrine-disrupting chemicals.
• Analyzing the incidence and risk factors of post-traumatic stress disorder in first responders.
• The role of socioeconomic status in the prevalence and management of diabetes.

Recent Studies: Public Health & Epidemiology

While the ideas we’ve presented above are a decent starting point for finding a research topic, they are fairly generic and non-specific. So, it helps to look at actual studies in the public health and epidemiology space to see how this all comes together in practice.

Below, we’ve included a selection of recent studies to help refine your thinking. These are actual studies,  so they can provide some useful insight as to what a research topic looks like in practice.

• Tutorials in population neuroimaging: Using epidemiology in neuroimaging research (Godina et al., 2022)
• Application of Big Data in Digital Epidemiology (Naaz & Siddiqui, 2022)
• Response to comment on: Incidence of ocular and systemic disease affecting visual function among state bus drivers (Kohli et al., 2022)
• Why epidemiology is incomplete without qualitative and mixed methods (Lane-Fall, 2023)
• Teaching epidemiology: An overview of strategies and considerations (Hossain, 2022)
• Social Epidemiology: Past, Present, and Future (Roux, 2022)
• Population health assessment project: An innovative strategy for teaching principles of epidemiology (Keen et al., 2022)
• The functions of veterinary epidemiology in public health (Shaffi, 2023)
• Readying the Applied Epidemiology Workforce for Emerging Areas of
• Public Health Practice (Daly et al., 2022)
• Some Social Epidemiologic Lessons from the COVID-19 Pandemic (Schnake-Mahl & Bilal, 2023)
• The Filth Disease: Typhoid Fever and the Practices of Epidemiology in Victorian England by Jacob Steere-Williams (review) (Steere-Williams et al., 2022)
• Epidemiology of Adult Obesity, Measurements, Global Prevalence and Risk Factors (Orukwowu, 2022).
• Which disciplines form digital public health, and how do they relate to each other? (Pan, 2022)
• Information Flow and Data Gaps in COVID-19 Recording and Reporting at National and Provincial Levels in Indonesia (Barsasella et al., 2022). Epidemiology Blog of Neal D. Goldstein, PhD, MBI (Goldstein, 2023)
• Sensitivity analysis of SEIR epidemic model of Covid 19 spread in Indonesia (Rangkuti et al., 2022)

As you can see, these research topics are a lot more focused than the generic topic ideas we presented earlier. So, for you to develop a high-quality research topic, you’ll need to get specific and laser-focused on a specific context with specific variables of interest.  In the video below, we explore some other important things you’ll need to consider when crafting your research topic.

Get 1-On-1 Help

If you’re still unsure about how to find a quality research topic, check out our Research Topic Kickstarter service, which is the perfect starting point for developing a unique, well-justified research topic.

Public health related with research methods.

Health science🔭

Research topics on public administration

Submit a Comment Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

• Print Friendly

• Find It Fast

Funding Opportunities

• All Funding Opportunities
• What & Who We Fund
• PCORI's Research Funding Process
• What You Need to Know to Apply
• Merit Review

Applicant and Awardee Resources

Research & related projects.

• Explore Our Portfolio
• About Our Research
• On the Path to Impact
• PCORI in the Literature
• Peer Review

Engagement in Research

• Foundational Expectations for Partnerships
• Background on the Foundational Expectations
• Benefits of Engagement in Research
• Real-World Examples by Foundational Expectation
• Promotional Toolkit
• The Value of Engagement in Research
• Engagement Award Program
• Engagement Resources
• Engagement in Health Research Literature Explorer
• Influencing the Culture of Research
• Engage with Us

Implementation of Evidence

• Putting Evidence to Work
• Evidence Updates
• Evidence Synthesis Reports and Interactive Visualizations
• Emerging Topics: Reports and Horizon Scans
• PCORI Stories

Highlights of PCORI-Funded Research Results

Health topics.

• Cardiovascular Disease
• Intellectual and Developmental Disabilities
• Maternal Morbidity and Mortality
• Rare Diseases
• Women's Health
• View All Topics

News & Events

• PCORI News Hub
• View All Events
• 2024 PCORI Annual Meeting
• The PCORI Strategic Plan
• Our Programs
• Our Vision & Mission
• Financial Statements and Reports
• Board of Governors
• Methodology Committee
• Authorizing Law
• Monitoring and Evaluating Progress
• Advisory Panel Openings
• Advisory Panels FAQs
• Application Review and Selection Process
• Procurement Opportunities
• Provide Input

Community Health Workers

Community health workers study spotlights.

The Role of Community Health Workers

Keysha Brooker, CHW, MSW, explains how community health workers (CHWs) can help address disparities for the patients they work with by providing support and resources to help patients thrive.

Reducing Asthma Health Disparities through Guideline Implementation

This project compares three different approaches to implementing guidelines for people with uncontrolled asthma.

The Bridge Between Clinics and Communities

Lisa Cooper, MD, MPH explains the role community health workers played in her PCORI-funded project that sought to help patients from disadvantaged populations better control high blood pressure.

Additional Projects on Community Health Workers

Community health worker and mobile health programs to help young adults with sickle cell disease transition to using adult healthcare services -- the comets study, does a program that focuses on lifestyle changes reduce heart disease risk factors in a rural community in appalachian kentucky, testing whether home visits by community health workers help african-american and hispanic patients with low incomes better manage asthma, working with bilingual community health worker promotoras to improve depression and self-care among latino patients with long-term health problems.

A .gov website belongs to an official government organization in the United States.

A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• Making the Business Case
• Partnerships
• Hierarchy of Controls
• International Symposium
• NIOSH WellBQ
• View All Home

Total Worker Health® in Action! September 2024

At a glance.

In this edition, NIOSH announces a groundbreaking data clearinghouse that aims to advance worker well-being globally. We also share the latest Total Worker Health (TWH) news and resources on topics like mental health, recovery, and industry-specific safety. Don't miss important deadlines, upcoming webinar announcements, and free training opportunities announced below.

The Health Enhancement Research Organization (HERO), in partnership with the NIOSH Office for TWH, launched the HERO Worker Well-Being Clearinghouse . The clearinghouse is an open-source database that houses de-identified data from uses of the NIOSH Worker Well-Being Questionnaire (NIOSH WellBQ) . De-identified data have no identifying information that can be linked to specific people. This innovative data clearinghouse aims to advance worker well-being globally.

HERO developed a free online platform to make the NIOSH WellBQ readily available for employers and organizations. You can use the online portal to easily administer the NIOSH WellBQ to better understand the workforces' safety, health, and well-being. You will receive a free report with your results and can choose to share anonymous data with the clearinghouse.

People can request access to the de-identified data from the clearinghouse for research or to benchmark worker well-being at no cost. These data will help practitioners, policymakers, researchers, and others gain deeper insights into worker well-being trends and dynamics.

HERO invites organizations and researchers across industries to join this groundbreaking effort in enhancing worker well-being. Read this press release or visit their website to learn more.

Free course for students

The Center for the Promotion of Health in the New England Workplace released an online course for college and university students. The materials help students understand TWH concepts and how they relate to their field of study. The free, two-hour course offers self-paced learning. Request an instructor guide with suggested readings and class activities by emailing [email protected] .

Free training for the forestry and logging industry

AgriSafe is offering free on-demand training to forestry and logging workers. Create a free Learning Lab account to access the content. You can also schedule a group training by emailing Knesha Rose-Davison , Public Health and Equity Director.

Shift work, sleep, and mental health

Many shift workers have work schedules outside of the traditional daytime hours of 6 a.m. to 6 p.m. A new resource from the Kentucky Occupational Safety and Health Surveillance program describes ways workplaces can support shift workers' mental health.

Small business toolkit for hiring employees in recovery

The Kentucky Occupational Safety and Health Surveillance program launched a new resource, Kentucky Small Business Toolkit for Hiring Employees in Recovery . The toolkit includes sample workplace policies and resources for employers and workers. You'll also find information on hiring and legal considerations.

Video highlights TWH occupational medicine

The National Environmental Satellite, Data, and Information Service released a new video about their 2024 TWH Occupational Medicine White Paper. The paper emphasizes the critical role of employee well-being and offers a comprehensive analysis of workforce well-being. For more information, email [email protected] .

Workplace mental health: Trends and best practices

Mental Health America evaluated 271 eligible employers' policies and practices through its Bell Seal for Workplace Mental Health certification program. They used these data to publish the new Workplace Mental Health Report: Trends and Best Practices of Top Employers . The report identifies emerging trends and best practices that can help support all employers' workplace wellness efforts.

Welcoming new NIOSH TWH Affiliates

Health Enhancement Research Organization (HERO)

HERO is a national nonprofit dedicated to connecting science and practice in the field of workplace health and well-being. HERO aims to demonstrate the value of the health and well-being employer ecosystem. HERO recently launched the HERO Worker Well-Being Clearinghouse, powered by the NIOSH WellBQ.

David Lynch Foundation

The David Lynch Foundation is a 501(c)(3) nonprofit organization founded in 2005. Their mission is to address the epidemic of trauma and toxic stress among at-risk populations. This is accomplished through implementation of the evidence-based Transcendental Meditation technique. The Foundation launched the Heal the Healers Now program in 2020. This new initiative intends to make the Transcendental Meditation program available to as many healthcare workers as possible. Heal the Healers Now advocates with hospital partners for institutional policies to facilitate adoption and success of worker well-being interventions. Policies would include, wherever feasible, increased flexibility in work schedules to allow protected break time and dedicated spaces for Transcendental Meditation. The goal is to foster and expand an on-the-job culture of staff wellbeing.

Mark your calendars

Call for proposals for two upcoming conferences, work, stress, and health conference.

Proposals are being accepted for the Work, Stress, and Health 2025 Conference being held July 8–11, 2025, in Seattle, Washington. NIOSH and the Society for Occupational Health Psychology organize the event to address the ever-changing nature of work. Submit your proposal by November 7.

International Symposium to Advance TWH

The 4th International Symposium to Advance TWH will announce a call for proposals in October. The symposium will be held in Bethesda, Maryland, October 21–24, 2025. Proposals will be due by December 20.

Celebrate National Work and Family Month with two free webinars

Designing workplaces that value worker and family well-being, now and beyond.

Register now to join us on October 17, 2-3 p.m. (ET). This webinar will share the results of a study that followed more than 370 lower-wage, working-class families over 10 years.

Public Policy and Employer Support to Improve Family Health and Well-Being

Register now to join us on October 31, 12-1 p.m. (ET). This webinar will describe how employer support and public policy contribute to the well-being of workers and their families.

Free National Farm Safety and Health Week webinars

During National Farm Safety and Health Week, AgriSafe will offer 11 free webinars . The webinars will be held September 16–20. The various agriculture, forestry, and fishing topics covered will relate to the theme "Don't Learn Safety by Accident."

Gala promotes healthcare worker well-being

The David Lynch Foundation, a new TWH Affiliate, will host a gala this month to celebrate the launch of Meditate America. This national initiative aims to use evidence-based meditation to relieve burnout and promote well-being for frontline healthcare workers and first responders.

Add to your reading list

Check out the latest NIOSH Science Blogs and articles featuring TWH research:

Did you know?‎

Stay connected.

There are several important health observances in September. Follow us on social media and reflect on these resources as we recognize the below topics:

• Healthy Aging Month: Productive Aging and Work
• National Preparedness Month: Employer Crisis Preparedness
• National Recovery Month: Workplace Supported Recovery
• National Suicide Prevention Month: Critical Steps Your Workplace Can Take Today
• National Yoga Awareness Month: Yoga and Meditation for Worker Well-being (video)
• Workplace Lactation Week: Breastfeeding Accommodations in the Workplace

Looking ahead to October, don't forget to register for two free webinars to celebrate National Work and Family Month!

Connect your calendar

Find more events on the NIOSH and Partner Events Calendar and Society for TWH Events webpage .

Connect with us

Follow us on social media @NIOSH_TWH , visit our website , or email us at [email protected] .

Connect with our partners

Stay up to date on the research and events happening at the Centers of Excellence for TWH:

About this newsletter

Total Worker Health ® in Action! is the quarterly newsletter published by the NIOSH Total Worker Health Program. Subscribe today!

Editorial & Production Team

Executive Editor L. Casey Chosewood, MD, MPH

Managing Editor Emily Kirby

Copy Editor Cheryl Hamilton

The Occupational Safety and Health Act of 1970 established NIOSH as a research agency focused on the study of worker safety and health, and empowering employers and workers to create safe and healthy workplaces.

For Everyone

Public health.

Lack of Vaccines, Social Instability Are Fueling Mpox Crisis in Africa

Threat of a pandemic remains low, but international collaboration is needed to contain the virus, DGHI expert says.

A vial of vaccine for mpox, the virus previously known as monkeypox. Photo from iStock

By Michael Penn

Published September 4, 2024 under Commentary

A critical shortage of vaccines and antivirals is driving an outbreak of mpox in sub-Saharan Africa, a situation the World Health Organization recently called a global health emergency. But social and political instability in the region where the virus is spreading may complicate efforts to control it, says Chris Beyrer, M.D., director of the Duke Global Health Institute and an expert on mpox. 

The current outbreak, fueled by a new variant of mpox that is proving to be deadlier and easier to spread than earlier forms, has now reached more than a dozen countries in Africa and caused more than 500 deaths. The WHO  declared a global health emergency on Aug. 14 , noting a significant risk of the virus, which was previously known as monkeypox, spreading further in Africa and beyond. Cases have been detected in Sweden and Thailand among people who had traveled in endemic regions.

Vaccines and supportive care exist for the virus, making a pandemic on the scale of COVID-19 unlikely, notes Beyrer, an epidemiologist who studies infectious diseases in Africa and other parts of the world. He currently serves on the WHO’s scientific and technical advisory committee on HIV, viral hepatitis, STI and mpox. 

"We have what we need to stop mpox,” Beyrer said in  an Aug. 16 article from the Associated Press that appeared in more than 100 media outlets worldwide. “This is not the same situation we faced during COVID when there was no vaccine and no antivirals.”

But vaccines and treatments are scarce in sub-Saharan Africa, making it critical for other countries to provide access, Beyre says.The WHO also needs to move more quickly to approve new vaccine candidates that are ready for use.

“ There is a political and human rights dimension to this outbreak. All of this complicates the situation and will hugely challenge both WHO and the Africa CDC in responding.

"“We're stuck in bureaucratic approvals and regulatory approvals that are basically barriers between vaccine supply – which is not enough – and people who need to be protected,” Beyrer said in a  Sept. 1 article in The National , an English-language news service  in the United Arab Emirates. 

Efforts to control the outbreak are also having to work around ongoing conflicts in the areas most affected by the virus, which are centered around the South Kivu region of the Democratic Republic of the Congo. Multiple militias are active in the region, which is near a disputed border between the DRC and Rwanda. It is also a locus of legal and illegal mining activity.

Beyrer says the majority of mpox cases in the region are among miners and sex workers who congregate around mining communities. Sex workers often travel from other countries in the region, increasing the risks that the virus will move into new areas, he adds. 

“There is a  political and human rights dimension to this outbreak,” he says. “All of this complicates the situation and will hugely challenge both WHO and the Africa CDC in responding.”

Mpox spreads primarily through skin-to-skin contact, and people infected with the virus can show symptoms similar to smallpox, including rashes and lesions on the skin. A multinational mpox outbreak in 2022, which led to around 100,000 cases in more than 100 countries, was caused by a different strain of the virus that was primarily transmitted through sexual contact among gay men. 

• Infectious diseases ,
• Immunization ,
• Social determinants of health
• Democratic Republic of the Congo
• Chris Beyrer

Related News

Student Stories

Notes from the Field: Hena Vadher MS’25

September 5, 2024

Education News

Duke Students Launch Childcare Center in Kenya

July 25, 2024

Research News

Why Aren’t More Boys Getting HPV Vaccines?

July 10, 2024

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Afr J Prim Health Care Fam Med
• v.14(1); 2022

Challenges experienced by community health workers and their motivation to attend a self-management programme

Levona j. johnson.

1 Department of Physiotherapy, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa

Laura H. Schopp

2 Department of Health Psychology, University of Missouri, Columbia, United States of America

Firdouza Waggie

3 Department of Clinical and Community Engagement, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa

José M. Frantz

Associated data.

Data are available upon special request from the corresponding author, L.J.J.

Community health workers (CHWs) are change agents expected to assist in decreasing the global burden of disease in the communities they serve. However, they themselves have health risk behaviours, which predispose them to non-communicable diseases and thus need to be empowered to make better health choices. There is a gap in literature detailing the challenges faced by CHWs in addressing their own health risk behaviours.

This study aimed to explore the challenges experienced by CHWs in carrying out their daily duties and the motivating factors to join a self-management programme.

The study was conducted in a low socio-economic urban area of the Western Cape, South Africa.

This study used a qualitative exploratory design using in-depth interviews to obtain rich data about the personal and professional challenges that CHWs experience on a daily basis.

Five themes emerged with regard to professional challenges (social conditions, mental health of patients, work environment, patient adherence and communication). This cadre identified ineffective self-management as a personal challenge and two themes emerged as motivation for participating in a self-management programme: empowerment and widening perspective.

The challenges raised by the CHWs have a direct impact on their role in communities. This study therefore highlights an urgent need for policymakers and leaders who plan training programmes to take intentional strategic action to address their health challenges and to consider utilising a self-management intervention model to improve their overall health status.

Introduction

Community health workers (CHWs) are central to driving health promotion and prevention strategies as part of community-based primary healthcare infrastructure. The global shortage of health professionals has driven an increase in the use of CHWs as a key cadre to meet the health needs of society. Globally, there is a shortage of health workers such as midwives, nurses and physicians. 1 Parallel to this shortage in the workforce is the increase in the disease burden in resource-constrained countries with an increase in communicable and non-communicable diseases. 2 Sub-Saharan Africa has only 3% of the total health workers in the world and this group provides service to a region that carries 24% of the global burden of disease. 3 South Africa has an inequitable distribution of medical resources as a result of the apartheid epoch, and has struggled to increase the formal health force with skilled health professionals, as many health workers opt to relocate to countries that provide higher incomes. 1 Consequently, the global shortage of health professionals has affirmed the resolve to invest in training more CHWs, to address these health and development needs. 4 Community health workers are regarded as an integral part of the model designed to increase the number of persons able to meet the health needs of society and simultaneously provide a vehicle for sustainable improvement in global health. 5

Community health workers have very basic-level healthcare skills and they require training to achieve ‘structural competency’ in primary healthcare practice. 6 Training helps CHWs to gain understanding of underlying complex structural, disease and individual factors related to patient non-adherence to recommended medical regimens, rather than attributing treatment failures solely to poor patient-level motivation. 7 , 8 Structural competence has been defined as ‘the capacity for health professionals to recognise and respond to health and illness as the downstream effects of broad social, political and economic structures. 6 Community health workers who by definition are trusted members of the communities they serve 9 understand and are knowledgeable about the environmental, social and political factors and the interpersonal networks community members encounter. 8 Community health workers’ intimate knowledge of these social determinants, coupled with their role as community advocates, enable CHWs to play a vital two-prong role: (1) to contribute to policy change 10 to redress imbalances in health care and (2) to foster long-term well-being of communities. 11 Community health workers have first-hand knowledge and information about local structural factors impeding community health position. They play an ideal role to use this cultural competence to deliver improved patient-centred health services. 12

The impact of CHWs in the care of non-communicable diseases has garnered empirical support. Community health workers’ roles as health educators, advisors, rehabilitation workers and group support facilitators stand them in good stead to influence community health. 13 Community health workers also play an important role in helping communities to meet their health and social needs. 14 As key frontline health workers who are active in communities and have a deep understanding of community needs, they are expected to provide appropriate health information and to advocate on behalf of the neighbourhoods they serve.

Literature highlights that CHWs use their personal experiences to play a crucial role as a buffer between communities and the health system. 15 A recent study emphasised that it is important that health trainers such as CHWs negotiate the tension between knowledge of health risk behaviours and individual lifestyle choices. 16 They are considered pivotal players in managing health risk factors and so must serve as local role models. In a study conducted in the African context, which focused on personal physical activity and patient counselling practices, the authors highlighted the need for the credibility of health professionals regarding health education that is in line with their own personal practices. 17 This is supported by researchers who highlighted the need for health workers to be more proactive in terms of their own risk behaviours and increase their own understanding as to why individuals make certain decisions about health behaviours. 18

One tool that has been identified as an effective way to promote behaviour change is self-management. Self-management is a health behaviour change strategy, 19 which zeroes in on the patient’s perception 20 and allows individuals to enhance their own health status by achieving graduated success in self-determined health goals. 21 It has been used successfully in a variety of disease management and positive changes in health behaviours were recorded. 22 , 23 A recent study 24 found that CHWs wanted to participate in self-management interventions in order to gain knowledge and skills to help themselves and others. This is important, as CHWs are seen as public health workers who can build individual capacity in communities. This article explored the challenges experienced by CHWs in carrying out their duties and their motivation to join a self-management programme.

Study design

This study employed a qualitative exploratory design using in-depth interviews amongst CHWs prior to enrolment in a self-management programme. The interviews were conducted with two primary purposes, namely to describe the CHWs’ personal and professional challenges in performing their duties and to examine motivations for wanting to join a self-management programme. This study design allows for the in-depth, rich and holistic understanding of the phenomena under investigation. 25

Research setting

The study was conducted in an urban setting in the Western Cape, South Africa. According to the 2011 Census of Cape Town, the high rates of poverty (47%) within the community tend to compromise the mental health and well-being of the residents. 26 The CHWs in this area work in environments, which are both socio-economically poor and have high rates of violence. Approximately, 84% of attempted murders in this area are attributed to gang activity and this region is in the top 10 for illegally possessing firearms and ammunition. 27

With the re-engineering of primary healthcare in South Africa, the support for the CHW workforce has expanded, consequently they are being employed by non-governmental organisations (NGOs) sanctioned by the provincial health departments. 28 Those lay healthcare workers who did not have formal training, worked in nurse-led teams 13 and their focus was directed towards health prevention and promotion.

Participants formed part of a bigger study where they completed a survey related to determining their risk factors for non-communicable diseases. 29 Based on the survey, participants were purposively selected to be interviewed. Purposive sampling is a technique used in qualitative research to obtain rich information from key participants 30 , thus allowing for recruitment of participants who met the predetermined criteria aligned with study objectives. 30 Stratified purposive sampling allows the researcher to capture variations in thoughts rather than identify a common core although the latter may emerge during analysis. 30 Thus, the number of participants is not important, but rather the information obtained from participants. The two inclusion criteria for participation in the study were that CHWs had to be employed as CHWs at the time of the study, and they had to indicate that they were willing to participate in a self-management programme. Participants were excluded if they were not willing to participate in the self-management programme. Fifteen participants were recruited from two NGOs that employ CHWs in the Western Cape.

Data collection

Data were collected by means of in-depth interviews. In-depth interviews are relevant when comprehensive insight about participants’ concepts, perspectives, behaviours and experiences regarding a specific intervention, idea or situation is sought. 31 Interviews allow the researcher to understand how participants view the phenomena under investigation. 31 , 32 This interview strategy provides a comfortable and natural atmosphere, which facilitates conversation, 32 as meeting one on one with the interviewer enables those who would normally shy away from contributing opinions in a group setting to voice their perspectives and provides more explicit information than surveys. 31 In this study interviews were conducted by a trained researcher at a mutually suitable date and venue. 24 The researcher has a background in physiotherapy and has conducted several interviews as part of research projects. She was also guided by experts as supervisors for this project. Informed consent and permission to record the interviews was obtained prior to interviews, and interviews lasted approximately 20 min – 30 min. Interviews were started with important questions and probes were used during the interview process. The interviews were based around two central questions: ‘What are the challenges you experience personally and professionally in conducting your duties? Why would you be interested to join a self-management programme or what would be your motivation to join a self-management programme?’ Individual interviews were conducted until saturation was achieved. The participants were interviewed in the language they preferred (English/Afrikaans) as the researcher was versatile in both languages. Field notes and observational cues were recorded by the researcher at the end of each interview.

Data analysis

Each interview was transcribed verbatim. Given the exploratory nature of the study, thematic analysis was conducted following a rich and detailed account from the participants. 33 The interviews were transcribed verbatim and each transcript read several times by the primary researcher. Initial codes were created by writing notes on the transcripts. Codes were then group and clustered together into agreed upon themes by the researcher and co-researchers.

To promote confidence in the research and ensure quality it is essential that the protocols and procedures employed in the study are detailed. 34 The following procedures were conducted to ensure trustworthiness: during interviewing the researcher repeated the central questions in different ways to ensure that the participants understood the questions (credibility). In addition, detailed notes were taken during the interview process and interviews were recorded (dependability). Co-researchers who were academics and had expertise in the field of qualitative research, reviewed all notes made during the analysis process and discussed the conclusions reached (confirmability). During the reporting of the findings, actual quotes are used relevant to the participants and a full description of the context is provided (transferability).

Ethical considerations

Ethical clearance was obtained from the Human and Social Sciences Research Ethics Committee at the University of the Western Cape (HS17/8/23), and permission was obtained from NGOs in the sub-district. Written informed consent was obtained from all respondents and confidentiality was ensured.

Fifteen participants were interviewed. As indicated in Table 1 , CHW participants lived in the communities in which they worked for an average of 21.5 years and have been working as CHWs for an average of 3.7 years. The participants were primarily female (80%), 33% were married and had a mean age of 43.2 years. All the participants received a monthly stipend through the two NGOs. Participants were primarily engaged in home visits, providing home-based assistance with activities of daily living, ensuring adherence to tuberculosis (TB) and human immunodeficiency virus (HIV) medication regimens and conducting blood pressure and blood glucose monitoring.

Description of the participants.

CHW, community health workers; TB, tuberculosis; HIV, human immunodeficiency virus; BP, blood pressure; ADL, activities of daily living.

Interpretation of the results yielded five themes (social conditions, mental health of patients, work environment, patient adherence and communication) of challenges experienced by the CHWs in performing their duties. Personal challenges revealed ineffective self-management as a theme, and motivation for participating in a self-management programme was characterised by two themes: CHW empowerment and widening CHWs’ perspectives ( Table 2 ).

Emerging themes of challenges.

CHW, community health workers; TB, tuberculosis; HIV, human immunodeficiency virus.

Quotations are used to illustrate how the information is rooted in the participants’ perceptions and experiences.

Challenges experienced by community health workers

The challenges experienced by the CHWs included influence of social conditions, mental health status of the patient, patient adherence, communication and work environment.

Social conditions

This theme comprised social factors influencing patient health status, such as the impact of socio-economic status on individual and community mental health:

‘Sometimes it is difficult for us to get through to them in a sense like they have their own house problems as well.’ (Participant 5, female, 23 years old)

Participants also observed that poverty affected patients’ response to healthcare interventions:

‘[ I ]t’s already poor communities so all that circumstances depress these people.’ (Participant 1, female, 37 years old)

The participants also commented about gaining access to patients’ homes and the patients’ reactions that arriving at their homes could evoke. These reactions are because of the CHWs daily interaction in the community and living in fear. They expressed being received poorly by patients, such as instances in which patients rudely addressed CHWs and were dismissive of CHWs when CHWs requested access to patient homes. These CHWs observed that this was particularly prevalent when the CHWs started working in a particular area and were not yet well known to community members.

Community health workers in the study also reported being denied access to clients’ homes, albeit for different reasons. Community health workers observed that clients were concerned that the police were at their door. This is consistent with the high-crime neighbourhoods in which the CHWs conduct their work and police visits were not associated with favourable news or outcomes:

‘I discovered that when you get to people, sometimes … A lot of them are very edgy if you knock they think it is the police.’ (Participant 11, male, 67 years old)

Mental health status of patients

This theme captured how participants experienced their patients when doing home visits. Although the CHWs realised that they cannot diagnose patients, they were able to recognise mental health symptoms and demonstrate empathy as they dealt with patients:

‘[ S ]ome of them are very depressed, they have other issues as well, so when you try and speak to them, they are very closed.’ (Participant 1, female, 37 years old) ‘[ M ]ost of them are in denial mode or they don’t want to know they are sick.’ (Participant 2, female, 31 years old) ‘It is basically trying to like bring yourself on the same level as the person because obviously you are not as sick as that person is, so sometimes it is difficult for you to get through to the patient.’ (Participant 5, female, 23 years old)

Patient adherence

Community health workers communicated frustration in getting community members to change their health behaviours:

‘She does nothing that I tell her – no exercise, nothing. Every time when I must go to treat her then her skin is everywhere and arms are stiff like rocks, then I massage it right again.’ (Participant 3, female, 50 years old)

Participants expressed a perception that patients refuse to adhere to health advice despite concerted CHW efforts:

‘I struggled a lot to get through because it puts a strain on me especially when I communicated with a patient but they don’t want to listen.’ (Participant 8, female, 42 years old)

Follow up of patients who defaulted treatments can be complicated and unsuccessful:

‘[ W ]hen the patient defaults and you are supposed to go and look for the patient and you find out that this patient doesn’t live there. This patient gives the incorrect address and stuff like that.’ (Participant 13, female, 43 years old)

Work environment

Community health workers in the study also identified this struggle to manage workload in their high-need, low-resource community settings:

‘Sometimes it feels like they didn’t think this through because there is just so much that a person can do in a day but then they expect you must have a workload of so much.’ (Participant 1, female, 37 years old)

Occupational stress triggered by perceived inadequate staffing to ensure patient safety was also a factor:

‘I was so scared that I will do something with the old people, because if they fall, I will get into trouble.’ (Participant 3, female, 50 years old)

Communication

Participants reported communication challenges when met with disrespect from community members and how they manage this dynamic as they ensure appropriate health service delivery:

‘Some of the patients are very rude. What we came to learn is that one must just be quiet.’ (Participant 9, female, 54 years old) ‘A lot of times I have been in peoples’ homes who are a bit rude, [ previously ] some of the patients were not rude, but they are now so rude.’ (Participant 12, female, 56 years old)

Community health worker participants observed that community members’ lack of education is a factor limiting their ability to comprehend healthcare instructions. Community health workers in this study showed insight into this barrier and were able to utilise their knowledge of the community to advance the treatment or programmes they were administering:

‘[ S ]ometimes we have to explain more detail for the patient because sometimes the people don’t know exactly about TB and then the stigma.’ (Participant 10, female, 39 years old) ‘I mean, not everybody is educated and etcetera, so you have to come down on a level of understanding so that would have to be patience and understanding also.’ (Participant 15, male, 32 years old)

Challenges with their own health

The second question of this study focused on the challenges that CHWs experienced with their own health. The themes that emerged were ineffective self-management with lack of self-care, lack of motivation and CHWs’ own personality challenges.

Ineffective self-management

‘The challenges that I had is to eat healthy and even if I’m on medication and not taking medication.’ (Participant 10, female, 39 years old) ‘For myself, I will say, yes because I’m very lazy hey – I’m not lazy, it’s almost like, I always need a coupling [ colleague ] to do something.’ (Participant 13, female, 43 years old) ‘I faced a lot of challenges and so with that I had destructive ways about me because that was the way I managed things to keep it there and not let it go any further.’ (Participant 15, female, 32 years old)

Motivations to participate in a self-management programme

The third line of inquiry in interviews focused on why the CHWs would want to engage in a self-management programme. The two themes that emerged were empowerment and widening perspectives.

Empowerment

Participants indicated a desire to become more confident and to take control of their own lives, including the need to focus on themselves at times rather than on the community:

‘So obviously that has to do with me personally and I wanted to like, basically just get to know myself much better also than what I do at the moment and manage myself properly also in a way that is pleasing and also pleasant for other people around me.’ (Participant 15, male, 32 years old) ‘The main emphasis … – I would say it was like mostly goal orientated and that was, kind of, exactly what I needed. To be honest with you, the way I grew up I wasn’t really motivated and I needed to get motivated.’ (Participant 14, male, 34 years old) ‘For me, it was that I wanted to learn more about myself and when I learn about myself, I can teach other people what I had learnt.’ (Participant 8, female, 42 years old)

Widening perspectives

Community health worker participants communicated their interest in gaining new knowledge. New knowledge acquisition fuels possible job advancement (personal benefit) and the transference of new-found knowledge to benefit others (community benefit):

‘I like to learn new things. I like to do so because to me, if I learn new things, tomorrow I come somewhere and I can educate somebody else.’ (Participant 13, female, 43 years old) ‘I told myself every training or something that you get … that …uhmmm … um … um … it makes you more … um … um … more aware of things, not just things that fit into your field of work, but to learn how to look after yourself, how to handle things, so I grab every opportunity that I get.’ (Participant 12, female, 56 years old)

The aim of the study was twofold: (1) to explore the challenges CHWs’ experience in carrying out their duties and (2) to explore their motivation to join a self-management programme. Based on the findings of the study the emerging themes that describe the challenges are discussed initially and then the motivation to join the self-management programme.

Social conditions and mental health

In this study, the CHWs reported that the social conditions of the patients led to fear, depression and an inability to focus on what the CHWs wanted them as patients to do. Literature from India commented on the CHWs’ description of not gaining access to clients’ homes as one of the negative experiences of the job. 35 A recent study determined that social conditions do have an impact on the mental health of an individual. 36 Although there is evidence that CHWs are not always safe when they enter the homes of patients with mental health problems, 37 concern for safety was not raised in this study. Rather, CHWs observed the need to understand the patient and how to communicate depending on the mental health status of the patient, and CHWs in this study demonstrated empathy towards their clients’ mental health needs. Understanding the mental health conditions of patients thus becomes a key aspect of the skills that CHWs require. The need to include mental healthcare training and coordination at the primary care level is consistent with needs expressed by CHWs in this study. 38 Using CHWs resourcefully in the primary care setting may result in stress reduction and mental health promotion amongst community patients, especially in low- and middle-income countries that are severely under-resourced with respect to mental health services.

Patient adherence and communication

The lack of patient adherence to the prescribed treatment regimens were identified as a challenge. Factors contributing to the lack of adherence to proposed health regimens are multi-faceted, ranging from undervaluing preventative measures to psychosocial and socioeconomic hurdles to fears over stigma and challenges with traversing the health sector. 39 , 40 , 41 As CHWs can play a key role in areas where health service access or motivation is poor, 13 ‘training on behaviour change techniques’ would stand CHWs in good stead to deal with adherence concerns. 42 Community health workers have themselves reported that they are capable of motivating community members to seek appropriate health services. 39 It is thus apparent that CHWs can make a positive difference in assisting patients to adhere to medical regimens if they receive the correct training. Communication between the community and the health system is vital. The CHW workforce is like an important conveyor belt that transports the key health messages to the community and simultaneously increases the formal health professional’s awareness of the social determinants contributing to the patients’ health status. Community health workers in their dual role are more effective when they receive the respect they deserve from the formal health professionals and the community they serve because they feel that their contribution is valued. 43 One advantage of the CHW workforce is that they come from the communities they serve and therefore have a unique ability to speak the language of the community. 40 Although the community may not always understand the role of the CHW, it is important that communication channels remain open as it has been shown that CHWs are effective in strengthening communication between the medical system and the community. 44 , 45

Work environment and ineffective self-management

In this study the CHWs raised workload and the environment as a barrier to successfully implementing their duties. Literature has previously highlighted CHW workload as a barrier to achieving goals set by supervisors or health systems. 46 In a study aptly titled ‘We are the people whose opinion don’t matter’, CHWs expressed their need to have their work environment challenges addressed by the NGOs with which they are affiliated. 47 World-wide it has been reported that increased workload and the absence of clearly defined boundaries for the job causes stress. 48 This is no different for CHWs, who are under tremendous pressure to meet health needs with subpar human resources, increasingly having additional responsibilities added to their workload and disconnection between themselves and the formal health sector. 47 , 49 , 50 Studies have documented these factors as significant contributors to occupational stress. 51 , 52

Aligned to the fact that the CHWs were not coping with their increased workloads, was their inability to successfully manage their own health. Literature reveals much research about the roles that CHWs play in addressing health challenges in the communities, yet there is a dearth of information on CHWs’ health needs and how they manage their own health. A substantial proportion of health professionals including CHWs struggle to manage their own health behaviours and to ‘practice what they preach’. 18 , 53 A recent study amongst rural CHWs reported that they present with chronic conditions such as those of the community members they serve and that they also experience physical and emotional barriers to managing their own chronic conditions, suggesting that CHWs themselves may be good candidates for self-management interventions. 54

In this study the participants highlighted empowerment and widening perspectives as two key reasons for joining a self-management programme. Research indicates that CHWs feel empowered when they are valued for the healthcare contributions they make, when they are included as part of the healthcare team and when they receive training to improve their competence. 35 , 43 , 55 With the expectation that CHWs need to contribute productively to improvements in overall community health, it is important that CHWs feel empowered. 55 Training is highly regarded amongst CHWs globally and a substantial contributor to CHW effectiveness and motivation. As such, CHWs need to be empowered to improve their own health behaviours and then to serve as a catalyst and role model by empowering the community members with increased knowledge and support. 56 The role that CHWs play in communities has been flagged as an empowerment strategy to reach communities with the aim of improving healthcare. Once communities are empowered there is an increase in the sense of self-determination and self-efficacy and a positive cycle of health behaviours may be perpetuated and sustained. 57

It has been found that CHWs were very keen to gain new knowledge, as such new information modified their worldview. 35 This study echoed these findings, but it also yielded further reasons for the CHWs participation in the self-management programme. These included the enjoyment they receive from gaining new knowledge, possible job advancement, the transference of new-found knowledge to benefit others, learning coping skills and the desire to learn ways to manage their health. The participants in this study also indicated that they would not pass up an opportunity for training.

Implications for practice

Research has shown that most engagement with the CHW workforce has been around upskilling to improve the health and empowerment in the communities they serve. 58 Much has been documented about CHWs as a liaison between the formal healthcare system 13 and the community and as a vital strategic resource to achieve global health goals, the actual CHWs and their own needs have been grossly overlooked. There is sufficient evidence to inform decision-makers about the factors that motivate CHWs into performing their roles effectively. 35 , 43 Empowerment of this cadre should be high on the agenda, as CHWs cannot transfer skill sets of confidence, goal setting and action planning needed to create behaviour change without themselves developing and maintaining these skills. A self-management programme, which by its design is problem-based and incorporates the person’s perception in the process, is ideally suited as a tool to achieve this end, and CHWs as frontline providers are ideal candidates to be trained as self-managers. 20 As members from the same communities they work in and share the same health and social needs as their communities, thus becoming effective self-managers will enhance CHWs’ cultural competence. Self-management programmes train participants in the key skills of decision-making, finding and utilising resources, forming partnerships with their healthcare providers, and taking action. The mastery of such skills would benefit CHWs in meeting role expectations. 21 , 59

Simply belonging to the same community and having shared experiences is not sufficient to equip CHWs to work with clients who are unresponsive, who undervalue CHWs’ role and who do not adhere to recommended health behaviours. Therefore, there is a need to incorporate these competencies into all training offered to CHWs coupled with regular maintenance sessions. Self-management is a cost-effective strategy 60 that can be used to address this, and it can therefore be successfully rolled out in low-income areas. As the CHWs become effective self-managers they can train community members and the positive cycle can continue.

The formal health system has been remiss in failing to fully accept the CHW as a critical link in the patient-centred delivery model. 45 , 47 It is important that health systems develop insight into the critical role of CHWs, the impact CHWs make in their communities and work to remedy the strained relationship that currently exists between CHWs and health systems. Self-management is an empowerment strategy of meta-skills that does not rely on deep content knowledge within an aspect of medicine. One strategy to improve mutual respect could be to enable CHWs to serve as self-management trainers to members of the formal health system. During these trainings CHWs can present their field findings to formal health professionals. Community health workers-led training may improve the structural competence of health professionals. Another way to address this current divide is to have more ‘multidisciplinary’ engagements, wherein all parties have an equal voice to contribute.

Community health workers affiliated with community-based organisations are central to the implementation of primary healthcare in district health services in South Africa. The themes presented here offer insight into the benefits and challenges described by CHWs. Although these findings are context-specific and so cannot be generalised to the global population, there is sufficient commonality amongst CHW roles worldwide to warrant an urgent response to these challenges. Hearing these often ‘silenced voices’ and responding with tangible risk mitigation strategies will support motivation and empowerment levels required by CHWs to work optimally. This study highlights that CHWs are eager to find solutions to these challenges and one of the ways they did it was by taking the opportunity to learn self-management skills by signing up for self-management training.

Equipping CHWs with self-management tools should positively influence the communities they serve and may ultimately result in healthier communities and a decreased disease burden.

Acknowledgements

The authors would like to acknowledge the community health workers who participated in this study.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors’ contributions

L.J.J. and J.M.F. analysed the data and drafted the article. L.H.S. and F.W. contributed to conceptualising the study and reviewing the manuscript.

Funding information

The authors acknowledge the NRF, through which funding was received, as a bursary to conduct this study.

Data availability

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

How to cite this article: Johnson LJ, Schopp LH, Waggie F, et al. Challenges experienced by community health workers and their motivation to attend a self-management programme. Afr J Prm Health Care Fam Med. 2022;14(1), a2911. https://doi.org/10.4102/phcfm.v14i1.2911