The psychosocial impact of COVID-19 mitigation measures on frontline staff providing sexual health and family planning services in Kenya: a mixed-methods study | Reproductive Health

The nature of the work and work environment have for long been recognized as important contributors to employees mental and physical wellbeing and it has become common practice for organizations to implement psychological interventions to promote the job performance and wellbeing of their employees [1]. Psychosocial wellbeing is however not impacted on or confined to the work environment alone: the work/home interface is recognized as an important source of stress since the demands of the home environment are significantly related to the occupational stress [2, 3]. Consequently, researchers include the work/home interface among the six main factors that are common sources of stress for all jobs, the other factors being, factors intrinsic to the job, career development, role-based stress, relationships at work and organizational structure and climate [2].

Although not so much research has been done to compare stress levels of different occupations [2], professions such as the health care professions, that involve human contact and rapid decision making have been described as most stressful [4, 5]. Moreover, pandemics such as the Ebola and COVID-19 have been identified as occurrences that exacerbate an already dire situation especially in low-income settings grappling with scarcity of human and capital resources [6,7,8]. The mental burden among HCWs, in times of pandemics is often attributed to the rapid increase of infected cases, deaths, absence of effective medications or vaccines, extensive media coverage, massive workload resulting in long hours of work, lack of personal protective equipment (PPEs) leading to anxiety about the risk of infection, feelings of inadequate support and exposure to fake news and rumors in an environment of rapidly changing knowledge about the nature of the pandemic [9, 10]. Previous research conducted on other infectious diseases such as the severe acute respiratory syndrome (SARS), the Middle East Respiratory Syndrome (MERS) and the Ebola virus showed that HCWs suffered significant stress both during and after the pandemics [8, 11].

This paper examines the psychosocial impact of COVID-19 and its mitigation measures on front line FP and STIs HCWs in Kenya. It uses quantitative and qualitative data collected in the course of a health systems analysis project that evaluated the barriers to availability, utilisation and readiness of sexual and reproductive health services in COVID-19 affected areas in Kenya. The study was conducted across 12 health facilities in Kenya, evenly distributed in the counties of Nairobi, Mombasa and Kilifi.

The COVID-19 pandemic

The first case of COVID-19 in Kenya was reported on the 13/3/2020 [12]. While at the beginning cases remained low, they continued to increase steadily reaching a first peak in July 2020 with approximately over 800 cases recorded daily. The Ministry of Health (MoH) provided daily updates of the COVID-19 situation, detailing among other statistics, the number of new cases reported, total number of tests conducted, distribution of cases within geographical locations (counties) and number of recoveries [12].

On the basis of the first case reported and events from other parts of the world, the MoH in Kenya announced a raft of nationwide precautionary measures to curb the spread of the disease. These included, information, education and communication, hand hygiene, respiratory etiquette, masks for everyone including the HCWs, isolation and treatment of sick individuals, monitoring symptoms of healthy contacts, traveller health advice, environmental fumigation and cleaning, social distancing and avoidance of crowds, institutions’ closures, restrictions on the use of public transport, workplace closures and public health quarantine for asymptomatic individuals and/or isolation for ill individuals [13]. In particular, the health sector was supported with training, PPEs and isolation and treatment centres in referral facilities [13].

As the different measures were implemented, HCWs in Kenya and globally remained at the forefront fighting the progression of the virus through treating of COVID-19 cases, in addition to other pathologies that occur in the healthcare centres on a daily basis [14, 15]. While uninfected members of the population were asked to stay at home as one of the mitigation measures, HCWs were required to go out to fight the progression of the disease, thereby exposing them to high levels of stress and work overload affecting their physical, mental and social health. Since COVID-19 was new to humans, the uncertainty of the progression of the disease, the rapidly changing information disseminated by the World Health Organisation (WHO) and other authoritative scientific institutions such as the Centres for Disease Prevention and Control (CDC), misinformation on social networks, and different levels of severity of disease placed many HCWs in a situation of adversity [16, 17].

Several studies have been conducted to explore the manifestations of psychological stressors among HCWs across the globe, [18,19,20,21,22,23,24,25]. In Kenya, a number of studies [26,27,28] have equally examined the prevalence of mental disorders among HCWs. However, many of these studies with the exception of Shah et al. [18] have employed quantitative methodologies to measure the prevalence of mental health symptoms among HCWs employing standardized questionnaires with preset parameters of mental health determinants. By contrast, this study employed a mixed methods approach, using in-depth interviews that allowed the HCWs to, in their own words, express the stressors engendered by the pandemic in the continuum between their homes and workplace.

Methodology

This study was carried out on two levels: at the individual level, where the perspectives of clients and HCWs were examined using qualitative methods of data collection (in-depth interviews) and at the health facility level involving a quantitative assessment of infrastructure availability and readiness to provide SRH services using the service availability and readiness assessment (SARA) tool. The results presented here will be based mainly from the IDIs with healthcare providers, augmented by quantitative data.

Study settings and facilities levels

This study was conducted in three counties in Kenya, namely Nairobi, Mombasa and Kilifi. These three counties were among the first ones to record COVID-19 cases and were subsequently placed under lockdown, with transport in and out of them restricted. In addition, while movement within the three counties was allowed, specific localities within Nairobi and Mombasa, i.e. Eastleigh in Nairobi and Old town in Mombasa, were placed under total lockdown at the beginning of the pandemic.

Twelve health facilities were selected as sites for these study i.e. 4 in each county and distributed to cover the urban, peri-urban, rural and youth friendly service facilities. Health service provision in Kenya is organized along six tiers: community (level 1), primary care dispensaries (level 2) health centres (level 3), subcounty hospitals (level 4) county hospitals (level 5), and tertiary referral hospitals (level 6) [29]. The four facilities selected in each county were distributed between levels 2 and 5.

Study participants selection

HCWs were purposively selected to participate in the IDIs and in the health facility assessment. The interviews were conducted during the pandemic and after the pandemic in order to assess whether there were any differences in impact at these two times. Although 2 HCWs per health facility were selected to participate in the IDIs, only 22 of these were available during the pandemic and 18 after the pandemic. The research team however determined that saturation point had been achieved with these sample sizes. Out of the 40, 10 HCWs provided STI care while 30 provided FP services. The selection criteria included only those 1) who delivered SRH services, 2) were most knowledgeable about readiness and availability of SRH services 3) were stationed in the SRH clinic and had been working at the clinic for at least 6 months prior to the pandemic. Participation was voluntary and only the HCWs who accepted to participate by signing an informed consent form were interviewed.

HCWs were interviewed using an IDI guide that covered WHO’s six building blocks framework with a focus on the delivery of contraception, comprehensive abortion care, STI prevention and treatment and gender-based violence care and support services during COVID-19; and their perceptions on the roles and responsibilities of different parties for providing these services in the context of COVID-19; health system capacity to provide good quality of care for people during COVID-19; training needs, attitudes, biases about contraception, abortion, STI and GBV in the context of COVID-19; and perceived psychosocial effects on men and women, their families and local communities. In describing their psychosocial health, the narrative approach was employed in which the HCWs described their states in their own words as opposed to using parameters commonly defined in mental health literature [30]. The IDIs were conducted by three qualified researchers with experience in conducting IDIs. The IDIs were conducted at two times; during the outbreak between August and December 2021 and after the outbreak between April and June 2022). All our informants were female as they were the ones who mainly provided FP and STI services in the facilities visited and were available for interview. All the IDIs were audio-recorded and transcribed. The audio recordings were destroyed after verification by the first author.

All the facilities selected in this study offered FP and STI management services by different categories of HCWs. Level 2 facilities had a nurse/midwife, public health technicians and community health extension workers (CHEW) while level 3 had a doctor or clinical officer over and above the HCWs available at level 2. HCWs at higher level facilities ( 4 and 5) included doctors (including specialists), clinical officers, public health officers and nurses/midwives. All FP HCWs were nurses/midwives while 4 and 6 of the STI management HCWs were doctors and clinical officers respectively.

Data analysis

An inductive approach was used for the analysis to allow for the emergence of the themes and codes from the data. The analysis of the qualitative data was based on the verbatim transcripts following the general approach of content analysis according to the steps suggested by Elo & Kyngäs [28]. The analysis involved reading through the verbatim transcriptions of the interviews several times to gain an understanding of what was being expressed by the participants, noting down emerging themes and patterns in the data and condensation of the data. The researchers decided on the unit of analysis and creation of units of meaning, which were condensed into codes, while ensuring the core meaning was not lost or distorted. The codes were then used to generate categories and condensation of related categories into themes that convey the meaning of the data.

Analysis of the quantitative data used the presence of the tracer items for the provision of these services, such as availability of guidelines, staff and availability of essential commodities. Quantitative data from the facility assessment survey was entered into an electronic database using a statistical analysis software/package. Descriptive analysis was used to illustrate the basic characteristics of the different facilities, including the monthly number of clients, types of procedures provided, number of medical staff and stocks of drugs.