International scientific literature since the early stages of the COVID-19 pandemic has documented how healthcare workers, particularly those deployed at the ‘front line’, are being exposed to high risk of psychological distress and psychiatric symptoms such as depression, anxiety and insomnia.^{Reference Lai, Ma, Wang, Cai, Hu and Wei1} An unprecedented workload in overstretched health facilities and all the uncertainties of the pandemic make their working environment stressful and frightening. Factors associated with negative mental health outcomes in this population include long shifts, shortage of personal protective equipment (PPE), the risk of getting infected and transmitting the disease to their relatives, fatigue, the need for separation from their families and feelings of loneliness. Another described problem is the stigma against them as potential carriers of the infection.^{Reference Ransing, Ramalho, de Filippis, Isioma Ojeahere, Karaliuniene and Orsolini2}

Burnout has been described as a psychological distress syndrome resulting from excessive and chronic workplace interpersonal stress not successfully managed. This condition shows up with a state of emotional, physical and mental exhaustion characterised by three key symptoms: overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment.^{Reference Maslach and Leiter3} Prior to this pandemic, studies had already shown increased rates of burnout among healthcare workers in comparison with the general population, with a prevalence varying between 25 and 60%.^{Reference Shanafelt, Ripp, Sinai and Trockel4} As burnout is well-known to have an effect not only on the individual, but also on their environment, thereby increasing the risk of healthcare errors, it is crucial to prevent it or address it early. A recent Austrian analysis of resilience in a healthcare system exposed to COVID-19 revealed that, although most healthcare systems are structured for delivering continuous medical services in normal circumstances, they may not be resilient enough to handle public health crises and other disasters.^{Reference Jovanović, Klimek, Renn, Schneider, Øien and Brown5}

In this article, we collected contributions from colleagues across world regions, who are members of a research think tank assembled through the World Psychiatric Association (WPA) Section of Early Career Psychiatrists (ECP Section).^{Reference Pinto da Costa6} Our objective is to describe an array of initiatives to support healthcare workers during the COVID-19 pandemic in different countries in the world.

Results

We identified ten groups of initiatives implemented across countries (Table 1). In general terms, some countries have continued to build on the lessons learned and existing structures from the Ebola virus disease outbreak and in combating poliomyelitis,⁹ whereas the current pandemic was a new challenge for the others.

Table 1 Overview of initiatives to support front-line healthcare workers during the COVID-19 pandemic across the world

Psychological support

Most contributors in our group reported that many hospitals and governmental institutions have activated psychological support guidelines and tools to counteract symptoms of burnout and adaptation (adjustment) disorders associated with the new situation in their countries. Also, services providing psychological help specifically for healthcare workers were expanded, being offered not only in major cities, but also in rural areas. Virtual group therapy and individual face-to-face as well as tele-psychiatry interventions have also been offered. Training groups for ‘life skills’ such as stress and anger management have been established. This is an important step, as psychoeducation via digital learning addressing mental health concerns has been found to be effective.^{Reference Blake, Bermingham, Johnson and Tabner10}

Accommodation services

In most of the countries represented in our group numerous tour operators, hotels and homeowners has made their facilities available free of charge or affordable for healthcare workers and their families. In some cases, private healthcare centres housed their staff in hotels that had been closed during the lockdown, intending to keep workers’ families safe from contagion.^{Reference Ohia, Bakarey and Ahmad11} However, only a few institutions could sustain this approach on account of the increasing costs and the indefinite nature of the pandemic. Some privately owned institutions currently run fortnight shifts where healthcare workers are lodged in nearby hotels for 2 weeks.

Meal services

Many restaurants in Italy have offered free meals delivered directly to hospitals, ensuring catering for healthcare workers. Additionally, local restaurants in countries such as Lebanon and Colombia have waived bills for healthcare workers in hospital areas or have donated their products to doctors and nurses as a token of appreciation, as it has been suggested that nutrition, rest breaks, time to decompress and time off are just important as providing PPE.^{Reference Adams and Walls12}

Proper personal protective equipment

Most contributors reported that voluntary and non-profit associations purchased proper PPE and other basic medical equipment for emergency rooms and intensive care units in the most serious phase of the shortages. As increasing fear of contracting coronavirus among healthcare workers was reported, this initiative seems to be important not only by ensuring their safety, but also by contributing to preventing psychological distress.^{Reference Shacham, Hamama-Raz, Kolerman, Mijiritsky, Ben-Ezra and Mijiritsky13}

Gratitude in communities

On a larger scale, communities in different countries came together with group rounds of applause in support of all the front-line healthcare workers. The ongoing pandemic revealed the unmet needs of healthcare workers. Feeling valued by receiving the gratitude of communities, especially positive attitudes such as recognition and awareness in the media, could add to individuals’ coping strategies, strengthening their mental resilience.^{Reference Billings, Abou Seif, Hegarty, Ondruskova, Soulios and Bloomfield14}

Financial support

Contributors in our group also reported that economic bonuses were offered to healthcare workers for babysitting services and summer camps for children, and free taxi services for the commute to hospitals were granted. In addition, in some countries (e.g. Belgium, Italy, the USA) banks also decided to delay or defer the payment of mortgage and loan instalments. In Nigeria, an increase in hazard allowances was paid to healthcare workers.^{Reference Shanafelt, Ripp, Sinai and Trockel4} In India, COVID-19 allowances were paid to healthcare workers in addition to the existing salary for their relentless service during the pandemic.

Spiritual and religious life

As the toll of the pandemic continues to increase and thousands of unexpected deaths add up, many healthcare workers are exposed to grief that could have a lasting impact, leading to emotional distress and possibly to mental disorders. In some countries, community leaders have been facilitating COVID-safe engagement in religious and spiritual practices. For healthcare workers who consider themselves spiritual, but not religious, non-denominational spiritual support has been reported as being helpful. For example, some doctors in Nigeria have a daily ‘time out’ and pray with their families and friends where they maintain contact and receive support via interactive apps. Most contributors reported that religious practices are helping healthcare workers to cope better and stay resilient, which supports previous observations of religion and spirituality as being important in mental health.^{Reference Milner, Crawford, Edgley, Hare-Duke and Slade15}

Child care

School closures in affected countries created unintended child care obligations for healthcare workers.^{Reference Bayham and Fenichel16} The contributors agreed that the relocation of children to relatives with lesser risk of being infected was one of the most common solutions. Some faith-based and private organisations established crèches and offered free babysitting services for healthcare workers, with the appropriate safety measures. Nevertheless, a considerable proportion of healthcare workers needed their spouses take on additional responsibilities in assisting with child care, home schooling and other family demands. Likewise, older siblings among their children have had to take on more responsibilities.

Voluntary help

The increasing numbers of COVID-19 patients rapidly overloaded the healthcare systems in many countries, especially affecting working hours and shifts for healthcare workers. As many hospitals struggled with the shortage of employees, healthcare volunteers have played a key role in supporting healthcare workers, especially in early detection of COVID-19 within their communities.¹⁷ In many countries (e.g. India, Lebanon, Lithuania, Thailand), the number of volunteers on ambulances as well as in hospitals increased during the pandemic.

Peer support

In Thailand, access to online help groups tailored for healthcare workers was controlled (by providing medical council registration number, specialty and institution affiliation), to ensure that individuals felt secure and free to speak within the group. Publications in these groups’ communication feeds were moderated by administrators to ensure mutual respect and avoid bigotry. Such groups seem to elicit resilience through emotional and scientific sharing.^{Reference Moazzami, Razavi-Khorasani, Doghaei Moghadam, Farrokhi and Rezaei18} Most of the contributors in our team reported that anxiety has been palpable among healthcare workers in online groups. Nevertheless, the concerns expressed by participants in these groups are finding reassuring responses from experts of various backgrounds, information resources and available local healthcare networks. Peer support has also helped some workers cope with distress associated with the current workload and with being away from home.^{Reference Billings, Abou Seif, Hegarty, Ondruskova, Soulios and Bloomfield14}