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Strengthening Health Worker Resilience in Sub-Saharan Africa During COVID-19

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COVID-19 has placed an unprecedented burden on health systems globally. The pandemic has exacerbated the situation in low- and middle-income countries, where frontline health workers already face challenging work circumstances and job demands.

Even prior to COVID-19, frontline health workers In Sub-Saharan Africa were experiencing high levels of burnout syndrome effects. Regions like East Africa experience high rates of mental health challenges among healthcare workers, including depression, generalized anxiety disorder, post-traumatic stress disorder, alcoholism and insomnia. These psychological pressures can lead to emotional exhaustion, depersonalization from patients and a sense of reduced personal accomplishment—adversely impacting the well-being of frontline health workers and the communities they serve.

The Johnson & Johnson Center for Health Worker Innovation, with support from the Johnson & Johnson Foundation, has been working with our partners in Sub-Saharan Africa to strengthen frontline health workers’ resilience during a time of immense loss and trauma. Now more than ever, we are committed to understanding and addressing these resiliency needs and to achieving sustainable improvements in health outcomes.

DG Murray Trust: Raising awareness around mental health and the need for ongoing intervention


Since 2020, the Center has collaborated with the DG Murray Trust on the Masked Heroes campaign to provide practical psychosocial support for some of the most important yet vulnerable groups in South Africa—Community Care Workers at the front line of the country’s national COVID-19 pandemic response. In 2021, the program strategy evolved from a focus on facilitating Psychological First Aid (PFA) workshops to expanding to provide grant funding for organizations that require psychosocial support for their Community Care Workers.

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“Going into this training, some of our Community Care Workers were of the notion that there is nothing like mental health… This has been an eye-opener for most people. They are excited to learn about mental health and to understand their own mental health. There is so much struggle: COVID, job losses, lives in general. We all need to heal.”
Southern African Catholic Bishops Conference

The PFA workshops provided Community Care Workers with an easy-to-remember framework to help them better support those in their care and to gauge and self-regulate their own mental and physical health during COVID-19. Grantee organizations, meanwhile, had the autonomy to select their own modalities of psychosocial support and to customize their proposed mental health interventions according to their specific needs and approaches.

Feedback from beneficiary organizations indicates that the interventions had significant impact on bringing basic mental health awareness to Community Care Workers and increasing their capacity to navigate mental health challenges. Mental health support is a relatively new concept for many grantees, with nearly 95% reporting that this was the first time that they had provided professional psychosocial support for their Community Care Workers.

Furthermore, the program support created a ripple effect prompting organizations to seed new ideas for ongoing mental health interventions. In some cases, grantees reported that they would look at ways to build mental health support into their own agendas and conversations and place more effort into mobilizing funding for these interventions.

Foundation for Professional Development: Strengthening measurement and evaluation systems to understand the impact of e-learning on mental health resilience

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For frontline health workers, exposure to sick patients and potentially life-threatening situations means they are foremost at risk, triggering a variety of emotions.

This is why we are working with the Foundation for Professional Development (FPD) to train 2500 frontline health workers across Africa in a mental health resilience e-learning course. The program, implemented in August 2020, aims to support frontline health workers in managing their mental well-being and fulfilling their professional and ethical obligation to the communities in their care. Once completed, participants have the opportunity to complete follow-up training on post-traumatic stress disorder.

In addition to the grant funding from the Johnson & Johnson Foundation, the FPD measurement and evaluation team received guidance from a Johnson & Johnson behavioral scientist to build a robust evaluation strategy, enabling FPD to measure the true impact of the intervention on behavioral change post training.

Participants’ pre- and post-training scores revealed significant increase across five primary domains.

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Furthermore, increases in the self-reported use of resilience-building behaviors, such as coping mechanisms for stress and self-care behaviors, were associated with the significant increase in well-being and resilience scores.

Student satisfaction, meanwhile, was overwhelmingly positive, with 96% of participants indicating that they would attend an FPD course in future. This feedback, together with the pre- and post-mean scores, suggests that e-learning is an effective method to improve the knowledge, confidence, skills and behaviors of healthcare workers—and that short online interventions can lead to behavioral change when the training goes beyond knowledge transfer and includes strategies to practically implement skills.

Aga Khan Development Network: Strengthening frontline health worker resilience through evidence-based research

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There is limited evidence and a knowledge gap around what works in terms of effective strategies to promote the well-being and strengthen resilience of frontline health workers in resource-limited settings, despite the dire need for these interventions.

In line with its 2025 vision to contribute to a healthier and more resilient frontline health workforce and to deliver universal health coverage in East Africa, Aga Khan Development Network, with support from the Johnson & Johnson Foundation, is working to generate an evidence base on the current psychosocial well-being and resilience of frontline health workers in Kenya, Tanzania and Uganda.

The project, launched in December 2020, is based on three dimensions: A robust baseline study to explore burnout risk and the overall mental health challenges facing frontline health workers during COVID-19; the design and implementation of interventions to improve psychosocial well-being of frontline health workers; and an evidence summarization and landscaping process to explore key insights, experiences, lessons learned and key stakeholders in relation to implementing resilience-based programs in East Africa.

Early findings from the evidence summarization phase identify fragmented infrastructures, hierarchal organizational cultures, and lack of government support and resources as key institutional barriers to protecting the well-being of frontline health workers. The evidence goes on to suggest several interventions in alleviating these and individual barriers, including effective organizational communication and leadership, policy-based interventions such as increased wages, medical benefits and professional identity, and the provision of safe spaces and psychosocial service delivery within healthcare institutions.

Through this project, scheduled to conclude in December 2021, we are working to achieve scalable impact for East Africa. We plan to mobilize the evidence generated through various convening events with key actors in East Africa and globally—bringing co-designed, well-informed, and practical solutions to frontline health workers in the context of the pandemic.

TIP Global Health: Building hopeful health systems to improve health outcomes

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People thrive when they feel valued, capable and hopeful. Hopefulness among frontline health workers and the community members they serve has significant impact on strengthening resilience, improving quality of care,and achieving sustainable health goals. This belief forms the cornerstone of the TIP Global Health (TIP) Hope Initiative, which focuses on rigorous research to transform healthcare systems in low-income settings.

Through the Johnson & Johnson Africa Innovation Challenge and the Johnson & Johnson Center for Health Worker Innovation Resilience Collaborative, TIP has made strides to understand the critical influence of hope on healthcare workers and recipients, to gauge the impact of hope on long-term health outcomes, and to assess the impact and effectiveness of interventions that aim to promote hope and resilience.

“If we do not measure hope, it will be impossible to accurately predict one’s commitment to sustaining short-term gains or to understand why an intervention has failed to achieve long-term success.”
TIP Global Health

TIP focused its study on Rwanda, which has achieved major and widespread health improvements for its 12 million people in the last decade. However, traumatic historical events such as the 1994 genocide has had lasting psychological effects on the country’s population. Depression, anxiety and post-traumatic stress disorder remain prevalent, with rates twice as high in women compared with men. Hope and mental health are thus important considerations when creating, implementing and evaluating health programs.

The research began by adapting a positive psychosocial tool, the Herth Hope Index (HHI), to measure hope and its key features, including interconnectedness, readiness for change and future-oriented mindset. This was the first rigorous cultural adaptation of the HHI in a low-income country.

The validation process included multiple translations and cross-translations, as well as in-depth focus groups with nurses and HIV-positive mothers. TIP then conducted over 220 surveys among these groups to test the reliability of the tool.

Findings from the study identify clear impact, highlighting the feasibility of cross-cultural adaptation and suggesting that the process can serve as a model for future HHI adaptations and evaluations in low-resource settings.

Results also suggest that the initial report on the psychometric properties of the tool can be used to generate further research on the capacity to measure and influence hope in low-income countries and enable more evidence-based interventions to promote healthy choices, build strong health systems, and help communities thrive.