A total of 15 participants were involved in this study. Of these majority were males (53.3%) and the majority age range was 25–34 years. Regarding Job security, majority of the participants were on short term contracts (66.7%, n = 10). Table 1 presents the socio-demographic characteristics of the participants.
Table 1
Characteristics of participants.
Demographics (N = 15).
|
Frequency
|
%
|
Age in years
|
|
|
18–24
|
03
|
20.0
|
25–34
|
07
|
46.7
|
35–44
|
03
|
20.0
|
≥ 45
|
02
|
13.3
|
Sex
|
|
|
Female
|
7
|
46.7
|
Male
|
8
|
53.3
|
Marital status
|
|
|
Married
|
9
|
60.0
|
Single
|
5
|
33.3
|
Divorced
|
1
|
6.7
|
Widowed
|
0
|
0.0
|
Occupation
|
|
|
Hygienist
|
02
|
13.3
|
Nurse
|
03
|
20.0
|
Pharmacist
|
03
|
20.0
|
Security Personnel
|
01
|
6.7
|
Doctor
|
03
|
20.0
|
Laboratory Personnel
|
03
|
20.0
|
Job Security
|
|
|
Permanent contract
|
02
|
13.3
|
Short term contract
|
10
|
66.7
|
Volunteer
|
03
|
20.0
|
From the focus group discussions held, four major themes were obtained. These were (1) Frontline health workers’ attitudes towards covid 19, (2) Psychological challenges among covid-19 frontline health workers, (3) Barriers to job satisfaction among covid 19 frontline health workers, and (4) Suggestions to support people working during covid-19 pandemic.
1.0 Frontline health workers’ attitudes towards covid 19.
Frontline health workers in all the three FGDs comprised of contract and permanent staff. They included; doctors, nurses, laboratory personnels, hygienists and a security personnel. Several frontline health workers said they felt an obligation to work on COVID-19 patients to fulfil the Hippocratic Oath in which they swore to save patients despite the stress they undergo:
When we finish our studies, we swear the Hippocratic Oath that we must serve. We are supposed to attend to these patients because it is our work... But also the healthcare professional must also be willing to be able to help others because that is the whole point of being a professional. (FGD_ Covid Frontline Worker_COVID-19 Treatment Unit Mulago Hospital _Participant (P4))
Most frontline workers said they treated patients with compassion. They were happy to see patients recover and go home safely which steered their morale to keep helping in a novel disease.
These last two weeks, we have been having quite a number of very ill patients. Managing them up to the day of discharge is a high for me. Delivering the COVID-19 pregnant mother, the very first COVID-19 mother in the country, it was a high for me as well. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P2)
There's nothing as interesting as seeing someone who came dying moving out while smiling and calling your name. This is someone who might have tasted death but he sees you've been with him there and then. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P1)
The value of staff maintaining psychosocial wellbeing, physical health, having good attitude, and good relationship with patients was deemed as critical during work. Patients appreciated the care frontline workers offered and that motivated HCWs because they felt their work was valued:
There have been some happy times, times when patients recognize and call you back and are very thankful. Being nice to us, makes us remember that what we’re doing is worth it and being appreciated. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P2)
2.0 Barriers to job satisfaction among covid 19 frontline health workers.
2.1 Health system barriers
Most frontline workers felt the Pandemic was unprecedented and as a result no person or government was prepared to fully manage COVID-19:
No one prepares for a pandemic but I want to give ministry and government credit because they have done their duty though they are not yet there. They have done their best but I will not say they are yet there. (FGD_ Covid Frontline Worker_COVID-19 Treatment Unit Mulago Hospital _P2)
Overwhelming unexpected patient crowds caused limited and or inconsistent medical supplies and equipment. Poor medical infrastructure such as limited beds and lack of ventilators at ICU was reported by some participants:
So because of the increasing numbers and the challenges that the pandemic has brought to the procurement plans, definitely there are some shortages. (FGD_ Covid Frontline Worker_COVID-19 Treatment Unit Mulago Hospital _P1).
Previously we have been having patients in ERRH sleeping on the ground. If they were sleeping on the ground, were they even keeping the 2m distance? (FGD_ Covid Frontline Worker_COVID-19 Treatment Unit Mulago Hospital _P3).
I think COVID-19 exposed the gap in Uganda’s health system. Before COVID-19, there were like probably close to 200 active ICU beds in the country, that’s including all the private ones. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P5).
Most frontline health workers including doctors said it was not practically possible for them to enter COVID-19 treatment rooms or touch a patient without PPE. This was because they feared being infected. They said, government provided N95 masks and sanitizers but they were few:
For example when I come and there is no PPE, I cannot dare enter those treatment rooms. For me to work, PPEs must be there. I take it that my life comes first and other things come later. (FGD_ Covid Frontline Worker_COVID-19 Treatment Unit Mulago Hospital _P1).
Poor Procurement lines affected sufficiency of medical supplies and equipment such as medical gowns, facemasks, and non-re-breather masks for patients who were desaturating, drugs, Personal protective equipment (PPE), alcohol, beds, ambulances as well as COVID-19 testing kits:
Procurement lines have been tampered with. They have been messed up. So because of that getting medical gowns, drugs etc. is a challenge. (FGD_ Covid Frontline Worker_COVID-19 Treatment Unit Mulago Hospital _P1)
Participants said they identified ‘’COVID patient champions’’ to talk to fellow patients when they lacked PPE to attend to patients. This made them feel that they were not doing a good enough job because the patients needed care from them not fellow patients.
We have been identifying patients’ champions among patients themselves who have been doing some work like talking or calling patients which some patients have been taking it in good spirit and some others thinking that we are giving them our roles to play. They don’t understand what we have been through and we cannot just come and say, ‘We cannot attend to you because we do not have ABC,’ because they will be calling people outside that we are lamenting. So we keep quiet while trying to find ways of making sure that work is done. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1)
Frontline workers were challenged with stock outs of drugs. Most of the drugs were not on essential drug list yet outsourcing was difficult:
I work in the pharmacy department, so there are some drugs the national referral doesn’t have on their essential drug list, however they are prescribed by the doctors so because of that as the pharmacy department, we are tasked to get medication from outside. Sourcing from out was a little bit difficult, still is a little bit difficult but we are handling it. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P3)
2.2 Facility related barriers.
Moreover, due to limited research in COVID-19, all healthcare workers including doctors, nurses and the management team doubted the treatment given to patients. They lacked the confidence to treat COVID-19 patients. There was knowledge gap among the health workers regarding COVID-19 management guidelines and plans. This put the staff in a Panic situation where they practiced “trial and error” treatment given they were uncertain about the effectiveness of the treatment. Participants Suggested evidence based information to determine treatment basis:
The management plans we are using are not evidence based. We are just trying out things. We are in a panic, trying out things here and there. Some treatment works in some people and in others it doesn’t work. Yeah so really, it is still challenging. We are not doing our best because we don’t have evidence. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P2).
The participants felt treating COVID-19 was challenging because it is a new illness that affected many people in the society yet the staff were limited:
There is a lot of understaffing here. I feel like we do not have an intensivist. Imagine we had ICU patients, who would look after them? We don't have that yet. We only have one physician on fulltime, so if he needs a break, what will happen? (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P5).
Majority of Participants reported about long turnaround time of COVID-19 test results due to the overwhelming numbers and Stock out of testing kits. Long turnaround time which is 2–3 days results in increased risk of transmission of COVID-19 among the population according to participants in all FGDS. Long turnaround time for test results causes patients to overstay in hospital which causes their anxiety and stress. One participant said, Plans are in place to get gene Xpert testing to receive test results within 2hours. Frontline workers Suggested reduction in turnaround time for results (30 minutes);
The turnaround time for covid results is 24 hours outside Mulago but in Mulago its 48–72 hours. The reason for the delay is partly because of overwhelming numbers but also because of the modality (DNA-PCR). If it were rapid diagnostic tests like those for Malaria and HIV on the market, it would have been shorter probably. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P5).
Poor remuneration in terms of low or delayed Salary, lack of or delay of risk allowance caused dissatisfaction among staff. This affected staff mentally given they were involved in risky work yet their families were suffering economically:
Limited and delayed salary definitely causes dissatisfaction and demoralizes the general staff because we come here every day to risk our lives yet we are not remunerated. We have personal needs and families to take care of. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P3).
Delays of salaries were reported by most participants. They felt demoralized because it was hard for them to go to work:
So far I have spent more than one and half months without being paid, so if it was because of money, I would not be here. But because I swore the Hippocratic Oath, patients’ lives come first. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P3).
Most Participants said they suffered transport constraints while coming for duty due to delay and limited money in form of allowances:
Of course we are not satisfied. Some of us are not getting even the transport and other allowances. But of course that is the reality we are dealing with right now yet we are the ones that risk more. You come work and you are not facilitated as you should be. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P2).
Corruption was reported by one participant who suggested that if government releases money, the anticorruption unit should intervene to follow up that money such that it does what its intended for. There was a feeling among participants that their allowances and salaries were shadowed somewhere in politician offices:
People are demotivated but they have to be there because those big bosses intimidate them. They need to be here but you are not providing the necessities for people to be at work. (FGD_ COVID Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
3.0 Psychological challenges among covid-19 frontline health workers.
3.1 Fear and anxiety of contracting Covid while on duty.
Most participants reported fear and anxiety of contracting COVID-19 while on duty because several people were dying in countries like Italy, however this has reduced over time:
At first, you could find that when I sneeze I’m like eh, have got COVID. But I overcame that. At first, I was at tension, but now I’m free surely. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
3.2 Fear to spread Covid to family members.
Family members were scared of acquiring COVID-19 from the frontline workers. Some tried to talk staff out of the COVID-19 work. It was a stressful moment for frontline workers who isolated and avoided their family members:
My family members initially were scared and tried to talk me out of it but later they became okay with it. So whenever I’m here, I try as much as I can to use the protective gears. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
Most participants were scared about infecting family members and neighbours with COVID-19. As a result, they had to get separate places where they could stay alone to avoid mixing with family members and friends commonly expressed as; ‘I won't even meet you, I fear getting COVID”:
When my family got to know that I’m going to be in COVID-19 treatment centre, they got scared. They wanted to tell me that I stay here at the hospital and not come back home because they were scared that I might infect them. I tried to tell them that we take all the necessary precautions to prevent infection but of course I could not convince them. Because of that, me I do not go home. I got somewhere to stay alone without mixing with my family members. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P2)
I told my wife to arrange supper and go to the bedroom while I was sleeping in the sitting/dining room. I told her to make sure that she puts water and soap outside for me to bathe and wash my clothes I'm putting on because of that fear. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P3).
3.3 Stress as a result of avoidance or isolation from friends and family members.
Most Participants said they missed their family members and friends due to avoidance or isolation as a result of working in a COVID-19 setting:
Psychologically, this is a disease that requires you to be in one place, so there's missing of your family, your loved ones and as you know ladies demand a lot of time, children need time, so that one also was a stress factor. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P3).
3.4 Burn out as a result of heavy work load.
Most Participants mainly from Entebbe reported stress, exhaustion, and burnout due to heavy workload, working long hours and days without day offs:
Also the burnout, you may burn out yet there's no one to leave on station, so it psychologically tortures you. You find you have an off but you can't even get to enjoy it because you'd be punishing a client. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P2).
It's been stressful for some time. I think long working hours and longer days have impacted. Sometimes you reach a point where you feel a burn out, you're dragging your feet to work. You know there are times I really thought I had COVID-19, 3 to 4 times. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P2).
3.5 Stigma and discrimination.
Most frontline health workers suffered Stigma and discrimination associated with working on COVID-19 patients. There was a lot of stigma attached to COVID19 and as a result community members and neighbours kept a distance when they got to know one was a frontline worker.
Stigma was very apparent in the first days when the disease was quite novel and the news that was breaking seemed to be very precarious. So at the time people would stigmatize it. When getting transportation to work, you would say you are going to Mulago, they would say do you have a card, you show your identity card only for them to leave you on the side of the road. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P3).
Children of one participant were isolated from others because their parent was working as part of the COVID-19 team:
It shocked me when I went home and people started ignoring me. Actually they even started ignoring my kid at home, not allowing her to play with theirs, so they were isolated. So I'd tell the mum to lock her in the house and she'd cry. So it was still a bit of a challenge. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P5)
Fear of stigma was the reason why most participants did not disclose to their neighbours about their workplace because they feared pointing fingers at them:
For me, the apartment where I stayed, I must say I took it deliberately not tell them (neighbours) because people were very scared about the disease and there was a lot of stigma. So If I had told them that I work in the COVID unit, I don’t know what would have been their reaction but I think it would not have been good. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P3).
3.6 Stress associated with handling critical patients.
Handling critical patients affected some participants mentally. They expressed need for stress management to be able to carry out their normal work efficiently:
I think it is part of continual growth. Mentally of course, there are times when you feel you need some time to digest everything around but of course, most of us have gone through worse days, treating critical patients. However, there are times when you feel you have broken down and you need some time to reassess and energize yourself. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P5)
Actually, the first case in Uganda tortured me as a person because when the results came back and showed it was the first positive in Uganda, I was shocked as a human being. That very day I went home because the administration had not yet got for us accommodation. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P5).
4.0 SUGESTIONS TO SUPPORT PEOPLE WORKING DURING COVID-19 PANDEMIC
4.1 Government Level
Government relocate budget resources to COVID-19 medical supplies and avail all infrastructure needed in the CTU (COVID-19 Treatment Unit). It should prioritize and increase PPEs and other sundries to all staff categories at the frontline:
But if those guys can increase the supplies to us, then I think we can do better. We are doing well but I think we can do better. Supplies especially PPEs should be given enough priority. May be we get a surplus budget or something else. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
I look at the resources, I think it's high time the government should consider WHO's guidelines on allocation of funds for infrastructure. Currently, our budget has been standing at 7.5% for the health sector. Let's increase to at least 15% so that facilities are able to handle any emerging or re-emerging cases at any time without running to donors. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P3).
Rectify salary and risk allowance delays, avail health insurance to frontline workers and compensate their family members to boast staff morale:
The government and ministry should re-strategize on how well to take care of the healthcare workers because if it was not us, a lot of dead bodies and graves would have been got and seen. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
Ministry should ensure allowances are given on time. If the money is not there, then it should not promise allowances to people.
Responsible government officials have to be reminded of the allowances for all the healthcare workers. They need to know that surely HCWs are risking their lives, although they are here as their profession demands, but they have families to care for. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
Psychosocial support including financial motivation, stress management and appreciation for frontline workers on ground was suggested:
At least they should not stress or disvalue the people on ground. Let them first mind their lives so that these people can be treated or handled well. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
4.2 Facility.
Offering extensive trainings to all frontline workers, availing Continuing Professional Development (CPD) and constant reminders on donning (proper wearing of PPEs as well as how to behave around CTU):
Streamline the procurement process of the drugs and include the unavailable drugs into the essential medicine list. Each department can be availed with Petty cash to buy out of stock drugs:
Avail petty cash to use, what could be the alternative to that because we need to be able to find solutions for each problem individually from each department. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
Reduction in turnaround time for COVID-19 test results, innovate rapid diagnostic tests with shorter turnaround time:
Then also maybe the issues with laboratories (labs), the labs should find a way of reducing turnaround time for testing. I’m aware of some tests that don’t take 24 hours before release of results, those are the ones that should be used. The lab should also increase on the follow up of the tests they take off from patients such that delay of receiving results by patients is somehow minimized. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
Are the lab technicians receiving the reagents they require to have short turnaround of results? Are they having everything they require so that they can be able to perform tests adequately? So if no let’s supply that. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).
Decongesting of hospitals was suggested. This could be done by opening up other treatment centers similar to Namboole stadium or encouraging patients to self-isolate at home:
We need to depopulate this center because a lot of asymptomatic people are here eating food, taking resources that could have been used for people who are critically ill. So, I suggest that asymptomatic patients should self-isolate while in their homes and not in hospitals. (FGD_ COVID Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P3).
Increasing staff personnel at the laboratory and offering all staff health insurance was suggested by participants:
I think increasing the number of personnel would help because then I think everyone would be more productive, have shorter periods of work but very productive. Then, I've heard of/seen the UK model where you work for 2 weeks, and stay home for 2 weeks. I'm not sure how feasible that is but I'm sure it would make people productive all the time. (FGD_ Covid Frontline Worker Entebbe Regional Referral Hospital_P2).
4.3 Community
Ensure continuous community sensitization about PPE, hand washing, putting on masks correctly and consistently, maintaining social distance and home isolating in case of flu-like symptoms:
But then, the Ministry Of Health should take a step of faith and allow people to home isolate. Because hospitals are over stretched and by the look of things, the ministry doesn’t have enough funds to give to hospitals. (FGD_ Covid Frontline Workers_COVID-19 Treatment Unit Mulago Hospital_P1).