Assessment of healthcare worker resilience at the epicenter of the 2022 Sudan virus disease outbreak in Uganda: implications for future preparedness

doi:10.21203/rs.3.rs-3902945/v1

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Research Article

Assessment of healthcare worker resilience at the epicenter of the 2022 Sudan virus disease outbreak in Uganda: implications for future preparedness

https://doi.org/10.21203/rs.3.rs-3902945/v1

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Background: Healthcare workers (HCWs) mental resilience can be challenged during times of adversity, including outbreaks. On September 20, 2022, the Uganda Ministry of Health declared an Ebola outbreak of the Sudan virus disease (SVD) subtype. We assessed the level and determinants of resilience at the workplace among HCWs working at the epicenter of the SVD outbreak (Mubende and Kassanda districts) in Uganda.

Methods: During March 2023, we conducted a cross-sectional survey among all HCWs (clinical and non-clinical) working from September 20, 2022─January 23, 2023 (the outbreak period) in the three health facilities that were directly involved in the SVD response in Mubende and Kassanda districts. Risk perception was assessed using 12 statements with a 4-point Likert-type scale. We assessed resilience using the Connor-Davidson Resilience Scale (CD-RISC-10). Resilience was dichotomized into ‘not resilient’ (score 1-29) and ‘resilient’ (score 30-40). Logistic regression was used to identify factors associated with resilience.

Results: Of 429 eligible HCWs, 400 (93%) were interviewed. Mean age was 35 (range: 20-58) years; 222 (56%) were male and median work experience was 8 years (range:1-38). One hundred and ten (28%) were support staff and 72 (18%) were nurses; 344 (86%) worked >40 hours per week. Overall, 93 (23%; 95%CI: 19-25%) were resilient. Three hundred and fifty-six (89%) expressed fear of contracting SVD and 356 (89%) expressed concern about stigma at their workplace if they became infected. Resilience was associated with age >40 years (adjusted odds ratio [AOR]=2.1; CI=1.3-3.5), work experience >10 years (AOR=2.2; CI=1.1-4.7), working >40 hours per week (AOR=6.8; CI=2.1-23), and receiving Ebolavirus-specific counseling (AOR=3.3; CI=1.7-6.5).

Conclusion: Most HCWs at the SVD outbreak epicentre in Uganda faced resiliency challenges during the outbreak, related to their infection risk and treatment by others if they became infected. Psychological counselling and mental health support to HCWs and addressing concerns that bring them a high risk of infection could improve on their resilience during future outbreaks.

Sudan virus disease

Ebola

resilience

stress

healthcare worker

Uganda

Worker resilience refers to an individual’s ability to cope with stressful work-related situations, to remain focused and interested in their duties, and to ‘bounce back’ easily after adverse events [1]. This is especially important for healthcare workers (HCWs), as the inability to work effectively can have an impact not only on the individual but also on the quality of patient care [2]. Stressors among healthcare workers can include universal events such as work overload, conflict at the workplace, or aggression from supervisors, to healthcare-specific issues such as fear of acquiring infections from the hospital or grief from seeing dying patients [3, 4]. If left unchecked, highly stressful environments may lead to long-term and persistent psychological effects such as anxiety or panic disorders [5]. Resilience enables HCWs to cope with their work environment and maintain a healthy mental state despite the presence of stressful factors.

During Ebola disease outbreaks, the healthcare system can experience extreme pressure due to sudden increased demand for medical resources, specialized equipment and isolation units, and disruption of routine health services. These pressures can have a negative impact on the mental health and resilience of the healthcare workers [6, 7], who may experience stressors such as limited availability of personal protective equipment (PPE), fear of infection, and spread to family members, illness and death of coworkers and increased working hours and workload [6, 8, 9].

On September 20, 2022, the Uganda Ministry of Health (MoH) declared an Ebola outbreak of the Sudan virus disease (SVD) subtype in Mubende District. The outbreak subsequently spread to Kassanda District, where the first case was confirmed on October 13, 2022. These two districts became the epicenter of the outbreak, which later spread to seven other districts (Kampala, Masaka, Jinja, Kyegegwa, Bunyangabu, Kagadi, and Wakiso) [10]. By the end of the outbreak on January 11, 2023, 19 of the 142 confirmed cases were healthcare workers, seven of whom died [10]. We assessed the level and determinants of resilience at the workplace among HCWs at the epicenter of the SVD outbreak response in Uganda to provide recommendations to the Ministry of Health (MoH) for psychosocial support for frontline HCWs during similar epidemics.

Study setting, design, and participants

We conducted cross-sectional survey of all HCWs at Mubende Regional Referral Hospital (MRRH), Kikandwa Health Center (HC) III, and Madudu HCIII who worked for at least one day during the SVD response period (September 20, 2022─January 11, 2023). These health facilities were selected due to their direct involvement in the response to SVD outbreak. The survey was conducted from February 27─March 24, 2022, six weeks after the end of the SVD outbreak was declared.

MMRH is a government-owned referral hospital located in Mubende District, which serves 8 districts in the north-central region of Uganda, and has 175 beds and 386 HCWs. Madudu HCIII, located in Mubende District, and Kikandwa HCIII, located in Kassanda District, are sub-county level health facilities, each with 15 beds and 21 health workers. MRRH and Madudu HCIII had formal Ebola Treatment Units (ETUs) established. Kikandwa HCIII did not have an ETU, but is located in a town which had a high number of SVD (48/142) confirmed cases. The facility served as an isolation center for suspected patients while they awaited evacuation.

We defined a HCW as a person listed under the International Standard Classification of Occupations by the International Labor Organization as a healthcare professional. These included medical doctors, dentists, nursing and midwifery professionals, premedical practitioners, pharmacists, psychologists, social workers, environmental, occupational, hygiene professionals, and support staff [11].

We collected data using an interviewer-administered structured questionnaire which we developed based on previous resilience studies carried out during disease outbreaks [12–14]. We included HCWs who directly took part in patient care and those who were not directly involved in patient care.

Data collection instruments and study variables

Data collected from HCWs included age, sex, level of education, professional cadre, hours worked per week, years of experience, number of children, monthly income range, number of persons with whom the health worker resides, whether the HCW directly or indirectly cared for a suspected SVD patient at the health facility, level of resilience as the outcome variable.

We defined resilience as the HCW’s ability to cope with workplace stress during the period of the SVD outbreak. We measured resilience using the Connor-Davidson Resilience Scale (CD-RISC-10). The CD-RISC-10 is a tool that measures the ability to cope with stress and adversity using a 10-item questionnaire with a 5-point Likert-type scale. Responses included ‘not true at all’ (scored as 0), ‘rarely true’ (scored as 1), ’sometimes true’ (scored as 2), ‘often true’ (scored as 3) and ‘true nearly all the time’ (scored as 4). Participants rated the items based on how they recalled feeling during the SVD outbreak. The CD-RISC-10 has been validated in low and middle-income countries (LMIC) and has been shown to have good validity and reliability among healthcare workers [15].

The risk perception of SVD was assessed using 12 statements relating to fear of contracting SVD, fear of spreading SVD, workplace conditions, and stigma, which was adapted from the Modified Stigma Scale [16, 17]. The scale has been validated and shown to have good validity and reliability when used as a screening tool for stigma during outbreaks [18]. Respondents rated each statement on a 4-point Likert-type scale, with ‘strongly agree’ being scored as 0, ‘agree’ as 1, ‘disagree’ as 2, and ‘strongly disagree’ as 3. A higher score signified a higher the level of risk perception. We used the percentiles to dichotomize those individuals with high-risk perception as high concern (≥ 25% percentile) and those with low-risk perception as low concern (≤ 75% percentile) as previously described [19].

Data management and statistical analysis

We entered data into Microsoft Excel and exported to Stata version 16 software (Stata Corporation, College Station, Texas, USA) for analysis. Data that were continuous and normally distributed were represented as mean and standard deviation (SD), while continuous non-normally distributed such as work experience, number of days worked and distance from home and workplace were represented as medians with interquartile ranges. We summarized categorical data like sex, marital status, employment status, having received SVD training, having contracted SVD, and having received SVD counselling by frequencies and percentages. We grouped respondents according to their resilience score: low resilience (scores 0–21, up to 25th percentile), moderate resilience (scores 22–29, above 25th percentile but below 75th percentile), and high resilience (scores 30–40, above 75th percentile) and this was based on categorization from previous studies [20].

We used logistic regression to identify the factors associated with resilience. The resilience scores were recategorized into a binary outcome, where a score of 1–29 (low and moderate resilience) was categorized as ‘non-resilient’ and a score of 30–40 (highly resilient) was categorized as ‘resilient’ [21]. Adjusted odds ratios and confidence intervals were computed for all variables in the model. Statistical significance was tested using a 95% confidence interval and p < 0.05.

Characteristics of study participants

A total of 400 HCWs were interviewed from all the health facilities. Among 429 HCWs working in MRRH, Madudu HCIII, and Kikandwa HCIII, 400 (93%) completed the survey, with the majority coming from MRHH (92%). The mean age of respondents was of 35.3 ± 8.2 years (range, 20–58 years), median distance from home to the workplace was 3 km (range 0.5–17 km), median number of days worked by HCWs was 102 days (range 73–114 days) and median work experience was 8 years (range:1–38 years). Approximately half of the respondents (56%) were male. Support staff (28%) and nurses (18%) comprised nearly half of the respondents. Three quarters of the participants participated in the SVD response (Table 1).

Table 1

Characteristics of respondents during a study to assess resilience amongst healthcare workers working at the epicenter of the Sudan virus disease outbreak, Uganda 2022 (N = 400)
Characteristic	Number	(%)
Health facility
MRRH	367	(92)
Madudu Health Center III	22	(6)
Kikandwa Health Center III	11	(2)
Age in years
20–29	94	(24)
30–39	217	(54)
40–49	58	(14)
> 50	31	(8)
Sex
Male	222	(56)
Female	178	(44)
Cadre of HCWs
Support staff**	110	(28)
Nurses	72	(18)
Medical doctors	49	(12)
Midwives	41	(10)
Clinical officers	38	(10)
Laboratory staff	33	(8)
Pharmacy personnel	18	(4)
Psychosocial staff	17	(4)
Dental personnel	11	(3)
Public health personnel	11	(3)
Marital status
Married	250	(63)
Single	142	(35)
Divorced	8	(2)
Work experience
≤ 5 years	120	(30)
5–10 years	174	(44)
> 10 years	106	(26)
With whom does HCW reside
Family	253	(63)
Alone	127	(32)
Friends	20	(5)
Distance from home to the workplace (kilometers)
< 5	320	(80)
5–10	63	(16)
> 10	17	(4)
Employment status
Permanent staff	316	(79)
Short term contract	31	(8)
Intern	37	(9)
Student	16	(4)
Monthly salary range (UGX)
< 1 million	140	(35)
1–3 million	218	(55)
3–5 million	33	(8)
> 5 million	9	(2)
Hours worked per week
≤ 40 hours	41	(14)
> 40 hours	259	(86)
Received SVD training
Yes	315	(79)
No	85	(21)
Contracted SVD
Yes	5	(1)
No	395	(99)
Received counselling services
Yes	115	(29)
No	285	(71)

**Support Staff included drivers, guards, cleaners, and administrators

MRRH: Mubende Regional Referral Hospital

HCW: Healthcare worker

UGX: Uganda Shillings

SVD: Sudan virus disease

Level of resilience amongst healthcare workers working at the epicenter of the Sudan virus disease outbreak, Uganda 2022 (N = 400)

The overall mean resilience score was 25.2 ± 6.1 (Fig. 1). Two hundred and one (50%) respondents scored as having ‘moderate resilience’, 106 (27%) scored as ‘low resilience’, and 93 (23%) scored as ‘high resilience’.

Concerns of healthcare workers working at the epicenter of the Sudan virus disease outbreak, Uganda, 2022 (n = 400)

The greatest concerns among HCW were around fear of exposure to SVD. Three hundred and fifty-six (89%) felt they were at risk of contracting SVD at their workplace. Most (89%) respondents were concerned about stigma and felt that their workmates would avoid them if they contracted SVD; 88% felt that there were no adequate infection prevention and control (IPC) measures at the health facilities, and 80% felt that their families would avoid them if they contracted SVD. Two-thirds (68%) of respondents felt that there was inadequate PPE at the health facilities and 64% considered resigning due to the SVD outbreak (Table 2).

Table 2

Concerns of healthcare workers working at the epicenter of the Sudan virus disease outbreak, Uganda 2022 (N = 400)
Statement of concern	High concern	(%)	Low concern	(%)
I felt that I was at risk of contracting SVD at my workplace	356	(89)	44	(11)
I think my workmates would avoid me if I contracted SVD	356	(89)	44	(11)
I felt that there were no adequate IPC measures available	351	(88)	49	(12)
I felt that my family would avoid me if I contracted SVD	321	(80)	79	(20)
I felt that there was no adequate PPE	273	(68)	127	(32)
I thought of resigning from my workplace due to the SVD outbreak	257	(64)	143	(36)
I thought that avoiding reporting for duty would reduce my chances of contracting SVD	235	(59)	165	(41)
I felt that the health facility was not well staffed to handle the SVD response	182	(46)	218	(54)
I felt that my workplace would not support me in case I contracted SVD	168	(42)	232	(58)
I felt that the health facility was not well equipped to handle the SVD response	150	(38)	250	(62)
I felt that I was coerced to take care of SVD patients who were admitted in the ETU	132	(33)	268	(67)
I felt that my workmates who contracted SVD did not get appropriate treatment	128	(32)	272	(68)
SVD: Sudan virus disease, IPC: Infection prevention and control, PPE: Personal protective equipment, ETU: Ebola treatment unit

Factors associated with resilience among healthcare workers working at the epicenter of Sudan virus disease outbreak, Uganda, 2022 (N = 400)

In multivariable analysis, resilience was associated with age > 40 years (AOR 2.1; CI: 1.3–3.5), having work experience of > 10 years (AOR 2.2; CI: 1.1–4.7) and working for > 40 hours per week (AOR 6.8 CI: 2.1–22.7). Additionally, there was an association between resilience and living > 10 km away from the workplace (AOR 4.5 CI: 1.3–15.6), working as permanent staff (AOR 3.6 CI: 1.3–9.7), and receiving Ebola-specific counselling services (AOR 3.3 CI: 1.7–6.5) (Table 3).

Table 3

Factors associated with resilience among healthcare workers working at the epicenter of Sudan virus disease outbreak, Uganda, 2022 (N = 400)
	Level of resilience				Bivariate analysis		Multivariate analysis
	Resilient (n = 93)		Not resilient (n = 307)		OR (95%CI)	P value	AOR (95%CI)	P value
	n	(%)	n	(%)
Age in years
20–29	9	(10)	85	(28)	1.0	Ref	1.0	Ref
30–39	27	(29)	190	(62)	1.2 (0.9–1.6)	0.241	1.4 (0.7–5.4)	0.71
40–49	32	(34)	26	(8)	1.5 (1.1–2.2)	0.022	2.1 (1.3–3.5)	0.002
≥ 50	25	(27)	6	(2)	1.4 (0.9–2.1)	0.149	1.7 (1.6–2.3)	0.04
Cadre of HCWs
Support staff	26	(28)	84	(27)	1.0	Ref	1.0	Ref
Nurses	12	(13)	60	(20)	1.7(0.5–1.8)	0.322	2.2 (0.3–2.1)	0.62
Medical doctors	9	(10)	40	(13)	1.3 (0.8–2.7)	0.131	1.9 (0.7–3.4)	0.08
Midwives	10	(11)	31	(10)	1.2 (0.3–7.1)	0.094	1.4 (0.2–6.3)	0.09
Clinical officers	11	(12)	27	(9)	2.1 (0.9–3.3)	0.072	1.6 (0.8–2.2)	0.14
Laboratory staff	7	(8)	26	(8)	0.9 (0.6–1.5)	0.189	0.3 (0.1–7.1)	0.08
Pharmacy personnel	3	(3)	15	(5)	1.7 (0.8–2.9)	0.671	2.4 (0.2–3.3)	0.33
Psychosocial staff	5	(5)	12	(4)	2.7 (1.7–1.3)	0.031	2.2 (0.8–1.2)	0.06
Dental personnel	4	(4)	7	(2)	0.4 (0.3–1.9)	0.231	0.1 (0.7–6.6)	0.42
Public health personnel	6	(6)	5	(2)	3.1 (1.2–5.5)	0.011	2.9 (0.1–4.7)	0.08
Work experience
≤ 5 years	28	(30)	92	(30)	1.0	Ref	1.0	Ref
5–10 years	21	(23)	153	(50)	1.3 (0.3–1.7)	0.083	1.1 (0.5–2.5)	0.08
> 10 years	44	(47)	62	(20)	1.4 (1.2–1.9)	0.028	2.2 (1.1–4.7)	0.04
Distance from home to the workplace (km)
≤ 5	66	(71)	254	(83)	Ref	-	Ref	-
5–10	17	(18)	46	(15)	1.4 (0.8–2.6)	0.264	0.8 (0.4–1.7)	0.53
> 10	10	(11)	7	(2)	5.5 (2.0–15.0)	0.001	4.5 (1.3–15.6)	0.02
Employment status
Short contract staff	21	(23)	10	(3)	1.0	Ref	1.0	Ref
Permanent staff	47	(51)	269	(88)	4.4 (1.5–12.8)	0.007	3.6 (1.3–9.7)	0.01
Intern	14	(15)	23	(7)	3.3 (1.0-10.3)	0.042	3.0 (0.7–8.8)	0.14
Student	11	(11)	5	(2)	2.2 (0.6–8.5)	0.266	2.5 (0.7–8.8)	0.16
Monthly salary range (UGX)
< 1 million	21	(23)	119	(39)	Ref		Ref
1–3 million	52	(56)	166	(54)	2.7 (1.8–7.1)	0.037	3.7 (0.4–3.2)	0.68
3–5 million	17	(18)	16	(5)	3.9 (0.2–11.2)	0.667	1.7 (0.1–9.8)	0.33
> 5 million	3	(3)	6	(2)	1.9 (0.5–1.4)	0.821	2.5 (0.7–1.8)	0.08
Hours worked per week
≤ 40 hours	4	(5)	37	(17)	Ref	-	Ref	-
> 40 hours	77	(95)	182	(83)	3.9 (1.3–11.4)	0.012	6.8 (2.1–22.7)	0.002
Received SVD counselling services
No	46	(49)	239	(78)	Ref	-	Ref	-
Yes	47	(51)	68	(22)	3.6 (2.2–5.8)	< 0.000	3.3 (1.7–6.5)	0.000

Ref: reference category, CI: confidence interval, OR: odds ratio

We assessed the level and determinants of resilience at workplace among HCWs working at the epicentre of the September 2022 SVD outbreak in Uganda. At the time of our study, most respondents were not resilient to stress. Resilience was associated with older age, more work experience, working for long hours, living further away from the workplace, working as permanent staff, and having received counselling services. The HCW’s main concerns involved being at risk of contracting SVD and stigma at the workplace if they had contracted the disease. This study demonstrates opportunities to improve services to HCWs and boost their resiliency as they provide healthcare in emergency outbreak responses.

Most HCWs were not resilient to stress. The work environment during an outbreak setting is chaotic and stressful for HCWs, which can affect mental health and resilience [22]. In our study, almost all HCWs felt that they were at risk of contracting SVD and that there weren’t adequate IPC measures to protect themselves, and felt concerned that their workmates would stigmatize them if they contracted SVD; two-thirds said IPC supplies were insufficient. These factors could have led to elevated stress levels hence contributing to low resilience amongst the HCWs. Studies have demonstrated that the unavailability of PPE, medical supplies, and poor implementation of IPC measures at workplaces contribute to low resilience among HCWs during outbreaks [23]. Low resilience was also reported in Italy amongst frontline HCWs during the COVID-19 pandemic [24]. The authors of this study argue that the fear of getting infected and spreading the disease to colleagues are among the reasons that increase the risk of getting stress and low resilience during outbreaks. During outbreaks, healthcare workplaces may need to specifically address the challenges that increase the risk perception of HCWs to getting infected at workplaces.

Older healthcare workers (> 40 years) and those with longer work experience were more likely to be resilient. This is consistent with other studies which have similarly reported that resilience was higher among older HCWs [26, 27]. Other studies have demonstrated that older people have a higher ability to bounce back and recover after physical and psychological adversity [25]. The additional life and work experience of older people may help develop stress resistance traits or stress coping strategies. HCWs who have stayed long on the job have cumulatively faced numerous work-related stressors during their career [28] and as a result, developed coping strategies to stress. An Iranian study amongst nurses during the COVID-19 outbreak demonstrated that nurses who had more work experience had a higher resilience [29]. Additionally, studies show that HCWs with little experience are more likely to be affected by the outcomes of low resilience like depression, burnout, and depression when faced with adversity [30, 31]. Senior HCWs with long work experience can be utilized as positive role models and mentors during emergency outbreak responses.

Interestingly, working longer hours was associated with resiliency, independently of age or experience. During an outbreak response, there is often an increased workload which necessitates long hours, a high sense of urgency, and teamwork aimed at addressing and stopping the spread of the threat [32]. It is possible that the support from workmates may have enabled higher levels of resilience. In the current study, most HCWs worked for more than 40 hours a week during the response period. Although our study links high resilience to long working hours, several studies conducted during the COVID-19 pandemic demonstrated that working long hours is associated with negative mental health consequences like burnout, and exhaustion at the workplace which in turn affect an individual’s resilience to stress [33]. The difference in results may be attributable to differences in outbreak duration; the SVD outbreak lasted for only a few months, while the COVID-19 response was long and protracted (more than 2 years) [34]. It is important to avoid working long hours even in emergency outbreak response situations.

Permanently employed staff were more resilient than short-term contract staff. Studies have shown that employees employed on a permanent basis have better job security and financial stability which shield them against some stressors that affect resilience at workplace [35]. Consistent with other studies, job insecurity and lack of financial stability have been identified as some of the stressors amongst HCWs, especially during epidemics [36–38]. Although outbreak response situations attract diverse human resources with different skill sets, the utilization of staff with permanent staff seems to be a protective factor against stress. Healthcare managers could provide additional support to short-term contract staff so as to imptove on their resiliency during outbreak response situations.

Healthcare workers who lived a distance further away from their workplaces were more resilient than those who lived nearer. This is consistent with a previous study in Ethiopia, which showed that high levels of stress and perceived risk of contracting diseases for HCWs during epidemics were linked to living near their workplace health facilities [39]. The findings of this study are also in line with a study done in Peru which indicated that HCWs' anxiety and mental distress decreased as the distance from the COVID-19 outbreak epicentre increased [40]. Other studies have affirmed that distance away from the epicentre during epidemics is a protective factor against mental health problems [41, 42]. This may be due to the ability to create physical space between themselves and their infectious workplaces. Physical space is important as it gives provides a sense of protection against infection at the workplace.

Healthcare workers who received Ebola-related counselling services were more resilient than those who didn’t. Counselling plays an important role in building resilience and coping during times of adversity as it relieves depression, anxiety, stress, and other mental health conditions [43]. Our findings agree with other studies that have shown that providing counselling services to HCWs is associated with improved psychological wellbeing and resilience [44]. This underscores the importance of offering counselling services to HCWs during emergency responses.

Study limitations and strengths

We acknowledge some limitations in our study. First, the exclusive reliance on self-reported measures for resilience may have had a risk of response bias including the social desirability bias. Secondly, the cross-sectional nature of the study made it difficult to draw the association between the study variables in terms of cause and effect. Another limitation of this study was that we didn’t have a 'before' period to compare, or a group outside of this area, so we could not attribute lack of resilience to the outbreak per se. However, findings from this study provide evidence to MoH about the key drivers of resilience amongst HCWs who worked at the epicentre of the SVD outbreak. These can be used to design policies that support the establishment of resilient HCWs at workplaces and during future similar outbreaks.

Our findings suggest that most HCWs working at the epicentre of the 2022 SVD outbreak in Uganda were not resilient to stress. Factors associated with resilience included being older, having more years of work experience, permanent employment status, working long hours, living further away from the workplace and receiving counselling services.

We bring forward several factors that healthcare managers may be able to use to build resilience amongst health workers during times of infectious disease outbreaks. We recommend that senior HCWs with long work experience be used as positive role models and team leaders during disease outbreak situations to mentor junior and young colleagues. Additionally, strategies aimed at reducing the perceived risk of infection in the workplace, like timely availability of PPEs and strengthening IPC measures, provision of counselling and psychosocial support services, team building activities to promote interaction and communication between co-workers, and assurance of safety at the workplace could improve on resilience amongst HCWs during such outbreaks.

AOR

Adjusted Odds Ratio

Confidence Interval

ETU

Ebola treatment unit

HCW

Healthcare worker

IPC

Infection prevention and control

LMIC

Low middle income countries

MoH

Ministry of Health

MRRH

Mubende Regional Referral Hospital

PPE

Personal protective equipment

SVD

Sudan virus disease

UGX

Uganda Shillings

Acknowledgements

We appreciate the HCWs who participated in this study. We are also grateful to the administration of MMRH, Kikandwa HCIII, and Madudu HCIII for the support administrative and technical support provided during this investigation. We also appreciate the Uganda Public Health Fellowship Program and the Ministry of Health, Public Health Emergency Operations Centre for the technical support and guidance offered during this study. Finally, we thank the US-CDC for supporting the activities of the Uganda Public Health Fellowship Program.

Authors’ Contributions
RZ: Participated in the conception, design, analysis, interpretation of the study and wrote the draft manuscript; PCK, BA, RM, DK, BK, PEO, LB and FLA reviewed the report, reviewed the drafts of the manuscript for intellectual content, and made multiple edits to the draft manuscript; RM, DK, PEO, LB, FLA, EB and ARA reviewed the manuscript to ensure intellectual content and scientific integrity. All authors read and approved the final manuscript.

Funding
The project was supported by the President’s Emergency Plan for AIDS (PEPFAR) through the United States Centers for Disease Control and Prevention Cooperative Agreement number GH001353-01 through Makerere University School of Public Health to the Uganda Public Health Fellowship Program, Ministry of Health. The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the US Centers for Diseases Control and Prevention, the Department of Health and Human Services, the Agency for Toxic Substances and Disease Registry, Makerere University School of Public Health, or the Ministry of Health.

Availability of data and materials

The datasets upon which our findings are based belong to the Uganda Public Health Fellowship Program. For confidentiality reasons, the datasets are not publicly available. The datasets can be availed upon reasonable request from the corresponding author with permission from the Uganda Public Health Fellowship Program.

Ethics approval and consent to participate
We conducted this activity in response to a public health emergency and as such was determined to be non-research. The Ugandan MoH authorized this study to assess the level of resilience amongst HCWs working in Mubende and Kassanda districts during the 2022 SVD outbreak. The office of the Center for Global Health, US Center for Disease Control and Prevention determined that this activity was not human subject research and with its primary intent being for public health practice or disease control. It was determined therefore, to not be human subjects’ research and the ethics approval was waived. The MoH through the Uganda National Institute of Public Health approved the protocols that were used. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^§§See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.

We obtained permission to conduct the investigation from the district health authorities of Mubende and Kassanda. Permission was also obtained from the Director of MRRH and the facility heads of Madudu and Kikandwa HCIIIs. We obtained written informed consent from all the respondents. They indicated their consent by checking an appropriate box for consent before proceeding with the interviews. Participants were assured that their participation was voluntary and that there would be no negative consequences for declining or withdrawing from the study (none declined or withdrew). Data collected did not contain any individual personal identifiers and information was stored in password-protected computers, which were inaccessible by anyone outside the investigation team.

Consent to publication
Not applicable

Competing interests

The authors declare that they have no competing interests.

Author details
¹Uganda Public Health Fellowship Program – Uganda, National Institute of Public Health, Kampala, Uganda

²Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda

³Mubende Regional Referral Hospital, Mubende, Uganda

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No competing interests reported.

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Assessment of healthcare worker resilience at the epicenter of the 2022 Sudan virus disease outbreak in Uganda: implications for future preparedness

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Study setting, design, and participants

Data collection instruments and study variables

Data management and statistical analysis

Results

Characteristics of study participants

Discussion

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