DANGER! Crisis Health Workers at Risk

Round 1

Reviewer 1 Report

Methodology:

 

The authors are not clear about the methodology for this paper. Was any framework such as PRISMA adopted in undertaking this review? What are the inclusion criteria in the search methodology and are there any exclusion criteria? What does “122 publications were found to be relevant” mean? Through what methodical process was the relevancy of the publications to the research question determined? Based on what criteria were the 47 publications shortlisted for full review? These are important questions to clarify and explain in the paper.

 

Results:

 

The results presented by the authors are inadequate and in such a way that is not sufficiently meaningful to the readers. I will suggest the authors consider adding an additional column to summarize and highlight the key takeaway points of each paper. For example, under specific barriers to care for migrants and refugees (Table 1), what are the key findings in barriers to care for each of the four reference papers listed?

 

 

Discussion:

 

The authors went on to cover much of the results in a descriptive format under the Discussion section. However, this is somewhat unstructured and a listing of findings from the shortlisted publications. There was no attempt to further define and analyze which medical conditions or infrastructural limitations were prevalent problems in different forms of crises. It would have been useful to distil common challenges and limitations as learning points, rather than only a descriptive listing of issues.

 

Overall comments:

 

The topic of challenges in crises is a complex one with a very broad scope. Depending on the type of crises (e.g. public health crises such as COVID-19, disasters such as earthquakes), the types of health, infrastructural and other challenges may differ. The authors attempted to be comprehensive in their review. However, in doing so, the scientific content and readability of the paper is compromised. It would be preferable for the authors to consider scoping the coverage so that deeper discussion can be undertaken as part of the review.

Author Response

We thank the reviewers for their constructive comments. Regarding Reviewer 1’s recommendations:

• Methodology: Reviewer 1 raised concern that we did not discuss use of PRISMA in our review. PRISMA is a standard framework used in systematic reviews/meta-analysis. The broad scope and diverse structures of our included references, including many qualitative studies, means that our paper does not fit neatly the criteria of a systematic review/meta-analysis. Following discussion with the Guest Editor for this special issue of IJERPH, we have reformatted our manuscript to fit a review format rather than a research format. We will include the search terms and databases searched in the introduction section of the review. In selecting studies for inclusion, we focused primarily on academic literature related to crisis health workers published after 1980. In some cases, however, we incorporated organizational guidelines and useful studies on humanitarian/relief workers in general and health workers in non-crisis settings to provide context and fill in gaps where literature on crisis health workers was scarce. This flexible inclusion criteria is another reason that we have changed to the more appropriate narrative review format.
• Results: We have updated the tables by providing a separate row for each included reference. The final column of the tables, titled “Relevant Terms,” highlights key terms describing problems and interventions identified in each paper. As noted above, we have included some literature on health workers in non-crisis settings and humanitarian/disaster workers in general; in order to improve the length and accessibility of the tables, however, we reduced the number of included references to primarily focus on studies about crisis health workers.
• Discussion: The revised tables, when paired with the revised text, provide additional context about which medical conditions or infrastructural settings occur in different forms of crisis. We also updated the concluding section of the review to summarize common learning points and limitations that were identified in the earlier sections of the review.
• We agree that the topic of challenges to health work in crisis situations is a very broad one. But there are certain challenges—such as lack of infrastructure (including human resources) and coping with mental stress—that affect most, if not all crisis settings. Comparing crisis health workers in different situations allows for examination of learning points common to a variety of crisis situations. The revised tables and text also do include descriptions of challenges unique to certain crisis settings (i.e. risk of nosocomial infection in Ebola and SARS infection, radiation exposure in a nuclear/radiologic emergency) that summarize key findings and include references that delve further in depth into those topics.

Reviewer 2 Report

The manuscript is timely and very important to help awareness of particular characteristics of individual clinicians that seem to do better and to some degree what can be done to help resilience through the crisis.

Crisis exposes the systemic flaws that could have been improved to have lessened the negative impact of crisis on clinicians. I believe the authors have an opportunity here to get more into what parts of the system are fixable to improve chances of wellbeing of CHW's. Manuscript does a great job of uncovering a variety of features and characteristics involved for better wellbeing outcomes and what are the more dangerous risk factors for them. However this paper would contribute so much more if the conclusion section could be more specific is what they suggest would improve chances for wellbeing of CHWs.

What can leadership do? Institutional leadership and direct supervisor style is highly correlated with burnout. The people reading this paper could be better helped in understanding what the key mechanisms are that determine the outcome of CHW wellbeing that is in their individual control and what must be known of the mechanisms of impact that the institution has under its control to improve chances of wellbeing. Although burnout occurs in healthcare around the world, some may have in common effect of upstream leadership decisions that affect practice and safety downstream. Some countries may have more effect of the business of medicine on the wellbeing of clinicians and may be more clearly uncovered during crisis.

Just a few thoughts that may help draw out whatever recommendations that are actionable.

Quick thoughts Table 2. Column of authors cited confusing how paired with year as different studies are separated by comma's but years are hard to match up.

p4 line 100 referring to Venezuela, I couldn't find reference to that situation mentioned earlier. Could you explain what is meant by case of Venezuela?

p4 line 113. What is the point you want to make comparing Renee Bach to the highly bureaucratic licensing, and waved requirements during COVID-19? 

 

Author Response

We thank the reviewers for their constructive comments. Our revised manuscript, now in a review format, includes changes based on Reviewer 2’s suggestions.

All of the tables, including Table 2, have a separate row for each reference. This change addressed the difficulty in pairing up the author name with year and allowed for the ‘Relevant Terms’ column to be customized to reflect key findings from each reference. 

The revised tables and manuscripts now identify risks and protective factors for CHWs more clearly, with an entire section focused on protective factors that improve CHW wellbeing. We revised the conclusion section to highlight common challenges and interventions that affect an array of crisis settings. The final table sorts out protective factors into individual qualities and initiatives versus interventions that can be implemented on an organizational level. Clear guidelines, accurate assignment descriptions, pre-deployment physicals, provision of appropriate personal protective equipment, security measures, support from mentors and experienced role models, educational sessions on non-technical aspects of work such as cultural competency and self care, development of a collegial atmosphere prioritizing teamwork, and post-crisis/deployment debriefings were all identified as interventions that can be implemented by organizational leadership to improve CHW health and wellbeing.

Regarding the Renee Bachman comparison, we have added additional context to clarify that while expedited licensing and credentialing requirements are key to addressing human resource shortage, care must be taken not to let unqualified individuals fill positions meant for trained health workers.

Round 2

Reviewer 1 Report

This is a broad, complex and and multi-dimensional topic. The result is a long, descriptive paper. Some parts of the paper, especially in the Discussion section, can be further tightened to more clearly present the authors' key points and opinions. There is also repeated elaboration of certain points (e.g. strategies for CHW resilience) between the Discussion and Conclusion sections, which will benefit from editing. 

An improvement in this revised manuscript is the restructuring of how the results are presented, which provides greater clarity to readers and helps focus the discussion in the subsequent section. The addition of the column on "relevant terms' succinctly summarises key findings and ideas from the respective papers, which is helpful.  

The following are additional points to note:

• In the abstract and main paper, the authors suggest that adaptation and resilience are "raw talent" and innate attributes desirable in CHW. However, there is a large body of research showing that these attributes can be trained and strengthened, and not necessarily inborn. 
• The authors may wish to consider re-phrasing certain points that can be perceived as broad-brush, not generalisable and/or unsubstantiated with evidence. Examples include "...unreasonably low wages..." and "...nearly impossible licensing and credentialing process...".

Author Response

We thank the reviewer again for the constructive comments. Below is a summary of our response to the three main concerns raised by the reviewer:

1. Redundancy and the need to tighten certain parts of the paper to more clearly present key points.

The reviewer has pointed out redundancy between the discussion and conclusion section as a particular concern. We have structured the conclusion to serve as a summary of key points from earlier sections, which will inevitably lead to some redundancy. Based on this comment, however, we have removed one paragraph on the topic of resilience from the conclusion that was specifically highlighted as being redundant with the discussion section. The key takeaway points were resummarized more succinctly and added to the end of the previous paragraph.

Revised version:

“Traits such as a high level of motivation, flexibility, adaptability, emotional stability, self-care skills, ability to work in teams, and a multidisciplinary background characterize CHWs who are successful in meeting the challenges of crisis work. Aid organizations and other employers of CHWs should recruit individuals with these traits and design training programs to further cultivate these traits and develop CHW resilience. Psychological debriefings following crisis work can also help CHWs process trauma and facilitate a trajectory of growth following stressful experiences and should be considered essential [2][45].”

Original:

“The ability to adapt to strenuous work conditions and resilience has been identified as necessary for successful outcomes for not only the patients and the outcome of crisis relief, but also for the CHW’s well-being. There are personality traits inherent to CHWs that are strengthened and utilized during highly stressful situations. Traits such as a high level of motivation, conscientiousness, flexibility, and a multidisciplinary background are common to CHWs who are successful in meeting the challenges of crisis work. Recruitment of CHWs should place priority on identifying and developing these traits in individuals. Experiences with crises have been found to be associated with protective qualities, however, this requires that the CHW first have experience [46]. Aid organizations and other employers of CHWs can alternatively cultivate these traits in CHWs through programs that develop skills crucial to self-care, such as counseling on as healthy coping strategies [44]. Psychological debriefings following crisis work can also help CHWs process trauma and facilitate a trajectory of growth following stressful experiences and should be considered essential [2][45].”

   Additional examples of areas where we focused our discussion include:

Line 83: removed the following sentences: The WHO Global Health Observatory predicts a net shortage of 15 million HWs by the year 2030. These challenges are already well-defined and demarcated; however, there are even more specific and dire issues for CHWs providing healthcare for displaced populations [8,9].

Line 198: Summarized studies on non-crisis setting HWs: “Other studies have demonstrated an increased risk of peptic ulcer disease, metabolic syndrome, and cardiovascular disease in HWs compared to the general population, especially in association with stress, adverse psychosocial working conditions, and night-shift work [27] [28] [29].” (versus original paragraph below):

Original: “In Taiwan, a large nationwide cohort study of peptic ulcer disease concluded that overall, HWs were at higher risk compared to the general population [27]. Compared to the general population, HWs are at an elevated risk of cardiovascular disease. Juarez et al. studied 1,678 CHWs for cardiovascular disease risk factors and found that being a physician was an additional risk factor compared to other HWs. Stress and adverse psychosocial working conditions were identified as contributory risk factors [28]. Throughout the literature, shift work has been repeatedly associated with an increased risk of cardiovascular disease. In a prospective study of nurses in Rome, Italy, metabolic syndrome was found to be strongly associated with night-shift work in nurses [29].” 

 

2.The characterization of personality traits as being innate versus the product of deliberate training

We agree that personality traits are not immutable quantities but can be shaped and developed by experience and training. In order to avoid conveying the impression that we believe otherwise, we removed the phrase “raw talents” as a characterization of personality traits from the abstract. In the main body of the paper, we developed section 4.3 further. The first paragraph now highlights personality traits in health workers that have been associated with success, without interpreting whether these traits were innate or cultivated. In the second paragraph, while we still note the importance of targeting recruitment of CHWs who have these traits, we also note that these positive traits can be developed through prior experience and through targeted training. The revised third paragraph further examines character traits such as flexibility and adaptability that are important to crisis workers but may specifically need to be bolstered before deployment to crisis settings because they may not be innate to a large portion of health workers working in non-crisis settings.

 

3. Rephrasing statements that can be perceived as broad-brush, not generalisable, or unsubstantiated.

We agree the examples cited by the reviewer would benefit from rewording. We have made the following revisions based on the reviewer’s comment:

Line 78: removed the word “unreasonably”

Line 99: removed the phrase “and nearly impossible”

Line 142: removed the phrase “relatively common”

Line 228 removed phrase “repeatedly”

Line 284: removed the word “repeatedly”