Impact Of Conflict On The Psychological Wellbeing Of Health Workers In Liberia
By Joy Turyahabwa1, Ojiambo Ochieng R2, Were-Ogutte J2, Gayflor V3, Howard Diawara L4, Eugene Kinyanda5
1Department of Human Resource, Makerere University Business School, Kampala, Uganda.
2Isis-Women’s International Cross Cultural Exchange (Isis-WICCE), Uganda.
3Ministry of Gender and Development of Liberia.
4Women in Peacebuilding Network (WIPNET/WANEP).
5MRC/UVRI Uganda Research Unit on AIDS.
Background: The 14 year Liberian civil war did not spare the health system including the psychological wellbeing of health workers. The extent to which the Liberian civil conflict did impact on the psychological wellbeing of the health worker is not known. The objective of this study was to examine the war trauma experiences and psychological wellbeing of 50 Liberian health workers who participated in Isis-WICCE pre medical intervention training conducted in 2009.
Methodology: Fifty health workers who were being trained to participate in a Isis-WICCE emergency medical intervention in post-conflict Liberia were assessed for their war trauma experiences and psychological problems
using structured assessment tools.
Results: The most reported torture experiences included: loss of close relative as a result of war (68.0%), suffering beating/kicking (52.0%) and loss of property/ livestock through destruction and looting (84.0%). Psychological problems reported included: major depressive disorder (26.0%), PTSD (14.0%), alcohol dependency (8.2%) and 12-month attempted suicide (2.0%).
Conclusion: Health workers assessed in this study suffered significant war trauma leading to psychological problems. The Ministry of Health and Social Welfare (MHSW) of Liberia should include psychological rehabilitation of the workforce in its human resource development plans in order to realize the workforce’s full potential.
AJTS JUNE 2011 2(1): 02-09
The 14 year Liberian civil war from 1989-2003 did not only affect the population, it also severely affected the health system including the health workers (Ministry of Health and Social Welfare, 2007). This war led to disruption of health services: with health workers forced to flee into IDPs or to go to neighboring countries; health facilities were looted and vandalized; medical supplies becoming unavailable; and eventually government funding to the sector stopped leading to the total collapse of the country’s health service (Ministry of Health and Social Welfare, 2007).
To rebuild this shattered health system, the Liberian Health Policy and Plan recognizes that developing a trained, educated and skillful workforce is a critical foundation for a quality health service (Ministry of Health and Social Welfare, 2007). What the Liberian Health Policy and Plan are silent about is the need for the psychological rehabilitation of this war traumatized health workforce in order to realize it’s full potential.
Department of Human Resource, Makerere University
Business School, Kampala, Uganda.
Previous Isis-WICCE studies and/or interventions in both Uganda and Sudan have documented gross war torture experiences among health workers (Isis-WICCE, 2009). Sadly, in most conflict and post-conflict societies in Africa, the psychological wellbeing of the health workers is often never addressed or even mentioned. Health workers living and working in conflict and the post-conflict situations in Africa do so under extreme working conditions, are disadvantaged in terms of training opportunities and promotion, and are often left to deal with their traumas alone with many adopting maladaptive coping strategies including abuse of alcohol and other substances, absenteeism and in the extreme, engaging in suicidal behaviour all of which impair their ability to deliver health care to the population (Isis-WICCE, 2009).
Health workers living and working in conflict and postconflict settings may develop psychological problems as a result of three possible mechanisms: firstly, as a direct effect of war on the psychological wellbeing of the health workers; secondly, through their role as care givers (secondary trauma, vicarious traumatisation, burn out); and thirdly, through the poor working conditions in conflict/post-conflict situations.
Direct effect of war on the psychological wellbeing of the health workers
Health workers who have gone through such experiences develop the typical psychiatric syndromes associated with war trauma namely major depressive disorder, PTSD, alcoholism and suicidal behavior. These psychiatric syndromes do not only cause psychological distress in the health workers, they also interfere with their ability to help others.
This is well illustrated by the results from the study by Leibling-Kalifani and Baker (2010) who observed that health workers from war affected Kitgum district hospital reported that listening to patient’s traumatic experiences re-activated the health workers own traumatic experiences.
Secondary trauma, vicarious traumatisation and burn out
Working with clients who have suffered significant war trauma has been known to significantly affect the therapist’s physical, psychological, emotional and/ or spiritual wellbeing (Ingeborg, 2005; Pearlman & Saakvitne, 1995; Ajdukovic and Ajdukovic, 1998; Franciskovic et al, 1998). Three concepts have been used to describe this phenomena: these are ‘compassion fatigue’ (secondary traumatic stress), ‘vicarious traumatization’ and ‘burnout’ (Ingeborg, 2005; Pearlman & Saakvitne, 1995; Ajdukovic and Ajdukovic, 1998; Franciskovic et al, 1998).
‘Compassion fatigue’ describes the reduced capacity or interest in being empathic with subsequent behaviors and heightened uncomfortable emotions, resulting from knowing about a traumatic event experienced by a person (Ingeborg, 2005). ‘Vicarious traumatization’ refers to the acquisition of trauma responses due to close association with traumatized individuals (Pearlman & Saakvitne, 1995). ‘Burnout’ describes a process whereby trauma therapists are increasingly incapable of dealing with stress as result of feeling unable to meet the demands of work, their motivation in fulfilling their tasks declines, and in the end they suffer a state of exhaustion which can often last a very long time. A central factor in burnout is a sense of being unable to meet the demands of work (Ingeborg, 2005). Signs of burnout include: increased vigour in pursuing work objectives (initial sign); later followed by exhaustion, reduced work commitment, emotional reactions including assigning blame, diminishment, flattening, psychosomatic reactions and despair (Ingeborg, 2005).
Poor working conditions leading to psychological distress
Given the nature of war, health infrastructure very often suffers destruction, neglect and underfunding. Health workers operating in conflict and post-conflict situations therefore have to do with very difficult working situations which may lead to psychological distress. Leibling-Kalifani and Baker (2010) hospital had this to say:
50 health workers who were being trained from 21st-27th May 2009 to participate in a Isis-WICCE emergency medical intervention in post-conflict Liberia were assessed for their war trauma experiences and psychological problems. Prior to this assessment the objectives of the study were explained to the health workers and only those who consented to participate in the study were interviewed (100% consented, the health workers welcomed the idea to discuss for the first time their personal war experiences). This study as part of the bigger Isis-WICCE medical intervention obtained science and ethical approval from the Liberian Ministry of Health and Social Welfare. Health workers who were found in need of psychological and psychiatric help were treated by mental health specialists who were part of the training team.
A structured questionnaires was self-administered to the respondents. It assessed for the following:
Socio-demographic characteristics: sex, age, religion, tribe, county and marital status.
Work related factors: post in hospital/health centre where working, duration of working in this health facility, monthly salary and whether this salary was sufficient to meet basic needs.
War torture experiences: Whether they had lost a close relative due to war, and ever suffered physical and psychological torture (Musisi et al, 2000).
Perpetrators of war torture: Using a structured proforma. Various domains of psychological distress were assessed, namely:
a) General health: Assessed by asking the respondents to rate their general health on a 1-5 scale, with one being the best and 5 the worst rating,
b) Major depressive disorder (MDD): This was assessed using the 15-item Hopkins Symptom Checklist (HSCL- 25; Derogatis et al, 1974) where a cut-off point of 31 (previously calibrated by Kinyanda et al, 2009) was taken as indicative of probable MDD.
c) Post Traumatic Stress Disorder (PTSD): This was assessed using the Harvard Trauma Questionnaire (HTQ; Mollica et al, 2001) where a score of 28 and above was taken as indicative of probable PTSD.
d) Problem drinking of alcohol: This was assessed using the C.A.G.E (Ewing, 1984) with probable problem drinking taken as having any two positive items on this scale.
e) Attempted suicide: This was assessed by means of two questions: ‘have you ever attempted to take your life? (by ingesting poison, hanging, taking a drug overdose, drowning, shooting) in the previous 12 months; and in your life-time?
Impairment of physical function: Assessed by a structured proforma.
Data was entered into the computer and analyzed using the statistical package SPSS. Frequencies were generated and presented using tables.
Table 1, fifty (50) health workers of whom 28% were female got interviewed for this study. Most came from the counties of Maryland (40.0%) and GrandKru (54.0%). Most worked in clinics (46.9%) and health centres (38.8%). On age, most respondents were in the 26-35 years (40.0%) and the +46 years (32.0%) age groups and on tribe, the majority (72.0%) belonged to the Grebo.
Table 2, on religion the majority (60.0%) belonged to the Christian ‘saved sect’ while on marital status, most (40.0%) were in monogamous married/cohabiting relationships. On highest educational attainment most health workers in this study had either a senior 5-6 level (40.0%) or a tertiary/university level (38.0%) educational attainment.
Table 3, on duration of work, most (70.0%) had been working at their job for more than 3years (+36 months). On salary, most respondents earned Liberian dollars, between 2001-5000 (44.0%) and 5001-15,000 (34.0%) with nearly all (96.0% ) of them reporting that the salary they were getting was not sufficient to meet their basic requirements.
Table 5, the most reported physical torture experiences included: beating/kicking (52.0%), deprivation of food/water (48.0%) and forced hard labour (42.0%) all reported more by males than females. The most reported psychological methods of war torture included: loss of property/livestock through destruction and looting (84.0%), detention by the army (68.0%), and forced to sleep in the bush/swamps (70.0%). All these psychological methods of torture were reported by both females and males in equal proportions.
Table 7, on physical wellbeing and psychological health, most respondents (72.0%) reported that their health was good to very good with more females (85.7%) than males (66.7%) reporting this. On psychological problems, 26.0% had scores suggestive of depression more among females (28.6%) than males (25.0%), while 14.0% of respondents had scores suggestive of PTSD significantly more among females (21.4%) than males (11.1%). Other psychological problems reported mainly among males were alcohol dependency (8.2%) and attempted suicide (2.0%).
Like has previously been reported in conflict and post-conflict settings in Africa and elsewhere in the world (Isis-WICCE, 2009; Ajdukovic and Ajdukovic, 1998; Franciskovic et al, 1998), Liberian health workers who were assessed in this study reported that they had suffered various forms of war torture. The war torture experiences included both physical and psychological torture experiences. The main perpetrators of these abuses on the health workers were the main protagonists of the Liberian civil war, (the rebels and government soldiers). These war tortures left psychological scars on these health workers as reflected by those who had depression, PTSD, alcohol dependency and attempted suicide as has been observed elsewhere in the world (Ingeborg, 2005; Pearlman & Saakvitne, 1995; Ajdukovic and Ajdukovic, 1998; Franciskovic et al, 1998). These psychological scars were in 16% of cases impairing the professional functioning of the health workers.
Work related factors could also be imputed to affect the psychological wellbeing of the health workers as only 4% of the health workers reported getting a salary that would satisfy their basic living requirements.
For recommendations, the Ministry of Health and Social Welfare (MHSW) of Liberia should include psychological rehabilitation of the health and other workforce in its human resource development plans in order to realize the workforce’s full potential. Secondly, the MHSW should work towards providing health workers with a living wage to reduce psychological distress associated with the daily struggle of making ends meet. Thirdly, there is need for bigger studies in order to be able to generalize research findings from this study to the wider body of health workers in Liberia.
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