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Gehlert N, Nguyen Truong Q X. Psychosocial support for healthcare workers in Vietnam during the COVID-19 Pandemic . HPHR. 2021;53.10.54111/0001/AAA6
As a national health care system becomes overwhelmed, healthcare workers (HCWs) are challenged in unique ways. Healthcare workers have been found to experience heightened levels of anxiety, depression, stress, burnout, and suicidality, along with decreased attention to self-care. The present study reviews a health education and capacity-building workshop in Vietnam, which focused on teaching HCWs how to develop positive coping and self-care strategies.
The three-hour workshop was presented to 856 HCWs in August, 2021, and had learning objectives related emotional intelligence, burnout, compassion fatigue, PTSD, and practical tips for self-care. Participants were surveyed eight weeks after the workshop to measure their implementation of self-care practices. Participants provided numerous comments about the helpfulness of the self-care skills they learned.
Eighty-six percent of participants either agreed or strongly agreed with the statement, I have applied what I learned about self-care to my self-care routine.
Participants in the sample clearly reported that they were implementing self-care strategies; their comments strongly support that this practice was not only functional, but also meaningful. The workshop presentations specifically targeted the areas of building social support, developing positive coping styles and self-care, improving lifestyle habits, and focusing on service to community and meaning-making. The fact that the vast majority of participants reported using these skills in their work and professional lives is an important outcome.
The available evidence demonstrates that participants in the workshop have implemented new strategies in their self-care practices. International collaborators in other countries are encouraged to partner with in-country teams to market and organize similar programs, and to be prepared to address the ongoing needs of the communities they support.
Until the rise of the Delta variant, Vietnam was one of the few countries to successfully contain the spread of the COVID-19 pandemic. On July 6, 2021, Vietnam still reported fewer than 100 total coronavirus deaths.1 How did a low/middle-income country achieve such success?
First, for geopolitical reasons, the Vietnamese people and government are wary of the Chinese state. This apprehension is due to the history of severe acute respiratory syndrome (SARS-CoV-1) in 2003, the long border with China, and the rising political tension over the South China Sea.2 Second, and perhaps more importantly, Vietnam has a history of longstanding engagement with social security (i.e. public health) at the national, regional, and local levels.3 The centralized system consists of 63 provincial health departments, approximately 600 district departments, and more than 11,000 community health stations.3 When COVID-19 was first detected in Vietnam on January, 23, 2020, the government took immediate steps focused on closing international borders, isolating and quarantining infected and potentially infected patients, contract tracing, and providing care for the hospitalized.4
Despite the success of this response, the COVID-19 Delta variant effectively overwhelmed the social health care system in Vietnam. Just two months after surpassing 100 deaths, Vietnam reported over 14,000 deaths on September 8, 2021 and at the time of writing in November, 2021, deaths have surpassed 24,000. While the country’s prevention and control mechanisms were robust, the highly contagious Delta variant quickly led to increased rates of hospitalizations, primarily in district hospitals and community health stations, which are equipped to provide only basic medical care.4 Additionally, each of the provincial and national hospitals has fewer than 100 beds and there are limited infectious disease physicians in a country of 97 million people.4
As a national health care system becomes overwhelmed, healthcare workers (HCWs) are challenged in unique ways. While research data on the impacts of the pandemic on HCWs was not available in Vietnam, current evidence from other countries illustrates the acute psychosocial needs of healthcare workers, especially in periods of crisis. During the COVID-19 pandemic and past pandemics, healthcare workers have been found to experience heightened levels of anxiety, depression, stress, burnout, and suicidality, along with decreased attention to self-care. 4,5,6,7,8,9 HCWs in many countries face severe workforce and resource shortages, leading to increased stress. HCWs also can experience an increase in moral dilemmas as resources and care are rationed, which can result in moral injury when HCWs’ morals and ethics are challenged.10 Furthermore, working on the front lines of care brings increased personal risk. During the 2009 novel influenza (H1N1) pandemic and past outbreaks of SARS, HCWs were found to have higher risks of infection than the general population.
11
The impact of the COVID-19 pandemic on the psychosocial wellbeing of healthcare workers has been studied significantly in China, though also in Italy, the U.S., and Saudi Arabia. 12 Common researched mental health outcomes in HCWs include anxiety, depression, stress, insomnia, and psychological well-being. Psychological distress has been found to be higher among HCWs than other professions during the current pandemic.13,14 In studies in China, Italy, and Saudi Arabia, rates of mild to moderate anxiety ranged from 23.7% to 63.8%.15,16,17,18,19,20 In those same countries and studies, rates of depression among HCWs varied from 12.2% to 55.2%. In Croatia, China, and Italy, and Saudi Arabia, rates of mild to severe stress ranged from 39.4% to 55.1%.15,17, 21,22,23,24 In studies on insomnia, rates were found to range between 14.3% and 38.4%.20,25
The effectiveness of various coping strategies for HCWs has also been studied during the COVID-19 pandemic. Strong social support has been found to have positive impacts for HCWs in studies conducted in China, Croatia, and Italy.21,22,21,26,27,28 Specifically, symptoms such as stress and anxiety were found to be negatively associated with social support and active coping. During a pandemic, HCWs often struggle with lack of self-efficacy because they lose a sense of control over their professional and personal lives. In studies in China, positive action through learning and implementing positive coping mechanisms were found to have a negative association with anxiety, depression, and post-traumatic stress syndrome.15,25,28
The authors of these studies make clear recommendations about supporting the psychosocial health of HCWs during the pandemic. First, tending to the social support of HCWs is fundamental.21,22,26,27,28 Second, it is important to train HCWs on developing positive coping styles and workplaces should provide psychological support.15,25, 28 Third, HCWs should develop healthy lifestyle habits in the areas of nutrition, exercise, and sleep hygiene.29 Finally, service to community, meaning-making, and religious coping can benefit HCWs.30
In the present study, we discuss a health education and capacity-building workshop in Vietnam. The aim of the workshop was to address the aforementioned recommendations and provide support for the psychosocial health of HCWs in Vietnam. Specifically, we focused on teaching HCWs how to develop positive coping and self-care strategies. The need for psychosocial support for HCWs is particularly important in Vietnam because psychology and social work are new fields in Vietnam, access to mental health services are limited, and stigma about mental illness is prevalent.31,32
In August, 2021, by analyzing available infection and death data and communicating with leaders at major hospitals in urban centers, we predicted that hospitalization rates would exceed capacity across Vietnam by mid-September. This event would not only be a significant stressor on the Vietnamese healthcare system, but also on the HCWs in the system.
We developed a three-hour online workshop entitled Psychosocial Support for Healthcare Professionals and partnered with the Vietnam National Palliative Health Care Association and Hanoi National University of Education, Faculty of Social Work, who promoted the workshop and organized the registration and presentation logistics.
The workshop was presented on August 31 as part of a one-week workshop series to coincide with the period when hospitals would begin exceeding capacity in Vietnam. The workshop was advertised on social media, through local and national professional organizations, and with social work and psychology faculty at other universities. The workshop was free to attend and presented via Zoom, and livestreamed on Facebook, from 7:30am – 10:30am Indochina Time. It was presented by a native English speaker with a native Vietnamese interpreter.
The curriculum of the workshop focused on the following learning objectives and themes.
Attendance at the workshop on Zoom was 856 participants. Additionally, 80 viewers watched the presentation on Facebook. Eight weeks after the workshop, a brief anonymous survey (no identifying information was collected) was sent to all registered workshop participants soliciting their feedback about the impact of the workshop on their professional work and positive coping and self-care habits. The sample of respondents included 125 participants, out of which 39 participants identified as non-HCWs (e.g. students, teachers, business workers). Because they were not representative of the target audience, these 39 individuals were excluded from further analysis.
The final sample of 84 participants consisted of psychologists (n = 38), social workers (n = 21), medical doctors (n = 10), other medical staff (n = 6), monks (a role akin to chaplain in the U.S.; n = 6), and nurses (n = 4). On the survey, participants were asked to respond to a Likert-type item related to the application of the learning objectives from the workshop. The response choices on both items ranged from Strongly Disagree (1) to Strongly Agree (5) on a five-point scale. As can be seen in Table 1, 86% of participants either agreed or strongly agreed with the statement, I have applied what I learned about self-care to my self-care routine.
Finally, participants were invited to provide open-ended feedback. Nearly every participant provided a comment and a selection of representative comments are provided here.
Table 1: Applying New Self-care Strategies | |||||
| Strongly Disagree 1 | Disagree 2 | Neutral 3 | Agree 4 | Strongly Agree 5 |
Self-carea (n=84) | 0% | 1.2% | 10.5% | 39.5% | 46.5% |
aI have applied what I learned about self-care to my self-care routine. | |||||
In the midst of a pandemic, educational and capacity-building programs need to be developed rapidly to meet the critical needs of HCWs. This workshop was no exception. Despite these factors, participants in the sample clearly reported that they were implementing self-care strategies; their comments strongly support that this practice was not only functional, but also meaningful. The workshop presentations specifically targeted the areas of building social support, developing positive coping styles and self-care, improving lifestyle habits, and focusing on service to community and meaning-making. The fact that the vast majority of participants reported using these skills in their work and professional lives is an important outcome. Importantly, our sample included a diversity of professions and a relatively small percent of doctors (11.6%) and nurses (4.7%), whereas most studies during the pandemic have focus primarily on these professions.33
There are important programmatic lessons learned from this workshop. First, we already had strong in-country connections that facilitated networking about the program and developing a curriculum that was sensitive to cultural differences. Second, dedicated in-country promotion and logistics support was essential in capturing a large audience. Third, in a time of crisis when many are under shelter-in-place orders, the online learning format worked well for reaching a sizeable and diverse audience. Fourth, we were not prepared for the outpouring of follow-up support that was requested by workshop participants. In the allotted presentation time we could not effectively respond to the large number of questions, case examples, and stories of trauma. We did develop an extensive packet of resources that were sent to participant. Furthermore, at the time of writing, we are developing a train-the-trainer programs to further support the needs of HCWs in Vietnam.
Regarding limitations to the present study, the COVID-19 pandemic has necessitated the rapid deployment of educational and capacity building programs and researchers have quickly published studies of low methodologic quality.34 The present study relied on data collected as part of routine workshop follow-up. Despite clear positive outcomes, our measures and analyses were simple. The use of pre- and post-testing with robust mental health outcome measures would have improved the quality of our results. Given the lack of a pre-test, we cannot know if the impact of the training was better than other educational materials and tools. Furthermore, we cannot demonstrate if the training actually increased the skills and knowledge of participants. Finally, despite the fact that the sample included a broader range of professions, there is still need for research on the impact of the pandemic on others involved in supporting patient care such as nutritionists, laboratory workers, and janitorial services.31
The COVID-19 pandemic has significantly strained the health care system in Vietnam and created many stressors for HCWs. Though not robust, the available evidence demonstrates that participants in the workshop have implemented new strategies in their self-care practices. International collaborators in other countries are encouraged to partner with in-country teams to market and organize similar programs, and to be prepared to address the ongoing needs of the communities they support. Such initiatives would also present the opportunity to address and investigate the limitations that accompany our findings.
The authors wish to acknowledge the support of the Vietnam National Palliative Health Care Association and the Faculty of Social Work, Hanoi National University of Education, in organizing the workshop series discussed in this paper.
The authors have no relevant financial disclosures or conflicts of interest.
Nathan C. Gehlert, Ph.D., is a licensed professional counselor and Associate Professor and Chairperson of the Department of Counseling at John Carroll University. He is also a Fulbright U.S. Scholar at the University of Social Sciences and Humanities, Ho Chi Minh City. His research interests include motivational interviewing, multicultural counseling, and the psychology of religion and spirituality.
Quynh Xuan Nguyen Truong is a public health Ph.D. candidate at Chulalongkorn University and a Fulbright Scholar and master’s student in School of Social Work at Boston College. Her practice areas include clinical and palliative care social work. Her research focuses on palliative care and public health policy and management. She is also a committee member of Vietnam National Palliative Health Care Association and a senior social work consultant for University Medical Center of Ho Chi Minh City.
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