1 INTRODUCTION

As the world seeks to comprehend the Coronavirus 2019 disease (COVID-19) pandemic and its impacts on human society, there is a need to understand the ways in which the disease has shaped (or reshaped or is reshaping) healthcare [1]. With limited information about the disease, doctors and nurses around the world have had to try and manage COVID-19 symptoms and treat the sick, all the while promoting public health measures to impede the spread of the disease and protect the larger populus [2, 3]. As the front line of defense in the event of any health crisis, healthcare workers across the world have had to deal with a series of obstacles and challenges as they put their health (and oftentimes, the health of their families) at risk for the wellbeing of society [3-5]. While no story is objectively more important than another, the stories of healthcare workers come with a sense of urgency to act because they are the first human line of defense against a disease and so should they fall, the risk against the collective health of the society increases [6, 7].

Koontalay et al. [8] completed a meta-analysis of 10 qualitative studies focusing on the psychological and emotional impacts of COVID-19 on healthcare providers. They looked at studies published in China, the United States, the United Kingdom, South Korea, Brazil, Iran and Lebanon, where four emergent themes became apparent: healthcare providers across the world were dealing with (1) inadequate preparedness, (2) emotional challenges, (3) insufficient information and equipment, and (4) burnout [8]. Their discussion reveals that although the themes remain consistent across geographic scope, the root cause of each theme was different. In Lebanon, for example, psychological distress stemmed primarily from ‘conflicts that they encountered between their professional duties and their duties toward their families’ whereas in the United States and South Korea, the same feeling of psychological distress came from ‘the unpredictability of COVID-19’ [8]. This study demonstrates that even where there are similarities and synergies between findings, results cannot be generalized across borders. The healthcare workers in each country have their own stories to tell.

Ali et al. [1] demonstrate the learning that can be achieved from an in-depth place-specific qualitative study by interviewing 20 physicians in Pakistan on the impacts they faced during the COVID-19 pandemic. Through their study, we learned not only of the mental health challenges doctors faced but also of the important role that religion, biomedical science, rural versus urban landscapes and professional status played in how COVID-19 was perceived and acted upon. Ali et al. [1] were able to confirm the significance of, and call for, further ethnographic studies on dealings of frontline care providers with COVID-19 and the way these conversations can inform policy. Ali et al. (2021) emphasize the role of place in these conversations, centering Pakistan, specifically the Sindh province, in the story that they piece together, recognizing that healthcare workers in other places may hold different perspectives and influences.

Malawi is a low-income nation whose healthcare system faced challenges similar to many other African and South American countries whereby they had to contend with COVID-19, while managing ongoing epidemics and eclosions of transmissible diseases such as malaria which accounted for 34% of outpatient visits before 2020 [9]; cholera, due to only 60% of the population having access to proper sanitation facilities [10]; and HIV/AIDS where an estimated 10% of the entire population live with the virus at any given time [11]. In addition to transmissible diseases, healthcare workers also have to navigate the growing burden of chronic illnesses including cancers, diabetes and hypertension [12]. Malawi, for example, demonstrates the highest incidence rates of cervical cancer in Sub-Saharan Africa [13].

The aim of this research is to expand on existing COVID-19 literature and knowledge by looking at the impacts that COVID-19 has had on frontline healthcare workers in Malawi. Using qualitative methods, we question what it meant to be a healthcare worker in a low-income nation during a global pandemic, looking for and listening to the stories, concerns, fears, wishes and hopes of the healthcare workers on the frontlines of the fight against COVID-19 in Malawi. Specifically, we want to understand (1) the impact that COVID-19 had on healthcare workers in Malawi, (2) the influence of individual healthcare workers' worldviews on their work in the context of COVID-19, and (3) the unique circumstances and conditions faced by being a healthcare worker in a low-income nation. The findings of this study seek to inform further targeted exploration of policies, measures and systems necessary to ensure that healthcare workers feel supported and valued in their work, thereby strengthening healthcare in the advent of a new disease outbreak.

2 MATERIALS AND METHODS

Data were collected through semistructured in-depth interviews (n = 14) with healthcare workers from across Malawi between September and December 2021. A follow-up unstructured interview (n = 1) with hospital leadership was conducted in June 2022 to help contextualize and better interpret findings. This study is part of a larger, qualitative research project (n = 44) examining the COVID-19 pandemic in Malawi.

To meet the research objectives, we used a hermeneutic phenomenological approach to qualitative research where our data gathering process focused on the relationship between the healthcare workers and their lifeworld, based on Heidegger's understanding where ‘lifeworld referred to the idea that “individuals” realities are invariably influenced by the world in which they live' [14]. Hermeneutic phenomenology is built on the assumption that people are experts in their own lives and lived experiences, therefore allowing us to explore the worldviews that influenced how COVID-19 was perceived, received and handled (objectives 1 and 2), as well as the realities that they operated and lived within (objective 3). Bynum et al. [15] successfully demonstrate the importance of hermeneutic phenomenology in the context of health research.

Following cultural norms, recruitment was conducted via a referral process led by community leaders. In this case, we partnered with Soils, Food and Healthy Communities (SFHC), a research-centered non-profit organization based in Ekwendeni, Malawi, that acted as a community liaison. SFHC was tasked with identifying potential participants through their national networks and ensuring a diversity of perspectives based on occupation, location, gender and ethnicity wherever possible. A total of 14 participants were recruited for the semistructured interviews, 8 men and 6 women, from a wide variety of professions in healthcare: clinical officers, nurses, traditional healers, students, dentists, outreach officers and lab technicians. Eleven participants had either completed or were in the process of completing postsecondary education, while three did not complete secondary school. Majority of the participants identified as Tumbuka (n = 10), with the remainder identifying as Ngoni (n = 3) or ethnically mixed (n = 1). There was a diversity of socioeconomic statuses, with most of the respondents living in urban areas (n = 8). Eleven interviews were conducted in English and three in Chitumbuka. Given the scarcity of health professionals in Malawi, the locations where the participants came from will not be revealed to better protect their anonymity. While each participant brought forth unique points and perspectives, we stopped after the 14th interview because we noticed that many of the same ideas were being repeated and judged that we had reached theoretical saturation.

The interviews were conducted using an interview guide that was co-created by the authors and field tested for cultural compatibility by the lead researcher before being translated and implemented by a team of four experienced Malawian research assistants (three males, one female) who were recruited to carry out the semistructured interviews. The interview guide featured questions and probes that addressed themes on COVID-19 in Malawi including personal perspectives on the disease, and government and societal responses to COVID-19. Participants were asked questions surrounding their understanding of COVID-19; any feelings that the disease invoked; its impacts on their work and on their patients; their thoughts on the way their government handles the pandemic; vulnerable populations; and what could have been done better from their perspective.

Before participation, prospective participants were read a consent form describing the objectives of the study and asked to confirm their willingness to take part, and whether they could be audio-recorded for their interview to later be transcribed, and when applicable, translated to English. For the purposes of privacy, pseudonyms were used in the recordings and written text. Analysis was conducted through the ATLAS.ti software using the framework method [16]. Interview transcripts were evaluated for content, seeking emergent recurring themes through the words of the interviewees. An open code was applied to each paragraph describing what the lead researcher determined as important after each interview. Given the inductive nature of this research, the coding was impressionistic. Comparisons and contrasts were formed between the highlighted codes for the different interviewees, with re-coding as new themes emerged. From there, codes were thematically grouped to form a framework for evaluation. Initial interpretations were shared with SFHC for reflective feedback, and any gaps in knowledge, context and interpretation identified were addressed through an unstructured in-depth individual interview with the head of a hospital in Malawi (given that Malawi has few hospitals, the location will not be shared to ensure the anonymity of the interviewee). Final findings were sent to SFHC to inform their work and share with appropriate community and government partners.

To minimize the risk of the spread of COVID-19 throughout the data collection process, COVID-19 measures were implemented based on the most up-to-date guidelines offered by the World Health Organization, the Malawi Ministry of Health and Health Canada [17-19].

3 RESULTS

Traditionally, knowledge in many African cultures is transmitted through stories, including in Malawi. Reflective of these practices, this results section has been organized in the format of a singular cohesive story built from the collective experiences and anecdotes shared by the participants in this study. The story has been thematically sectioned off with subheadings to facilitate reading [20].

Please note that in this context, “looked at him” is meant in the literal sense. Hospital staff refused to interact with, diagnose and treat the patient. Instead, they just looked at him while saying and doing nothing.

This is built heavily on Malawi's communal culture where people and communities come together in times of hardship to provide help, support, and care to one another. There was a strong sense of solidarity built amongst healthcare workers that enabled them to better serve the communities that needed them.

4 DISCUSSION

The results of this study have allowed us to glimpse into what it was like to be a healthcare professional in Malawi during the first 2 years of the COVID-19 pandemic. Themes and subthemes that emerged from the data analysis process include the fear that COVID-19 invoked, the impacts it had on the relationship between healthcare workers and their communities, the importance of public health communication and the role of government in a pandemic response.

Through this study, we confirm the importance of worldview. As healthcare professionals, all of the participants interviewed for this study who worked in the hospital system held some form of tertiary education. We had thus assumed that they were likely to take a scientific approach to describing COVID-19 and its impacts; however, as was seen in a similar study conducted with doctors in the Sindh province of Pakistan [1], the healthcare workers in Malawi interpreted COVID-19 through both personal and sociocultural lenses. Rather than simply being seen as a virus or a disease, participants imbued COVID-19 with meaning. They spoke of the impact that the disease has had on their friends, families and communities; they shared their fears about catching the disease; and some even associated the disease with whiteness, believing the disease to move along racial lines. These results show that educated medical professionals are not exempt from being swayed by public discourse, general bias and misinformation through the (social) media, thereby calling attention to the importance of prioritizing immediate and direct discourse with healthcare professionals to circumvent these beliefs from influencing their work and the treatment of their patients.

Furthermore, our study incorporates informal healthcare systems (traditional medicine) where the education and mentorship that they receive to do their work is largely spiritual. In these instances, a cultural interpretation of disease becomes even more prevalent in the actions taken to treat the illness. Early government intervention is key in educating traditional healers on new disease outbreaks and giving them the tools that they need to ensure the wellbeing of the people who seek out their services. Traditional medicine is sometimes the main, and often the only, source of affordable medical care for many people in Malawi. National policies across the continent of Africa creating a formal relationship between governments and traditional healers are few and far between, but case studies in Ghana, Ethiopia and South Africa show the potential of what could be commonplace, and could provide avenues for knowledge sharing between different forms of knowledge production, and lead to better health outcomes in public health crises like a pandemic [21-24]. As demonstrated by our results, when given the opportunity, traditional healers can be champions for public health policies like vaccination and support their patients in knowing when to transition to using “mainstream” forms of healthcare.

This study also affirms the negative impacts that the COVID-19 pandemic had on the mental health of healthcare practitioners in Malawi. A literature review by Manchia et al. (2022) [25] revealed that in studies conducted across the world, healthcare workers as a whole faced a greater psychological burden from the COVID-19 pandemic than any other sector of society. Similar to what was revealed in our study, Manchia et al. (2022) [25] noticed a pattern where this burden stemmed from a variety of factors including fear of being infected by the virus and of infecting their family and others, working overtime hours in demanding work conditions, and witnessing the limitations of their country's healthcare system as it is pushed to the brink. In Malawi, however, mental health is not a part of mainstream discourse and thus is not well understood. A study by Kauye et al. [26] revealed a 0% diagnosis rate for anxiety and depression by primary healthcare workers in Malawi without specialized training. Nevertheless, in our research, the resulting conversation around fear revealed the mental health impacts of the COVID-19 pandemic on healthcare workers, including decreased performance and discomfort in the workplace, as well as a loss of communal coping mechanisms. Even traditional healers spoke of rejecting patients out of fear of catching the disease. These stories exemplify the need to build culturally appropriate mechanisms and systems of psychosocial support for healthcare workers, especially in the advent of a new disease, as there are very real consequences to patient care without these measures. This is especially important for healthcare worker retention and recruitment. When looking into why there is such a scarcity in healthcare professionals in Malawi, a 2014 study by Chimwaza et al. [27] found that 69% of the 84 people they interviewed “had experienced a demotivating incident in the previous three months that had made them seriously consider leaving their job”.

In addition to the mental health consequences stemming from a fear of COVID-19, our findings reveal the ways in which a new disease can harm community relationships in Malawi and the impact this can have on both the healthcare system and individual healthcare service providers. Following the politicization of COVID-19 was an uptick in violence against healthcare workers across the world. Cukier and Basky [28] write about escalating violence towards hospital staff in Canada during the pandemic, and Dyer [29] describes a surge of violence in the United States. In Malawi, our results show how a combination of government policy and misinformation put healthcare workers in danger, where they were either physically attacked for acting on COVID-19 measures or socially shunned because of their (perceived) proximity to the disease and death. Even more disappointing was the need for individual hospitals to initiate their own outreach with communities to assure the safety of their personnel, rather than a larger scale government/political endeavor. These attacks depict the need for reflection on the part of policymakers as to the ways their policies will be received, thereby recognizing the impact on those who carry out the policy, as well as the importance of empowering communities in the event of a pandemic to counter the sense of powerlessness that is all too often at the origin of violent acts.

We wanted to know what healthcare workers in Malawi felt that they needed to feel supported throughout the COVID-19 pandemic. The respondents spoke of the need for better resources and resource allocation, citing corruption and embezzlement being at the heart of the supply shortages they had. They talked about struggling to access adequate personal protective equipment, oxygen cylinders and furnished isolation wards, which not only made their jobs more difficult but more dangerous as well. There was the issue of risk pay which was resolved through a collective nation-wide strike at the height of the first wave of COVID-19, and the need for earlier public health communication to educate the general public. These requests are not uncommon in other parts of the world. Cox [7], in her commentary piece, argues that in seeing healthcare workers as heroes, we deprive them of their humanity, and thus the very real things they need to navigate this pandemic, including personal protective equipment and a ‘general public, who must play a role in supporting the healthcare system, “both during an epidemic and in times where there is no crisis”’. The onus now falls on decision-makers to hear these requests and build out reciprocal procedures that protect and celebrate healthcare workers, thereby strengthening the overall health of the community.

5 CONCLUSION

AUTHOR CONTRIBUTIONS

The authors confirm contribution to the paper as follows: Study conception: Chúk Odenigbo. Study design: Chúk Odenigbo and Eric Crighton. Data collection: Chúk Odenigbo. Analysis and interpretation of results: Chúk Odenigbo. Draft manuscript preparation: Chúk Odenigbo. Review of drafts: Eric Crighton. All authors reviewed the results and approved the final version of the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

This project received approval from the Research Ethics Board at the University of Ottawa in Canada (application number: S-03-21-6554) and the National Committee on Research in the Social Sciences and Humanities at the National Commission for Science and Technology in Malawi (reference number: NCST/RTT/2/6).

INFORMED CONSENT

All participants were presented with a consent form in their preferred language. Interviewers read the form outloud to participants and provided them with the opportunity to ask questions. Participants were aware that their participation was voluntary and that they were free to withdraw at any given time, without giving a reason and without cost. They were each given a signed copy to keep for their records with the contact information of both authors as well as the ethics board at the University of Ottawa.