By Reana Thomas, Hannah Webster, Stephanie Perlson, and Joy Cunningham

Stress. Anxiety. Depression. Numbness. Health providers who provide gender-based violence (GBV) services who may themselves be survivors of violence, often endure significant mental and physical health effects from their work, such as stress and trauma. The COVID-19 pandemic has only exacerbated these effects.

The World Health Organization (WHO) defines mental health as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community.” When health providers are not well themselves, they are less likely to effectively help others.ⁱ Addressing the mental health of health providers as they provide GBV services to survivors requires approaches that strengthen the mental health wellness and resiliency of both individuals and their communities.

This blog provides an overview of the mental health effects of care work and GBV service provision on health providers, approaches to support self-care and improved health systems, and policy recommendations for the future.

Firsthand account from Žene sa Une (ZSU), a women’s organization in Bosnia and Herzegovina:

“We believe we’re living through a time in the world where both large and smaller scale-events are having significant impacts on those who choose to work on the front lines of response to social crises. During the COVID-19 pandemic, rates of domestic violence have spiraled, which has impacted women in particular, and there continues to be a growing population of asylum seekers and refugees on the move, looking for a place to call home. Their stories are always distressing and harrowing, and ongoing as they journey from place to place, often encountering continued violence along the way. The caring professionals who support these people hear these stories on a daily basis, and for many, it’s not easy to simply switch off at the end of the day, nor do they understand the cumulative effect and impact it has on them.”

The Effects of Compounded Stress on Health Providers Who Provide GBV Services

GBV prevention and response can be fulfilling work, helping to foster safety and justice among survivors. But this work can also harm health providers if organizational and societal structures fail to provide personal and community support. In a 2018 study in Barcelona, Spain, health providers addressing GBV survivors’ needs cited an inability to disconnect from work, lack of supervisory support, and overwork as common stressors.ⁱⁱ The stress resulted in physical and psychological effects, such as anxiety, depression, and feelings of burnout.

The risk of health provider burnout is greater in many low- and middle-income countries, which often have a smaller health workforce and limited access to mental health services. Health and frontline workers in these contexts are predominantly women and usually fall at the bottom of health system hierarchies. This lack of autonomy can lead to additional stress and poor mental health outcomes for these workers.ⁱⁱⁱ

Why do health providers suffer these mental and physical health effects? Research literature, an Interagency Gender Working Group (IGWG)  GBV Task Force event and the GBV Area of Responsibility (AoR) have identified the following factors:

• If health providers are survivors of GBV or intimate partner violence (IPV), they may relive their own painful and traumatic experiences in their work.
• Some health providers report they have not been trained to cope with the trauma of their clients.
• Health providers may feel that they are unable to meet their own high expectations in helping their clients.
• Health providers may face tension with family and friends because of work stress they carry home, or stress from their home may seep into their work.
• Health providers may experience vicarious or secondary trauma, wherein they begin to identify with their clients’ traumatic experiences.
• Health providers may be frustrated with local and national laws that do not support their clients’ clinical needs.
• Health providers may not have adequate supervisory support, and their supervisors may also experience negative mental and physical health effects from their work.

Why Is the Mental Health of Health Providers So Important?

The COVID-19 pandemic has exacerbated the stress that many health providers experience. Health providers in places with chronically under-resourced health systems feel the biggest strains.^iv A meta-analysis of 65 studies covering 97,333 health care workers in 21 countries identified a high prevalence of moderate depression (21.7%), anxiety (22.1%), and post-traumatic stress disorder (PTSD) (21.5%) during the COVID-19 pandemic.^v Women, who make up the majority of health providers, took on more unpaid care work at home in addition to their employed work.

As health providers near the two-year mark of working under the stressful conditions introduced by the pandemic, they face a higher risk of burnout. Burnout negatively affects health providers as well as their clients, and can also induce emotional exhaustion, cynicism, depersonalization (or a distancing from clients), and reductions in personal achievement.^vi A 2020 study that asked Lebanese, Syrian, and Palestinian women about barriers to seeking GBV-related psychosocial support services noted a lack of qualified practitioners and previous mistreatment or negative experiences with health service providers as primary barriers.^vii To maintain quality health services and address the needs of GBV survivors, health providers need continuous support, including self-care and regular training to build and maintain skills, confidence, and empathy in caring for others.

How Can Individuals, Facilities, and Policy Systems Support Wellness for Health Providers?

Individuals: While self-care is essential for all health providers, the emotional toll of GBV prevention and response work makes it even more critical for these practitioners. Self-care can be practiced individually—through awareness, balance, and connection (ABCs)—to create feelings of rest, recovery, and stability. Through awareness, the health provider is attuned to their needs, limits, emotions, and resources. Through balance, the health provider finds stability between work, family, life, rest, and leisure. Through connection, the health provider establishes and maintains positive relationships with coworkers, friends, and family to elicit support and avoid isolation. Practices that allow health providers to reach the self-care ABCs include mindfulness, connections to spirituality, exercise, education, and counseling.^{viii, ix}

Firsthand account from ZSU:

“We see staff wellness and ‘care for the carer’ programs like ours as vital in terms of educating and disseminating information about secondary stress and its impact, as well as clear and practical resources on how to manage.

For example, during a recent training session, ZSU staff learned (and then practiced through role plays) a few shifts in body posturing which would protect themselves a little bit from the overwhelm of particular stories. The body posturing shifts (such as changes in eye movement, softening one’s gaze, swiveling one’s body slightly to the right or left, planting one’s feet firm in the ground to feel contact with the floor) would be used to create small boundaries between their emotional supply and demands.

We are trying to help the participants realize that they can be both very empathic and supportive towards those they support while, at the same time, bring self-compassion and care to themselves.”

Individuals should use skills outlined in reputable resources, such as this illustrative stress-management guide from the WHO that provides theoretical and practical strategies for coping with adversity based on five actions: grounding oneself in beliefs and priorities, unhooking or releasing from stressors and tasks, acting on one’s values, being kind to oneself, and making room for reflection and joy.^x Organizations can also use these principles when developing plans to promote well-being for health providers who provide GBV services.

Firsthand account from ZSU:

“We aim to build an ongoing structure for awareness and implementation of self-care practices across the organization. We will create a working group from across the different sectors/functions of the organization (safe house, center for children and families, field work/projects, etc.) to identify needs and develop approaches and policies/protocols which can cover different challenges across the organization.”

Health facilities/systems:  To support individual efforts at well-being, organizations must also shift their operations to prevent mental and physical strain on health providers supporting GBV survivors’ health needs. Studies have found that domestic violence advocates working in health care settings who received more support from colleagues and quality clinical supervision were less likely to suffer from job-related stress.^xi The same study also reported that respect for diversity, mutuality, and consensual decision-making can lead to healthier workplace environments for health providers.^xii The following strategies from the literature, an IGWG GBV Task Force event, and the GBV AoR can be used by organizations to support the mental health of health providers who work with GBV survivors:

• Involve women and GBV survivors in decision-making, and ensure they hold key decision-making positions.
• Ensure health providers can offer input on clinical and program policies that affect them and their ability to work.
• Allow flexibility with scheduling and provide adequate time off.
• Create supportive structures for employee child care for health providers.
• Mix caseloads for providers, allowing them to serve clients with and without trauma-related concerns, if possible.
• Strengthen relationships between supervisors and providers, and provide resources and support for high-quality supervision. 
• Communicate organizational decisions clearly, particularly in response to women’s and GBV survivors’ concerns and ideas.
• Flatten the hierarchy by sharing power between leadership and staff. Rotate roles within the organization; staff who provide counseling for clients can rotate into administrative roles to mitigate the emotional toll.
• Provide monthly professional and social support groups to address feelings of isolation and allow space to share experiences.
• Treat staff to short-term mood boosters such as free snacks, additional time off, and group activities, such as outings or retreats, to relieve stress and promote a culture of well-being.^xiii
• Provide supplies for staff to properly fulfill their role supporting GBV survivors while protecting their own health, such as menstrual health products, personal protective equipment (such as masks for COVID-19), and post-rape kits.
• Provide and require mental health sensitization and trainings for staff, especially managers and leadership.
• Take an intersectional approach to wellness provision so that systemic inequalities are recognized and addressed. For example, if health providers are experiencing poverty or housing instability, ensure support structures or networks are in place for those who may need access to anti-poverty or housing resources.
• Ensure the professionalization of health providers through providing livable wages, benefits, and retirement options.

Additional Resources for Individuals:

• Domestic Violence & Mental Health Collaboration Project: Mindfulness Resources (see an example of a pilot program from 2016)
• Self-Help Plus (from the WHO)
• Psychological Coping During Disease Outbreak: Healthcare Professionals and First Responders
• Basic Psychosocial Skills: Training for COVID-19 Responders

Additional Resources for Health Facilities:

• Preventing, Recognizing & Addressing Vicarious Trauma (EQUIP Health Care)
• Principles of Trauma- and Violence-Informed Care (TVIC) (EQUIP Health Care)
• Trauma- & Violence-Informed Care (TVIC)—A Tool for Health & Social Service Organizations & Providers (EQUIP Health Care)
• Trauma Toolkit/Organizational Self Assessment (Manitoba Trauma Information and Education Centre)
• The Sanctuary Model (Sanctuary Institute)
• Workplace Strategies for Mental Health: Trauma in Organizations (Canada Life)
• Securing the Safety and Wellbeing of Women Frontline Healthcare Workers in the COVID-19 Response (GBV AoR Help Desk)

Firsthand account from ZSU:

“The negative impact of these roles grows slowly but exponentially, and it is not easy to recognize on a day-to-day basis. Therefore, both preventative work and ongoing attention to the stresses staff are living with is vitally important, and it builds better contact, better communication, and more enhanced confidence in the organization. By showing concern and care for their staff, the organization, in turn, models the care and concern that staff will show to their beneficiaries and the people they support (a positive down drift).

Additionally, staff who carry a lot of secondary stress (and don’t address its impact) can experience fatigue and burnout, which has significant costs to the organizations (time out of work, staff turnover, loss of organizational experience and knowledge, etc.). An investment in staff care can be pivotal in maintaining and growing an organization’s capability and capacity to deliver its objectives.”

Policy Systems: Holding decisionmakers accountable and better equipping health providers to do their work and provide GBV services will require advocacy for comprehensive policies that fund mental health services.  Organizations, facilities, and government ministries, especially health and finance, must improve GBV mitigation policies, programming, and structures so that: (1) health providers have the resources, capacity, and supervisory support they need to do their jobs, and (2) health facilities can rely on sound policies to support health providers to provide GBV services. District- and national-level initiatives include providing fair pay for workers, supporting adequate staffing in health care systems, and promoting social media campaigns destigmatizing mental health. Other strategies include engaging health providers in co-creating new policies and building national databases for resiliency resources.^xiv

GBV advocates suggest that “post-pandemic planning and recovery cannot simply ‘return to normal’ but must involve a fundamental reimagination of how GBV work is supported and connected to other large systems in ways that ensure an intersectional, systemic approach”.^xv Sustainable solutions to promote the mental health and well-being of health providers working in GBV prevention and response services must be developed and implemented at the individual, organizational, and policy levels. More attention must be given to the people who take care of our communities and work toward a future without violence.

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Many other helpful resources exist to address GBV and support survivors and health providers during the COVID-19 pandemic beyond those provided here. Please let us know how you are using these resources and/or other resources you’ve found helpful. Please share your insights by writing to the GBV Task Force.

This document is made possible by the generous support of USAID under cooperative agreement AID-AA-A-16-00002. The information provided in this document is the responsibility of Population Reference Bureau, is not official U.S. government information, and does not necessarily reflect the views or positions of USAID or the U.S Government.

©2021 PRB. All rights reserved.

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References

ⁱ Lene E. Søvold et al., “Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority,” Frontiers in Public Health 9 (2021): 679397, https://doi.org/10.3389/fpubh.2021.679397. 

ⁱⁱ Alicia Pérez-Tarrés, Leonor M. Cantera, and Joilson Pereira, “Health and Selfcare of Professionals Working Against Gender-Based Violence: An Analysis Based on the Grounded Theory,” Salud Mental 41, no. 5 (2018): 213-222, http://doi.org/10.17711/SM.0185-3325.2018.032.

ⁱⁱⁱ Lene E. Søvold et al., “Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority.”

^iv Moitra M et al., “Mental HealthConsequences for HealthcareWorkers During the COVID-19Pandemic: A Scoping Review to DrawLessons for LMICs,” Frontiers in Psychiatry 12 (2021): 602614, https://doi.org/10.3389/fpsyt.2021.602614.

^v Yufei Li et al., “Prevalence of Depression, Anxiety, and Posttraumatic Stress Disorder in Health Care Workers During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis,” PLoS ONE  16 (2021): e0246454, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246454.

^vi Davy Deng and John A. Naslund, “Psychological Impact of COVID-19 Pandemic on Frontline Health Workers in Low- and Middle-Income Countries,” Harvard Public Health Review 28 (2020), https://pubmed.ncbi.nlm.nih.gov/33409499/.

^vii Rassil Barada et al., “‘I Go Up to the Edge of the Valley, and I talk to God’: Using Mixed Methods to Understand the Relationship Between Gender-Based Violence and Mental Health Among Lebanese and Syrian Refugee Women Engaged in Psychosocial Programming,” International Journal of Environmental Research and Public Health 18, no. 9 (2021): 4500, https://doi.org/10.3390/ijerph18094500.

^viii Jennifer Null, ABC’s of Compassion Resilience, Tanger Place, https://tanagerplace.org/wp-content/uploads/2018/05/ABCs-of-Compassion-Resilience-symposium.pdf.

^ix Laura Guay, “Self Care: Awareness-Balance-Connection,” Tribal Youth Resource Center, Feb. 20, 2020, https://www.tribalyouth.org/self-care-awarness-balance-connection/.

^x World Health Organization (WHO). Doing What Matters in Times of Stress: An Illustrated Guide (Geneva: WHO, 2020), https://www.who.int/publications-detail-redirect/9789240003927.

^xi Suzanne M. Slattery and Lisa A. Goodman, “Secondary Traumatic Stress Among Domestic Violence Advocates: Workplace Risk and Protective Factors,” Violence Against Women 15, no. 11 (2009): 1358-1379, https://doi.org/10.1177%2F1077801209347469.

^xii Suzanne M. Slattery and Lisa A. Goodman, “Secondary Traumatic Stress Among Domestic Violence Advocates: Workplace Risk and Protective Factors.”

^xiii Lene E. Søvold et al., “Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority.”

^xiv Lene E. Søvold et al., “Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority.”

^xv AnnaLise Trudell and Erin Whitmore, Pandemic Meets Pandemic: Understanding the Impacts of COVID-19 on Gender-Based Violence Services and Survivors in Canada (Ottawa and London, ON: Ending Violence Association of Canada and Anova, 2020), https://endingviolencecanada.org/wp-content/uploads/2020/08/FINAL.pdf.