Project description template:
Title
Connecting the dots: The intersection between frontline health workers experiences with Coronavirus Disease of 2019 and the Malawi Government’s response to the pandemic
Start/end of the project.
January, 2022 – December, 2024
Background for the project
The emergence of Corona Virus Disease 2019 (Covid-19) has not spared Malawi as a country. To date, over 670, 000 people had tested positive and over 88, 000 have died of the disease (Ministry of Health Malawi, 2023). Globally, over 575 Million people had contracted the Covid-19 virus and more than 6 million died of the disease (World Health Organization, 2022). The pandemic has created unprecedented losses and disruptions across the world. From developed to developing, no country has been spared from its brunt (Aneja and Ahuja, 2020:1). On the other hand, for the least developed countries, the pandemic has created numerous challenges, particularly for the health care systems and health workers. As Mehta et al (2021:227) indicate, “Low and Middle Income Countries (LMICs) saw an internal drain on human resources as health care workers were pulled from clinical practice to join Covid-19 committees and task forces”. At a personal level, Covid-19 has had serious ramifications among health workers. Mehta et al (2021) point out that health care workers have continued to provide care for patients despite exhaustion, personal risk of infection, fear of transmission to family members, illness or death of friends and colleagues, and the loss of many patients. Additionally, in Japan, hospitals have reported the occurrence of verbal abuse against both infected and non-infected health care personnel and their family members (Tagashira et al, 2020). Studies have also shown that health care workers were at risk of mental health problems as a result of the burden of caring for people with Covid-19 (Chorwe, 2021; Hiremath et al, 2020; and Liu et al, 2020). In his study amongst nurses in Malawi, Chorwe (2021) identified a prevalence of anxiety and functional impairment among the participants. Spoorthy (cited in Chen et al, 2021) confirms that this largescale public health challenge has caused fear and physio-psychological stress among nurses. Effects are particularly severe due to anxieties with the unknown future of the disease. Bennett et al (2020) also noted the emerging evidence of ‘long Covid-19’ as a key future challenge, a the persistence of Covid-type symptoms in infected persons over a long period of time.
Whilst health workers provide care and support to persons affected by the pandemic, services must be delivered in a responsive system that appreciates the enormity of the crisis. Even in ordinary times, Malawi faces a range of challenges to sustainably finance and efficiently manage the delivery of high-quality health services (USAID, 2016). It’s worth noting that, as a country, Malawi is characterized by a heavy burden of disease evidenced by high levels of child and adulthood mortality rates and high prevalence of diseases such as tuberculosis, malaria, HIV/AIDS and other tropical diseases (WHO, 2018). This is against a background of a weakened public health system as a result of the structural adjustment programs like in most African countries (Kalipeni, 2004; Sewpaul, 2021; Kamanga and Kasembeli, 2022). However, it is important to note that there has been a great deal of donor support towards mitigating the impact of the pandemic on the country. Nonetheless, it is critical to reflect on what Sewpaul (2020: 23-24) stated:
While global solidarity is critical to deal with the pernicious consequences of Covid-19, what is evident is that national self-sufficiencies, resources, capacities and ethical leadership constitute quintessential criteria that determine how nation states engage in preventing the spread of the virus, and in mitigating its effects.
This study therefore, focuses on Malawi’s response to the pandemic and its implications in the experiences of health workers caring for persons with Covid -19. It seeks to develop deeper insights into the country’s responses from the perspective of frontline health workers involved in caring for persons infected with Covid-19. While a number of studies have been carried out on the Covid-19 pandemic, there is a predominance of quantitative research in the literature regarding the epidemiological, immunological, and clinical characteristics of Covid-19 (Al Ghafri, Al Ajmi & Anwar, 2020:2). Through the use of a qualitative approach, the study will elucidate important insights into Malawi’s response to the pandemic. It will interrogate the power, political and the socio-economic dynamics as conceptualized and experienced by the health workers at the centre of the fight to mitigate the effects of the pandemic. While similar studies may have been done elsewhere and may have commonalities, the experiences, perceptions and values of health care professionals may be shaped by local cultures, the health care system and the government’s responses to the pandemic (Bennet et al, 2020:1).
Aim
The aim of this study is to connect the dots between the micro and the macro environmental dynamics by examining the intersection between frontline health workers’ experiences of caring for persons with Covid-19 and the Malawian government’s response to the pandemic.
Research questions
- What were the experiences of frontline health workers vis-à-vis the structural conditions of their work environment?
- What were the frontline health workers’ meanings and understandings of their own experiences in caring for persons with Covid-19?
- How the media and news reporting influence frontline workers experiences of and responses to Covid-19?
- What were the systemic/ structural factors that enabled or hindered Malawi government’s response to the Covid-19 pandemic?
Theoretical Framework
Given the main aim and objectives, this study is informed by critical theory. Thomson (2018:1) defines critical theory as:
a distinctive form of theory in that it posits a more comprehensive means to grasp social reality and diagnose social pathologies. It is marked not by a priori ethical or political values that it seeks to assert in the world, but by its capacity to grasp the totality of individual and social life as well as the social processes that constitute them. It is a form of social criticism that contains within it the seeds of judgment, evaluation, and practical, transformative activity. Critical theory is, then, a radically different form of knowledge from mainstream theory and social science.
Thompson (2017:3) asserts that what is central to critical theory as a form of thought is its ability to see the inherent relation between thought and action. Truly rational (i.e., critical) thought would lead to transformation, to new shapes of human activity, since it “anticipates a release of emancipatory reflection and a transformed social praxis” (Schroyer, cited in Thompson, 2017:3). Seiler (2008) puts across the following as key tenets of critical theory:
Critical theory would enhance the provision of what Geertz (in Muller, 2015) called thick description. Kostova (2017:1) asserts that thick description “is used as a way of describing observations and interpretations that incorporate a level contextual detail. Thick descriptions take into account the directly unobservable contextual understandings that make an action or social event meaningful”. The critical theory would allow me to develop important insights into the worldview of the frontline health workers as shaped by Malawi’s response to the pandemic, and to understand the language and ideologies as conceptualized by the study participants. These are central in understanding the study participants’ subjective positions and to providing a window into contextual realities. As Giroux (cited in Sewpaul, 2003) indicated, “subjectivities are produced within those social forms in which people move but of which they often partially conscious”. On the other hand, Gramsci (cited in Sewpaul, 2003) noted that “ideology is located not only at the level of language, but as lived experience”. Interrogation and exposing of ideologies to critical scrutiny is central in this study, “for ideology becomes critical to the extent that it has the potential to reveal truths by deconstructing historically conditioned social forces”. Critical theory is, therefore, crucial in developing insights into the lived experiences of frontline health care workers as they provided care to persons with Covid-19 within the socio-political and economic contexts of the Malawian Government’s response to the pandemic, which are located within the global context of Covid-19 with all its complex and competing narratives regarding best care and treatment practices, mitigation and prevention.
Study Methodology
The study design and methods
This study will use the interpretive research design to understand the word views of the frontline health workers as shaped by their experiences in provision of care to persons affected by Covid-19. “The main point about interpretivism is that we are interested in people and the way that they interrelate – what they think, and how they form the ideas about the world; how their worlds are constructed.” (Thomas, 2017:110). Schwartz- Shea and Yanow (2012: 46) point out that:
The sine qua non of interpretive research—the sensibility that is its hallmark and which makes it distinctive in comparison with other research approaches—is its focus on meaning-making: it seeks knowledge about how human beings, scholars included, make individual and collective sense of their particular worlds.
Using the interpretive research design, this study will seek to understand how the frontline health workers conceptualized their world as they provided care to persons with Covid-19. It will interrogate the nexus between the Malawi government response to covid -19 and the meanings and the realities as constructed by the health workers as they functioned within their sociopolitical and cultural environment which was constantly shaped and reshaped by the presence of covid-19 virus. Schwartz- Shea and Yanow (2012: 46) assert that
In interpretive research, human beings are understood not as objects, but as agents. Such persons are seen as actively and collaboratively constructing (and deconstructing, meaning both critically assessing and changing) their polities, societies, and cultures—along with the institutions, organizations, practices, physical artifacts, and language and concepts that populate these
Using the qualitative approach, the interpretivist research design will therefore, allow for building insights into the “insiders or emic view” (Babbie and Mouton, 2003:270) of the frontline health workers experiences of the care of persons with Covid-19 as mediated by Malawi government response to the pandemic
Study site(s)
This study will be carried out amongst the frontline health workers at Mzuzu Central Hospital in Northern Malawi. This is one of four tertiary hospitals that has been the major treatment center for Covid-19 persons in Malawi. The study seeks to identify and engage the frontline health workers in the hospital that have been at the center of the fight against the pandemic among the people admitted for treatment.
Study participants
The participants in this study will include frontline health workers who provided care to persons with Covid-19 at Mzuzu Central Hospital in Northern Malawi. The study will also include key informants. These will include administrators and politicians as they played a crucial role in shaping Malawi government’s response to the pandemic. Thus, their decisions had direct and indirect impact on the health care workers. The administrators and politicians were at the heart of shaping the policy and operational direction of the health care system. They, therefore, on the basis of their positions, will be information rich for the benefit of this study. For this study, frontline health workers include medical doctors, clinical officers, medical assistants and anesthetists, as well as nurses, counselors and social workers. The study would also include other frontline workers, the ancillary workers who include hospital cleaners, patient attendants and ambulance drivers who equally faced risks of Covid-19 infection and their voices too would speak to the aims and objectives of this study.
Sampling Methods
Durheim, (in Durheim, Terre Blanche and Painter, 2009: 49) indicates that sampling is the selection of research participants from an entire population, and involves decisions about which people, settings, events, behaviours and/or social processes to observe. This study will triangulate data through three different data sources: 1) the primary sample of frontline workers; 2) a secondary sample of key informants, including administrators and politicians as key decision-makers; and 3) analysis of relevant documents such as Covid-19 related government and hospital regulations and memos sent to staff.
This study will use stratified purposeful sampling to identify frontline health workers to participate in this study. “This is similar to stratified random sampling. In order to obtain a stratified purposeful sample, the sampling frame is first divided into strata; then a purposeful sample is selected from each stratum” (Omona, 2013:180). Stratified purposeful sampling design can facilitate group comparisons (Miles & Huberman, cited in Omona, 2013). This sampling strategy has been chosen with recognition that the frontline health workers comprise of multiple professions which are not quite homogenous. Thus, the study will engage them within their stratified professional category. “Stratified sampling is a method for getting a greater degree of representativeness” (Babbie and Mouton, 2004:191).
The administrators and politicians will be identified through purposive sampling. Bryman (2012:418) indicates that the goal of purposive sampling is to sample cases/ participants in a strategic way so that those sampled are relevant to the research questions that are being posed. The researchers select information rich cases or cases that can teach them a great deal about the central focus or purpose of the study (Green and Thorogood, 2004; Patton cited in Grove, Burns and Gray, 2013:365). Information saturation will determine the upper limit in the number of participants to be involved in the study.
Apart from triangulating data from the primary sample of frontline workers and the key informants, key documents will be purposefully identified that will be used as secondary sources of information for the study. These will include policy documents, memos sent to staff, hospital and government regulations
Sample size
Information saturation will determine the upper limit in the number of participants to be involved in the study. However, a minimum of 40 frontline health care workers is the anticipated working target before reaching saturation (Morse, 2000; Mason, 2010; Dworkin, 2012). It is anticipated that owing to the high numbers of nurses, they will have the highest representation in the study.
Data Collection instruments
In-depth interviews
The study will use semi-structured in-depth interviews with an interview guide that will be conversational in nature to collect data from the frontline health care workers involved in the care of persons with Covid-19, and with the key informants. Taylor and Bogdan (cited in Kumar, 2011) indicate that in-depth interviewing is repeated face-to-face encounters between the researcher and informants directed towards understanding informants’ perspectives on their lives, experiences, or situations as expressed in their own words. “In this type of interview, the researcher attempts to achieve a holistic understanding of the interviewees’ point of view or situation” (Dawson, 2009:27). With the permission of the participants, all interviews will be audio recorded.
Document analysis
This study will also collect useful information through analysis of secondary sources of data. These will include policy documents, memos sent to staff, hospital and government regulations. The documents will be purposively selected for their information that will contribute to the aim and the objectives of the study.
Data management methods
Primary data collected in this study will be safely stored in a password controlled computer. I will ensure that at all times, data are safely managed to ensure credibility of the study and the safety, integrity and anonymity of the participants. The data will be stored in the University of KwaZulu Natal School of Social Work upon completion of the study for a minimum duration of five years. I am cognizant that some of the participants, particularly ancillary workers, the cleaners, patient attendants and ambulance drivers, may not be as comfortable with interviews in English. Therefore, the interview guide to be used in these interviews, will be translated in local language for their proper participation.
Data analysis methods.
The study would use a combination of Thematic Analysis and Critical Discourse Analysis (CDA). Thematic Analysis would be used to analyze the data and identify emerging themes. Thematic analysis “is a method a method of analyzing qualitative data that involves searching for recurring ideas in a data set” (Riger and Sigurvinsdottir, 2016:33). Kumar (2011) adds that in thematic analysis, writing is organized around the significant themes of the study and that within a theme, the information is provided in an integrated manner following a logical progression of thought. “The result should be the identification of a story, which the researcher tells about the data in relation to the research question or questions” (Vaismoradi, Turunen, and Bondas, 2013). Thematic analysis would be complemented by the use of CDA for advanced analysis (Botelle and Willot, 2020; Afroze, 2010) of the emerging themes and discourses.
CDA, which is aligned with critical theory, sees language as a social practice, where discourse is understood as socially constitutive and socially conditioned. CDA analyses written texts and spoken words to unveil sources of power, dominance, resistance and inequality, and how these are maintained within socio-cultural, economic, and political contexts. It accepts the central premise that language is not neutral; language does not only reflect the world but actively constructs the world that we live in, and it speaks to the complex relationship between structure and agency (Fairclough, 1989). CDA will allow this study to pursue insights into the language used by the participants, casting it in time and space within which it is used. A critical reflection on the language and discourses will enable appreciation of the role of ideology which “becomes critical to the extent that it has potential to reveal truths by deconstructing historically conditioned social forces” (Sewpaul, 2003:312). Critical discourse analysts want to understand the role of structures, strategies or other properties of text, talk, verbal interaction or communicative events (van Dijk, 2008 & Wooffitt, 2005). Importantly, CDA aims at revealing the relationship between language, ideology and power (Liu and Guo, 2016:1076). Therefore, the analysis of the language in this study will be crucial in the understanding of the experiences and subjective positions of the health workers in their care of persons with Covid-19 within the context of the structural/systemic responses to the pandemic by Malawi as a country. Critical discourse analysis will also be used in the analysis of relevant documents such as policies, reports and memos to staff.
Ethical consideration
Walsh and Wigens (2003:106) indicate that the ethics of research are concerned with the standards of behaviour and the practical procedures that researchers are expected to follow. The research approvals has been obtained from the National Commission for Science and Technology (NCST) and the University of KwaZulu Natal’s Humanities and Social Sciences Research Ethics Committee. Gatekeepers permission to conduct the study has also been obtained from Mzuzu Central Hospital, Mzuzu City Council and the Mzimba North District Health Office.
In as far as research is concerned, it is important that the researcher is particularly aware of the impact that the research can have on the subjects under study. Special attention must be given to ensure that participants are not negatively impacted. Creswell (2009:88) emphasizes that ethical practices involve much more than merely following a set of static guidelines, such as those provided by professional associations. Researchers need to anticipate and address any ethical dilemmas that may arise in their research. Bulmer (cited in Humphries, 2008:20) adds, “the researcher has always to take account of the effects of his (sic) actions upon subjects and act in such a way as to preserve their rights and integrity of human beings.”
This study will ensure that the participants are provided with informed consent to participate in the study and that they consent to being audio recorded. Will also ensure that the study participants are aware that they have the freedom to withdraw at any stage of the research process, with no repercussions. This will clearly be spelt out in the consent form that the study participants will sign before the start of the research process. They will sign two forms, one for themselves to keep and the other for the researcher.
This study will involve accessing the participants in their own practice setting and engaging them in conversation, some of which have the potential to be sensitive and uncomfortable. The researcher will adhere to the principles of confidentiality at all times and reassure the participants about this. The participants will be assured of anonymity and confidentiality by using pseudonyms, and when necessary, by camouflaging identifying details, in the analysis and reporting of the data. The research process has the potential to arouse deep seated emotional issues, thereby potentially causing harm. I am a competent and practicing social worker who would be able to recognize those moments, and I will provide the requisite support. I will strive to be a supportive professional and equally an inquisitive researcher during this study process. Crucially, this study is carried out on the premise that there exist mental health issues amongst health workers involved in the care of persons with Covid-19. I will, if necessary, refer those with the need for mental health services to the right members of the multi-disciplinary teams within the existing health services.
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