Feeling like Cannon Fodder – researching the challenges of frontline doctors in the response to Covid-19

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By Dr Liz Jenkinson, Senior Lecturer in Health Psychology and Co-chair of the UWE Bristol Healthy University Group

With a new variant pushing healthcare capacity to its limits, understanding the challenges of responding to Covid-19 on the frontline is pivotal. As a Health Psychologist, I am driven to inform and develop evidence-based policy and practice in healthcare. I have been working with Jo Daniels and Sophie Harris at the University of Bath, Edd Carlton (University of Bristol/Royal College of Emergency Medicine) and Tom Roberts (North Bristol NHS Trust/Royal College of Emergency Medicine) to capture the scale of the challenge faced by healthcare professionals responding to the pandemic. Despite the popular media narrative of healthcare workers being our Covid-19 heroes, our research documents that many simply do not feel that way in terms of how they are being supported. The research highlights how frontline healthcare workers are angry at being treated as ‘Covid cannon fodder, not Covid heroes’ after responding to the virus for nearly two years.

‘It’s been ugly’: A large-scale qualitative study into the difficulties frontline doctors faced across two waves of the COVID-19 pandemic’ is the first study of its kind to capture the views of over 1,300 doctors in the UK and Ireland responding to Covid-19 since early 2020. The study was published in the International Journal of Environmental Research and Public Health this week and featured in the Sunday Times, BBC news and beyond.

Despite working at ‘100% capacity, 100% of the time’, the frontline healthcare workers told researchers of their frustrations at those not following public health advice, and towards Government for ‘failing in so many ways to support us.’ Doctors said they felt ‘expendable’ and left traumatised by events. The dual issues of a worrying lack of support for doctors’ basic needs (e.g. insufficient places to rest, food to eat, and relentless shift patterns), and a significant lack of appropriate psychological support to help them decompress was also highlighted.

Participants recruited for the study comprised frontline doctors who worked in emergency medicine, anaesthetics, and intensive care medicine in all parts of the UK and Ireland. All genders, ethnicities and seniority levels were represented in the sample of 1,379 participants who responded to a longitudinal survey asking them to answer freely: ‘What has been most difficult about the pandemic?’

Clinical psychologist at the University of Bath, Dr Jo Daniels, explains: “We are seeing increasing levels of staff attrition, absenteeism, poor psychological health, and loss of life, yet frontline doctors are expected to just carry on.”

These findings build on recent work, including the CERA study, which sought to quantify psychological distress experienced by emergency doctors during Covid-19, and the Covid-19 Clinician Cohort (CoCCo) study model, which highlighted a hierarchy of needs for frontline workers responding to the pandemic. These ranged from supporting workers’ basic needs with hot food and drinks, through to embedded peer support, psychological care, and interventions. The team say it is imperative policymakers learn lessons from this study as they respond to the impact from the latest Omicron variant.

Dr Edd Carlton, Professor of the Royal College of Emergency Medicine and Emergency medicine doctor, co-authored the research. He said: “This work demonstrates the massive impact the pandemic has had on our frontline medical workforce in terms of working conditions, morale and psychological distress. What is most worrying is that Covid-19 has compounded issues that were already commonplace pre-pandemic and now are putting a tangible strain on doctors’ own physical and mental health.”

My work at UWE Bristol continues to collaborate with the team, bringing my expertise in Health Psychology into this space. We are very grateful to those who gave up their time to tell their stories, which were striking in their agreement that this had been unrelenting, traumatic and had placed unsustainable pressure on frontline doctors. As we move into what may prove to be yet another wave of the pandemic, this research shows that there needs to be a renewed focus on properly supporting doctors to protect their health and wellbeing so that they can be there for all of us when we most need them.

Read the academic paper here and click here for an animation based on Covid-19 healthcare research.

Assessing health volunteers’ success in Thailand’s COVID-19 response

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By Professor Vikas Kumar, Director of Research and Professor of Operations and Supply Chain Management

Thailand is one of the countries that has successfully managed COVID-19 outbreak control – the number of new infections is on the decrease and related deaths are limited. Playing a huge role in this success has been the country’s 800,000 active Village Health Volunteers (VHVs).

Each volunteer acts as a messenger and goes into the community to relay the latest news about  public health, as well as providing primary healthcare and planning for and monitoring of health issues. Their dedication strengthens the primary healthcare system and helps tackle the healthcare crisis, which now includes COVID-19. Each province contains approximately 104,000 VHVs, many of whom were active during SARS in 2002 and Avian influenza in 2004.

Having received a Newton Fund Institutional Links Grant, we are working with Mahasarakham University in Thailand and will initially assess how effectively VHVs are performing their role in COVID-19 limitation across Thailand, whether in suburban or more remote rural areas.

I will be leading an interdisciplinary team of researchers in Thailand (Dr Kittipol Wisaeng, Dr Amporn Kai, Dr Petcharat Lovichakorntikul, Ms Aim-on Tarakam, Ms Somsri Sungkharom and Dr Worawat Sa-ngaimvibool) who will be working closely with a range of local stakeholders (VHVs, Local medical practitioners like doctors and nurses, local government, councils, etc.). Also included in the team are researchers from the Innovation Operations Management and Supply (IOMS) research group (jointly led by Prof. Wendy Phillips and myself) at the Bristol Business School.

We will then look at ways in which VHVs might perform more effectively in COVID-19 control in the future as their ability to social distance, help implement curfews etc. is hindered by extraneous factors such as climate change. We will also outline operational and logistical challenges they face while executing their role in remote areas. These could include short- and long-term changes in mobility, landscapes, other emergencies (e.g. epidemics).

In line with these potential challenges, we will look at the associated developmental needs and ultimately our work will look at how we can re-conceptualize the role, forms, and management of VHVs in preparation for impacts of COVID-19 and other emergent epidemics.

Baed on our conclusions, we will put produce effective strategies and a toolkit to help VHV perform better in COVID-19 control in changing contexts.

All these additional innovations to the VHV scheme and lessons learned will better facilitate contributions to other countries in COVID-19 control as well as the control of other emergent epidemics.

By achieving the objectives, this project hopes to contribute significantly to existing literature and community practices in Thailand. The developmental strategies will help local government/authorities to increase the potentials of the volunteers for COVID-19 and similar outbreak control in the future. There is also an opportunity for other countries to learn from this project who are struggling to manage this pandemic.

Public transport and future pandemics – is there a Plan B?

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By Dr Steve Melia, Senior Lecturer in Planning and Transport

Demand for trains is likely to rise again “assuming at some point there will be a vaccine and we will return to some sort of normal” said the Chief Executive of HS2 recently. His assumption might be right, but vaccines are rarely 100% effective. What if they don’t eradicate the risk and social distancing continues to constrain the capacity of public transport? Many ecologists are now warning that human interference with natural systems will cause more pandemics in future. What would happen to public transport if pandemics and social distancing became a recurring feature of 21st century life? What is Plan B?

Six months after the lockdown caused patronage to collapse, I was going to write about the strange silence of the transport world on these questions. But perhaps that silence is not so strange. Whose interests would it serve to acknowledge those possibilities? Whose ideology would it bolster? Clearly not the public transport industry or its supporters. Nor would it help the petrolheads’ case for unrestrained driving. So, at the risk of provoking the ire of all sides, I want to consider what might happen and how we might collectively respond if public transport remains constrained in the longer-term.

A few articles on these questions, from elsewhere in the world, have raised the nightmare scenario, where fear of infection causes people to shun public transport and flee cities, reversing the past few decades of urban regeneration. In countries like the USA and Australia with low population densities, that would gently accelerate the spread of car-based sprawl, which had slowed but never stopped. In Britain, and particularly England, that prospect would be far more serious. As I have written elsewhere, the claim that England has plenty of land available for development without destroying what remains of our natural environment is unfortunately untrue.

In recent decades, UK governments have tempered their push for more house building with planning policies encouraging densification of central urban areas. I am looking at the result of that strategy through my window in central Bristol – 375 flats on a site the size of a football pitch with only a handful of parking spaces. This type of urban intensification depends on high-capacity public transport for new residents, who will be unable to own cars because there is no space for them. Remove that capacity and the densification of cities will become unviable. Rural areas will suburbanise and suburban roads will fill with congested traffic.

Social distancing regulations are not the only problem; Covid has reduced people’s willingness to travel in close proximity to others. When I have asked people in the industry: ‘what if things don’t return to normal?’ their answers are all around funding, which is hardly a solution for the long-term. I recently met a government transport official who had considered the longer-term risks. He said “there is no solution”, and within life as we know it, he is right. Trains and railway stations could conceivably be converted to allow people to travel in separate compartments without inhaling each others’ breath, but at a cost that would make HS2 look like a bargain. Buses would have to be replaced by some entirely different type of vehicle. The capacity of both would be permanently reduced, which would not solve the problem. People could continue to drive cars but not at higher concentrations in urban areas, so they wouldn’t solve the problem either.

If there is a workable Plan B it would have to transform both public and private transport. The early hype around autonomous vehicles has subsided as researchers (including some of my colleagues) have shown how some of the barriers to full automation cannot be solved by technology alone. To allow autonomous vehicles to interact with pedestrians in dense urban areas would require big changes to the way we organise our cities. Whether those changes are made or not, we can expect incremental automation such as platooning on motorways.

Putting all those factors together with the imperative to decarbonise transport we could imagine a world where autonomous electric pods, smaller than today’s cars, follow a network more limited than today’s roads. They could travel at low speeds through urban areas until they join interurban networks, where they could travel in platoons at higher speeds. Similar principles could transform the way we move freight into, out of, and between urban areas. If you think that vans and lorries are the only ways of moving freight around cities, take a look at Joel Crawford’s books about carfree cities. Such a system could replace the motorway and rail networks, reducing the overall land-take of transport networks. I float that idea, not as “the solution”, but to illustrate the scale of the transformation that Plan B might require.

Of course, we might be lucky; Covid-19 might fade into history and future pandemics might be more benign – or not, so where does that leave us in the meantime?

The case for joined-up cycle routes and traffic-free environments for walking remains relevant under any conceivable scenario. So will the need to remove or replace vehicles powered by fossil fuels. Road building remains a damaging option under any scenario. But should we be pressing ahead with plans to build big public transport infrastructure at this moment? Is it possible to genuinely future-proof such infrastructure?

My colleague Professor Glenn Lyons has written some useful articles about planning in uncertain situations. But on the specific questions I can give no definitive answers; I can point you to no relevant research. I can only conclude that we must break the silence and start treating these possibilities more seriously.

This article was first published in Transport Times

Apart but not Alone? Neighbour support during lockdown

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By Amy Beardmore, Research Associate in Public Health and Community Development

As the UK went into lockdown on 23 March in response to the Covid-19 pandemic, communities across the country sprang into action and initiated a rapid process of self-organisation, the likes of which had never been seen before. Help for people within communities was quickly coordinated using online platforms such as Facebook, WhatsApp and the hyperlocal social network Nextdoor, alongside more traditional forms of communication such as phoning neighbours or dropping notes through letterboxes. The pace at which this unprecedented community response to the crisis was organised appeared to overtake the implementation of more formalised voluntary and statutory sector support in the area. The result was a complex network of street, neighbourhood and community level help, support and resources.

Rapid research

It quickly became apparent to researchers in the Centre for Public Health and Wellbeing that a unique opportunity was emerging to document the extent of this sudden surge in ground level support and how it might be affected by levels of social deprivation. Enlisting the help of colleagues from within the centre and external partner organisations, as well as a number of community researchers and public contributors, the team designed a piece of research consisting of three distinct phases. This work began just four days after lockdown on 27 March under the heading Apart but not Alone, starting with an online cross-sectional survey.

Survey One

Launched on 2 April and promoted largely through online channels, email and text messages, the first survey asked respondents about who and how they were helping, and their wider experiences of personal involvement in neighbourhood life. Of the 862 people who responded to the survey, a total of 539 responses from the Bristol built-up area were eligible for analysis.

Complex picture in areas of higher deprivation

The results showed that help and support unsurprisingly tended to be aimed at the most vulnerable in communities – specifically the over 70s and those self-isolating. Interestingly, the data also indicated that respondents from more deprived areas of the city and surrounding areas tended to be disproportionately supporting those with disabilities and mobility issues, those with no access to outdoor space and those experiencing financial difficulties. These areas of higher deprivation were also less likely to strongly agree that neighbours were supporting each other well.

Women shouldering majority of the burden?

It is notable that 80.9% of survey respondents were female. There could be a number of reasons for this, including the possibility that women are more actively engaged in social and community networks – both on and offline – and men’s helping behaviours therefore exist but are simply less visible. It may also be that women are shouldering the burden of caring for their community as well as immediate family members, with many also trying to work from home, often with children present.

Low BAME response rate

Bristol has a BAME population of around 14% (although this figure is much lower for South Gloucestershire and North Somerset), so a survey response rate of 5.3% does not appear to be representative of the local population. This may well be due to the restrictive nature of an online survey promoted largely via social media, although the sample did specifically include BAME organisations. It is hoped that the experiences of the BAME population will be explored in more detail through the qualitative element of the project.

In-depth interviews reveal lived experience

The second phase of the project consists of in-depth qualitative interviews with some of the survey participants in order to get a better understanding of how social capital – the resources and connections that people have access to that can influence their ability to navigate systems or to generally do well in life – influences individual and community experiences of lockdown. Eighteen interviews have been conducted so far as part of a unique piece of research in which the researchers themselves are living through the same experience as their interviewees.

“Two of my neighbour’s cousins have died because of Covid-19…and it’s difficult for her because they can’t get together as a family to mourn…”

Research participant

Follow-up survey on community spirit

Participants from the original survey who expressed an interest in taking part in further research were also invited to take part in Phase Three – a follow up survey, published on 27 May. This survey asked about positive and negative experiences in communities since the easing of lockdown on 10 May, and early analysis suggests that whilst many reported a continuation of positive activity (such as increased communication, street level events and volunteering), participants also identified a number of emerging concerns. These tended to indicate that tensions were starting to creep in, particularly associated with confusion over the rules and social distancing as well as more general concerns about previous negative behaviours being exhibited by some members of the community. Of particular note were a number of negative comments about the behaviour of young people and teenagers, indicating potential generational conflict.

What next?

Results from Survey One were recently published in Emerald Open Research, and it is hoped that a second article will be published in the next few weeks summarising the findings of Survey Two, which is currently undergoing analysis. The qualitative element remains ongoing as we continue to explore the participant links to social capital and the impact it has had on their experiences of lockdown. For regular project updates, please follow us on Twitter @ApartAlone.

Providing essential training for frontline staff working at Nightingale Hospital Bristol

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By Dr Marc Griffiths, PVC and Executive Dean, Faculty of Health and Applied Sciences

Over the last week the Glenside Campus has been set up to receive volunteers who will be working as frontline staff at the Bristol Nightingale hospital when it opens on the 18th April. The development and preparation for frontline staff training has been a collaborative effort between the University and colleagues from the NHS.

This approach further supports our excellent partnership working with NHS organisations across the region and many of our academic and technical staff were working over the Bank Holiday weekend to ensure facilities were ready for training purposes. The clinical simulation spaces at our Glenside Campus are equipped to deliver frontline training to 1,000 volunteers over the coming weeks and our staff have risen to the challenge.

Colleagues from across the local and regional NHS have come together with UWE staff to create a local version of the London Nightingale Hospital staff training programme. Having a campus that is equipped to deliver staff training on the required scale for the Bristol Nightingale site is testament to the investment by the University in clinical skills and simulation training for our health and social care students.

UWE Bristol has over 3,000 health and social care students and annually graduates approximately 1,500 practitioners into the local and regional health and social care system. Our integrated working with NHS partners and state of the art simulation learning facilities create the required environment for the local and regional health and social care workforce pipeline.

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