COVID-19: Experiences of Social Workers Supporting Older Adults With Dementia in Nigeria

Abstract

Amidst the COVID-19 pandemic, numerous public health protocols were instituted by government agencies to safeguard individuals with dementia, their family caregivers, and formal care providers. While these preventive measures were implemented with good intentions, they inadvertently imposed significant challenges on medical social workers in Nigeria. This paper explored the experiences of medical social workers caring for people with dementia during the COVID-19 pandemic in Nigeria. Twenty-six medical social workers from 6 government hospitals in Southwestern Nigeria participated in an in-depth interview. The research reveals 3 pivotal aspects: Firstly, the escalating demands within the work environment, where medical social workers grapple with the intricate task of conveying sensitive information about dementia diagnosis and COVID-19 prevention protocol, managing expectations regarding dementia diagnoses, and navigating resource constraints for individuals with dementia during the pandemic. Secondly, discernible impacts on the work climate and interprofessional relationships shed light on the challenges these professionals face in collaborating with other healthcare providers. Lastly, the reverberations on social workers’ personal lives underscore the pandemic’s toll on their well-being. Thus, the findings underscore the need for proactive measures to equip medical social workers to face the distinctive challenges in dementia care during future pandemics. Recognizing the potential resurgence of global health crises, the research highlights the need for strategic preparedness to mitigate the impact of future pandemics on the well-being of individuals with dementia and the professionals dedicated to their care.

• What do we already know about this topic?

• • Dementia is on the rise across Africa, including Nigeria, and there is a shortage of infrastructural facilities to support this growing population.

• • COVID-19 had a significant impact on older adults with dementia in low- and middle-income countries like Nigeria.

• How does your research contribute to the field?

• • The African region lacks studies on the experiences of social workers caring for people with dementia during the pandemic as they navigate numerous challenges and limited infrastructural facilities.

• What are the implications of your research for theory, practice, or policy?

• • Our findings suggest that, because social workers were considered essential workers during the pandemic, they should be prepared and supported in caring for older adults living with dementia in Nigeria.

Introduction

The COVID-19 pandemic profoundly affected societies worldwide, with significant implications for vulnerable populations, including older adults with dementia.^1,2 Dementia, a degenerative cognitive disorder, poses significant challenges for individuals, families, and communities worldwide. ² The World Health Organization (WHO) has designated dementia as a public health priority ³ ; the current dementia estimate is 4.5% of the total population of adults above 65 years old,^1,4 and this proportion is steadily increasing in an aging population.^1,4,5 In Nigeria, dementia prevalence stands at 4.9%, as per aggregated data. Notably, women exhibit a significantly higher prevalence (6.7%) than men (3.1%). Regionally, the North-central reports the highest prevalence (6.4%), followed by North-west (5.4%) and South-west (4.6%) regions.^1,6,7 These findings underscore gender and regional variations in dementia prevalence across Nigeria, emphasizing the need for targeted healthcare interventions.

Social workers play an important role in the care and management of older adults with dementia in Nigerian hospitals.^8,9 Though there is no national data on number of medical social workers supporting older adult or individuals with dementia in Nigeria, still report from the Association of Medical Social Workers of Nigeria indicated that there more than 80 medical social workers directly working with older adults in government geriatric hospitals in Nigeria. ¹⁰ While the number of medical social workers dedicated to older adults with dementia in Nigeria may not be precisely known at a national level, there presence as a professional entity underscores the recognition of the importance of their role in enhancing the overall care and quality of life for older adults with dementia and their families. Ongoing efforts to expand and support the social work workforce in this context can further contribute to improved dementia care in Nigerian hospitals.

In the wake of the COVID-19 pandemic, social workers played a vital role in supporting the unique needs of older adults with dementia. As the world gradually emerges from the pandemic, empirical information from a large country like Nigeria on how social workers in hospital settings navigated the precarity of limited infrastructures and the complexities of managing dementia with people affected and their families remains scant. There is no doubt that COVID-19 pandemic had profound and far-reaching impact on people with dementia, and social workers, for example, Nigeria, like many other countries, has experienced disruptions in routine healthcare services, impacting the physical well-being of dementia patients, especially challenges in vaccine distribution exacerbate the vulnerability of individuals with dementia to COVID-19.^11-14 In addition, The enforced isolation, disruption of familiar routines, and limited social interactions have contributed to increased cognitive decline, heightened anxiety, and exacerbated behavioral symptoms among dementia patients.^12,15-18 Social workers, acting as crucial intermediaries, encountered heightened stress, burnout, and emotional fatigue due to the intensified demands of remote care and the inherent emotional toll of witnessing the deterioration of their clients’ mental health. ⁸ Social isolation, a key preventive measure, resulted in decreased social engagement, exacerbating cognitive decline and behavioral symptoms. ¹⁹ Social workers, facing increased caseloads and logistical challenges, have grappled with ensuring continuity of care and facilitating meaningful social connections for their clients.^20-22

Nigeria, an African country with a large population of older adults, has faced the severe impact of COVID-19, with its health care system stretched to its limits.^11,23 Prior studies have reported the adverse impact of COVID-19 pandemic on health, social connection, economic stability and overall wellbeing of older adults in Nigeria.^24-28 Major gaps in these studies are that they lack comprehensive interdisciplinary studies that integrate health, social connection, economic stability, and overall well-being of older individuals. Existing research tends to compartmentalize these aspects, hindering a holistic understanding of the multifaceted challenges faced by older adults during the pandemic. Moreover, the majority of prior studies have primarily focused on health vulnerabilities, neglecting the intricate interplay between physical health and socio-economic factors of older adults during the pandemic. The economic ramifications on older adults, including pension disruptions and financial insecurities, remain inadequately explored. Additionally, the social isolation experienced by older individuals, a critical determinant of mental well-being, requires deeper investigation. The literature often overlooks the nuanced dynamics of how cultural and community factors influence the mental health of older adults during times of COVID-19 pandemic.

Despite these difficulties, social workers in Nigeria demonstrated exceptional professional dedication by bridging the gaps in social care and providing essential support to older adults with dementia. ⁸ Social workers in the Global North have shown examples of commitment to supporting people with dementia,^29-32 with empirical data regarding their unique blend of empathy, expertise, and unwavering commitment to enhancing the well-being of older adults with dementia and their families.^33-36 Much empirical evidence has focused on the challenging experiences of social workers caring for older adults^11,27,37,38; however, such experiences specific to individuals with dementia remain understudied in Nigeria in particular. This dearth of knowledge impedes the development of targeted social work interventions and support systems, potentially compromising the quality of care provided to individuals with dementia and their overall well-being. Among older adults without dementia,1 key obstacle was the abrupt shift to remote and virtual modes of service delivery. ³⁸ The strict social distancing measures and lockdown restrictions rendered traditional face-to-face interactions impossible, necessitating innovative approaches to maintaining continuity of care for older adults. The abrupt shift to remote services due to COVID-19 poses challenges, particularly for older adults without dementia, while limited data on the impact of the pandemic on those with dementia further underscores the need for focused research for people with dementia and their families.

Older adults with dementia often experience difficulties communicating their feelings and experiences, requiring extra vigilance by caregiver in observing and reporting new or unusual activities. ³² A few studies, commentaries, and policy documents from governmental and nongovernmental organizations have acknowledged the challenges social service workers face in complying with pandemic safety measures when working with older adults with dementia some of which includes frustration, loneliness, isolation, stigma and increase work-load.^8,39 Thus, Social service workers need specialized training to navigate safety measures while providing empathetic support, combating stigma while provide support for older adults with dementia. To date, there have been no empirical studies on the experiences of social workers caring for older adults with dementia during COVID-19 in the African region. It is important to explore how social workers cope and support dementia patients emotionally can contribute to strategies for mitigating the mental health impact of COVID-19 on both caregivers and patients. New empirical findings could offer insights into the role of communities and families in supporting dementia patients during pandemics. Social workers can then incorporate this knowledge into their practice, fostering collaboration and a more comprehensive approach to care. Therefore, this study aimed to explore the experiences of medical social workers caring for older adults with dementia during the COVID-19 pandemic in Nigeria. Findings from this research can be utilized to advocate for increased resources for dementia care during or future pandemic, including funding, personnel, and access to essential supplies. Incorporating cultural competency training into social work education and professional development, ensuring that social workers are equipped to address the cultural nuances affecting dementia care in Nigeria. Finding could be inform the development of a community-based initiatives that involve families and communities in supporting dementia patients during pandemics. Invest in capacity-building initiatives to strengthen the overall infrastructure for dementia care during pandemics, including facilities, equipment, and support staff. This study intends to answer the following research questions: (a) What were the key challenges social workers faced in caring for older adults with dementia during the COVID-19 pandemic? and (b) How did social workers adapt their service delivery methods to ensure continued support for older adults with dementia during the COVID-19 pandemic?

Methods and Design

Study Area

We conducted this study in 6 southwestern states of Nigeria: Oyo, Osun, Ekiti, Ogun, Lagos, and Ondo State. The southwestern region’s population comprises a majority of Yoruba native speakers, and the region stretches far along the Atlantic seaboard from the international border with the Benin Republic. According to the National Population Census of Nigeria, the southwestern region has a population of 32.5 million people. ⁴⁰ These 6 states were selected because they collectively represent a substantial portion of Nigeria’s population, ensuring a diverse and representative sample. Lagos, being a major urban center, might exhibit distinct challenges compared to more rural areas like Ekiti. Additionally, the selected states have varied healthcare infrastructures, potentially influencing the impact of COVID-19 on dementia patients and their caregivers. This region of Nigeria was chosen because it was an epicenter of COVID-19 in Nigeria, and older adults were significantly impacted by COVID-19 ⁴¹ ; the region is also known for its relatively developed health care infrastructure and availability of resources compared to other regions in the country. During COVID-19, social workers were part of the essential service team in the region. ⁴² In specialized clinics such as psychiatry hospitals, geriatric centers, and palliative care clinics, social workers are termed “medical social workers.” They offer psychosocial services to older adults with chronic health conditions, including dementia and also support their families. In addition, we focused on the southwest region of Nigeria because it has a rich cultural heritage, including traditional beliefs, norms, and practices that may influence the experiences of medical social workers caring for people with dementia during the pandemic.

Participants and Recruitment

A qualitative design aligned with the descriptive phenomenological approach to delve into the phenomenon of challenges experienced by medical social workers caring for people with dementia during the COVID-19 pandemic. This methodology was selected for its emphasis on exploring and deriving meaning from participants’ lived experiences through their perspectives and interpretations. ⁴³ Purposive sampling guidelines were adhered to in participant selection of participants for the study, ⁴⁴ 27 medical social workers were selected for the study after obtaining approval from the national president of Association of Medical Social Workers of Nigeria (AMSWON). This study is part of the ongoing effort of the Federal Ministry of Health through the Association of Medical Social Workers of Nigeria to improve health service delivery in Nigeria. We used a purposive sampling technique to select health institutions with medical social workers as part of the hospital COVID-19 team. We purposively selected 7 government hospitals because 86% of medical social workers in Nigeria work in such hospitals (Association of Medical Social Workers of Nigeria, 2021), and the study was conducted between February 2021 to November, 2022. In addition, the government manages most services focused on caring for older adults in Nigeria. The participants were exclusively from government-owned hospitals include the Geriatric Centre, University College Hospital, Ibadan (5 medical social workers), Memory Unit of the Lagos University Teaching Hospital (Six medical social workers), Dementia Care Unit, Neuropsychiatry Hospital, Yaba, Lagos(4 medical social workers), Geriatric Unit, Osun State Hospital, Osogbo(3 medical social workers, Dementia and Old Age Department, Federal Neuropsychiatry Hospital, Aro, Abeokuta(6 medical social workers) and Ondo State Medical Centre(2 medical social workers). We chose these hospitals because they offer dementia care services for more than 3 years (eg, each of these hospital provides weekly memory clinic). During the COVID-19, medical social workers were considered members of the essential multidisciplinary team that provided service in all Nigerian hospitals. Inclusion criteria for this study includes: medical social workers with more than 3 years of experience providing direct care for older adults with dementia in the hospital and must be registered members of the Association of Medical Social Workers of Nigeria. Medical social workers selected for the study showed willingness and consented to participate, whereas we excluded those who refused or did not consent to participate. The exclusion criteria include medical social workers with no experience caring for older adults with dementia or are not member of the association of medical social workers of Nigeria, or have not had 3 years of experience caring for an individual with dementia in the hospital setting or is not fluent in English of Nigerian pidgin English. We refrained from employing interpreters due to their tendency to condense or modify participants’ remarks, which could compromise the accuracy and dependability of the collected data. ⁴⁵ Despite the qualitative nature of this study, the sample size yielded sufficient data to achieve data saturation.

Data Collection Process

We aimed to understand experiences and amplify social workers’ voices regarding caring for older adults with dementia during COVID-19. Before the pandemic, geriatric centers opened their doors to families without restrictions. When collecting these data, public health guidelines transitioned to enable family members to assist in providing care to their patients in geriatric settings when needed. As a result, the view of the participants might reflect the early days of the COVID-19 pandemic when family members were restricted from visiting or providing care to residents in geriatric or dementia care settings. While managing COVID-19 restrictions, medical social workers and staff in geriatric settings witnessed dementia patients, families, and colleagues struggle with the devastating impact of the pandemic, including isolation, high morbidity, and mortality. We recruited participants from the database systems of the Association of Medical Social Workers of Nigeria (AMSWON) through the approval of the national leaders of the Association. We used a qualitative descriptive phenomenological approach embedded in symbolic interactionism, which viewed meanings are developed through social interactions. ⁴⁶ This approach uses a restrictive level of interpretation to offer an honest description of the phenomenon and allows the use of multiple philosophical assumptions such as symbolic interactionism. ⁴⁷ This method focuses on learning more about a poorly understood phenomenon like dementia in the Nigerian professional context. The researchers are from the southwestern region, and hence they shared cultural and professional similarities with the participants, allowing effective probing to gain an in-depth understanding of the meanings derived during the data collection process. The first author (O.O) is medical social worker and clinical researcher for more than 8 years supporting older adults living with chronic health conditions in Nigeria, while other authors have more than 5 years experience caring for older adults.

A single semi-structured, face-to-face interview consisted of the following open-ended questions: (a) Have you had COVID-19 in your setting as either an outbreak or an investigation? (b) What did your role look like prior to the COVID-19 pandemic? (c) What has been your role since the beginning of the COVID-19 pandemic? (d) Was there a change in your role? If yes, how did that affect your practice? (e) When policy restricted access, how did this affect residents and families? (f) What were your frustrations and successes as a medical social worker? (g) What support would be valuable to assist you through this time? (h) Is the support you mentioned above any different since the onset of the pandemic; if yes, please describe. Because of busy schedule of the medical social workers in these hospital, a second interview could not be conducted, still a confirmatory interview was utilized to confirm the accuracy of the data with the participants. The Secretariat of the Association of Medical Social Workers of Nigeria assisted in emailing the study information and invitation for an interview to 63 medical social workers in government geriatric settings, government nursing homes, and palliative care settings across Southwestern Nigeria. Participants interested in the study responded to the email in March 2022, and the interview was completed in November, 2022. The researcher prevented the risk of disclosure of identified information, especially because the participants’ demographic details were not collected during the interview, and all identifying information was removed before data analysis. Twenty-seven medical social workers consented to participate in the study (17 women and 10 men), and their ages ranged from 24 to 53 years. The interviews ranged from 45 to 68 min, and was conducted in the office of the medical social workers. According to Charmaz (2014), K.M undertook memo writing concurrently to support the audio recordings; throughout the process, codes and ideas were explored by all the researchers in the emerging categories noted during the interviews. The first author (O.O.) transcribed the interviews and memos verbatim. The participants were fluent in English; hence, understanding the medical social workers’ experiences throughout the interview was not difficult.

Ethical Considerations

This study received ethics approval from the National Bioethics Board, XXX (XX/2008A) and the University of XX/University College Hospital, XX Joint Ethics Board (XX/0612). The national president of XX approved this study. We informed all the participants about purpose of the study with an information leaflet. We also assured them of strict confidentiality and anonymity of all information they shared with the research team. Participants gave both verbal and written consent before the commencement of the interviews and were informed of their freedom to withdraw from the study at any time and to request that their data or information be deleted within 3 months of the study. We noted and documented all nonverbal cues and other vital information from the field notes.

Data Analysis

We used descriptive phenomenology approach by reflecting on the narratives of the participants, and conducting multiple reads among ourselves before generating themes and sub-themes from the data; We analyzed the responses from the survey in 3 steps: (a) reading responses multiple times to get a sense of the data (reviewing), (b) using an inductive approach to analyze the responses of the participants (organizing), and (c) rereading the transcript to understand the underlying meaning of the data (reporting). During the inductive approach, we conducted an iterative 3-step process of coding meaningful data (open coding), developing meaningful data into units (creating categories), and interpreting these meaningful units (creating themes). The data was coded using the NViVo version 12 software by the first author (O.O) who is an expert in the use of the software, by starting with a simple descriptive codes to a more analytical codes. Codes that have similar ideas were grouped to form a coding trees which consists of the grandparent, parent, and child coding-nodes. The process of constant comparison was employed to discover comparable codes, and parallel codes were consolidated. The initial codebook, displaying the coding trees featuring parent and child nodes, was distributed among all authors for analysis and theme identification. Each author thoroughly reviewed the coded data, pinpointing emerging themes while ensuring a focus on participants’ statements rather than their manner of expression. Instances where 1 author identified themes not recognized by others were discussed, taking into account additional transcripts and interview memos. O.O. analyzed the interview transcripts, and team members (K.M, O.A) reviewed the data for verification of coding, categorization, and theme generation for the study. Through collaborative deliberation, these themes were either accepted or rejected based on the collective judgment of the researchers, thereby minimizing the impact of any individual author’s perspective on the findings. We ensured rigor via member checking with members of the Association of Medical Social Workers of Nigeria conference in 2022, and we conducted an appraisal of the fitness of the emerging codes, themes, and categories. ⁴⁸

Results

We presented the results of our findings in themes and subthemes. First, we presented the demographic features of the study participants. Four themes emerged from the experience of medical social workers supporting people with dementia during COVID-19: (a) increasing demand in work environment, (b) impact on work climate and relationships, (c) impact on personal life of social workers (d) Suggestions for Future Pandemics.

Demographic Characteristics of Respondents

There are 27 study participants (16 women and 11 men), aged 25 to 57 years, who are medical social workers caring for people with dementia in Southwestern Nigeria. Twenty-six of the medical social workers had more than 3 years of experience caring for an older adult with dementia in their hospitals. A preponderance of the participants were Christians by religious affiliation and were married. The majority (74%) of the participants had a bachelor’s degree in social work; 14% had a Master of Social Work; and 12% had degree qualifications, allowing them to practice as a medical social worker in Nigeria. A majority (94%) of the participants were from the Yoruba ethnic group, whereas less than 10% were from other ethnic groups such as Igbo and Itshekiri (See Table 1).

Table 1.

Demographic Characteristics of the Medical Social Workers.

S/N	Participants I.D	Age (years)	Gender	Highest level of education	Years of experience as a social worker
1	GAO	57	Female	MSW	19
2	MDF	55	Female	BSW	10
3	KOE	47	Female	Dip Social Work	7
4	ROA	48	Female	BSW	10
5	AYE	42	Female	BSW	15
6	TOA	42	Male	BSW	10
7	YIO	34	Female	BSW	9
8	ERA	37	Male	BSW	8
9	ATA	28	Male	BSW	3
10	POA	31	Female	BSW	6
11	TMO	32	Female	MSW	6
12	YIP	34	Female	MSW	10
13	ADF	45	Female	BSW	17
14	HLO	43	Male	Dip Social Work	12
15	PEH	38	Female	MSW	9
16	JJA	53	Female	BSW	21
17	WAN	36	Female	BSW	9
18	RIO	47	Male	BSW	14
19	FGA	52	Male	BSW	11
20	BNP	46	Female	MSW	11
21	JKL	29	Male	MSW	7
22	TYA	31	Female	BSW	11
23	MYO	26	Male	Dip Social Work	8
24	LWA	51	Female	BSW	18
25	REA	53	Male	BSW	13
26	KEO	45	Female	MSW	7
27	LTW	40	Female	MSW	27

Note. MSW signifies Master of Social Work (Issued in government approved institutions in Nigeria, or other regions in Africa); BSW signifies Bachelor of Social Work degree, and Dip of Social Work signifies Diploma in Social Work.

Theme 1: Increasing Demand in Work Environment

The COVID-19 pandemic brought a new dimension to dementia care in Nigeria by implementing several public health protocols, including imposing social distancing measures in most hospitals. Two sub-themes emerged from the interview with the participants: adapting to Evolving Public Health Protocols and Increased Workloads in Dementia Care during the COVID-19 Pandemic. Many participants reported having changed their styles in bedside visits and meetings with families according to shifting protocols, whereby home visits had to be conducted in full compliance with public health prevention protocols and support group meeting to remote delivery. The sudden changes in the pattern of the work environment increased demand on the social workers’ caseloads, hence demanding adjustment in the pattern of services provided. Beyond working with families of people with dementia, most participants considered conveying new public health protocols to families and people with dementia during the pandemic as an additional task. This is because they have to keep up with several workloads at the same time when working with families and people with dementia in their homes, as 1 of the participants highlighted:

It was indeed a difficult time. There was an increase in demand for medical social workers. Initially, there was a lack of awareness about our role, but with time, health care providers have recognized the value we bring to the health care system, especially when COVID-19 stroked the country. As health care becomes more patient-centred, the need for our expertise in ensuring a patient’s overall well-being has grown exponentially. In addition to this, we had to implement strict quarantine measures, which meant limiting social interactions among our patients, home-visiting had to be restricted. This resulted in increased feelings of loneliness, confusion, and agitation among individuals with dementia. We had to work tirelessly to ensure the safety and well-being of everyone by convening new health information during the pandemic. (THM, 45 years)

Participants explained that adapting to the changing public health protocols was extremely challenging because it increased their workload and changed the dynamics of their work environment because they had to quickly instill diverse restrictions that limited physical and social interactions. The participants complained that they had to do this without adequate preparation to accommodate the changing needs of people with dementia and their families in hospital settings.

Participants responded to questions of evolving public health protocols when caring for people with dementia during the pandemic. One of the participants revealed that:

COVID-19 changed the game for us, medical social workers in dementia care. Strict rules like social distancing made our jobs tougher, and demand skyrocketed. At first, our roles weren’t fully recognized, but as the pandemic hit, healthcare providers saw how crucial we are. Dealing with quarantine measures, especially for those with dementia, led to more loneliness and confusion. We had to adapt fast, managing new restrictions in hospitals. Despite the pressure, our main goal was ensuring everyone’s safety during this challenging time. It was tough, but our dedication never wavered (AYE, 42 years)

Participants’ transcript indicated that, COVID-19 had a major impact on the approach to dementia care for medical social workers in the hospital setting. Stringent protocols such as social distancing posed formidable challenges to the profession, coupled with a surge in demand for our services. Although, the roles of social workers was not adequately acknowledged by government, but the pandemic underscored the pivotal nature of their contributions to healthcare. Medical social workers have to swiftly adapt to the situation, as they grappled with the implementation of new restrictions within geriatric and hospital settings.

Theme 2: Impact on Work Climate and Relationships

From our interviews, we noted that an increased workload and dynamic changes in the work environment negatively influenced how medical social workers build connections with patients with dementia, their families, and colleagues. We found 4 sub-theme emerged from the interview: communication challenges with people with dementia and their families, limited resources to meet needs of people with dementia and their families, camaraderie and appreciation from colleagues, and lastly more stressful and less relational work environment among senior staff of the hospital. Although some participants felt that the new public health protocols created some safety measures for contracting COVID-19, the participants also reported mixed reactions from their relationship with patients with dementia, their families, and their colleagues. A majority of the participants described how COVID-19 prevention measures caused poor communication with people with dementia and their families, causing feelings of stress and loneliness for families because they were restricted from visiting their loved ones in the hospital. This experience caused additional stress for social workers who had to ease the families’ emotional strain. One of the participants described the experience:

The increased workload and stress impacted our relationships with our clients and their families. We were required to handle an influx of cases like families stressed because of the restrictions placed on them. The emotional toll was immense, and it strained our relationships with families of people with dementia. We often had to work extended hours and juggle multiple responsibilities, which left little time for self-care and maintaining healthy relationships with our patients and their families. (GAO, 57 years)

For some participants, the preexisting increased stressed work environment was amplified because of limited resources, and meeting the needs of patients and their families was difficult. Because of limited resources, the participants also had to grapple with the hospital’s high workloads. In addition, there were limited options for remote service delivery for medical social workers supporting people with dementia, and this also created uncomfortable relationships in the workplace. One of the participants described the following:

Initially, there was fear and uncertainty among us as medical social workers, even in the face of limited resources. We had to quickly adapt to new protocols, personal protective equipment (PPE), and constantly changing guidelines. Our caseload increased daily, which created a tense and stressful atmosphere, as we were unsure about our safety and of our clients, and remote service was not really guaranteed options for us in the hospital. (KOE, 47 years)

Although some participants focused on the negative impact of the pandemic on their relationship with colleagues in the hospital, the pandemic also brought them closer, fostering comradeship and appreciation. One participant described their experience with colleagues in the hospital caring for people with dementia:

The challenges brought us closer as a team. We started appreciating each other’s efforts and became more empathetic towards our colleagues. As we adapted to the new circumstances, we developed resilience and a stronger sense of camaraderie. We actively supported each other through virtual meetings, sharing experiences, and providing emotional support. This strengthened our relationships and helped alleviate the sense of isolation. We also began recognizing the importance of self-care and prioritizing our well-being, which positively impacted our work climate. (ROA, 48 years)

However, some participants felt that the COVID-19 pandemic created a more stressful and less relational work environment for them because they experienced reduced team cohesion from poor communication among senior staff, lower team spirit, and reduced interpersonal collaboration. A few participants felt that their organization did not adequately recognize their efforts. One participant attested to this:

I feel being used, and my hard work was not sufficiently appreciated and recognized by my hospital. Some of our colleagues in other health care profession were given but we are not considered for such opportunity. I have learnt to be strong and community to my patients. (AYE, 42 years)

Theme 3: Impact on Personal Life of Social Workers

The participants described both positive and negative impacts of COVID-19 when caring for older adults with dementia in the hospital. We found 2 sub-themes which emerged from our interview with the participant: blurred boundaries and physical separation and isolation from the friend and families. Some participants considered the impact an opportunity to strategize new ways of supporting individuals with dementia while, importantly, relying on their resilience. However, some participants revealed how difficult it was to sustain relationships with their families and clients in the hospital. The participants confirmed that social services in some hospitals were considered an essential duty. However, they experienced burnout, feeling overwhelmed with tasks and maintaining a work–life balance. One of the participants described the following:

The pandemic has taken a toll on my personal life in various ways. The increased workload and the shift to remote work have blurred the boundaries between my professional and personal life. It has become challenging to disconnect and take time for self-care. Moreover, the fear of contracting and spreading the virus adds an extra layer of stress and anxiety to our daily lives. I constantly worry about inadvertently exposing my family to the virus. (TOA, 42 years)

Participants had mental stress from the pandemic and reported having to physically separate themselves because of the concerns of transmitting the virus to their families, causing strains in their personal relationships with their families and friends. One participant with several years of work experience described the COVID-19 experience as follows:

For me, the most significant impact was the heightened anxiety and fear of transmitting the virus to my loved ones. Many of us resorted to isolating ourselves from our families, which meant spending extended periods away from our homes and loved ones. This separation took a toll on our mental health and strained our personal relationships. It affected my ability to relax and rejuvenate, which ultimately impacted my personal life and prevented me from fully engaging with my family and friends. (ROA, 48 years)

Theme 4: Suggestions for Future Pandemics

The majority of participants revealed the need for the Nigerian government to improve the system’s capacity to cope with the emerging demands of those with chronic health conditions like dementia and support for their families during the COVID-19 pandemic. Two sub-themes emerged from the interview: Adaptation and flexibility for medical social worker, and emphasis on self-care. One of the participants echoed the importance of adjustment and flexibility for medical social workers by getting updated on the latest guidelines and protocols related to dementia care in a post-COVID world, most notably the use of telehealth services:

Flexibility and adaptability will be key as we transition into the post pandemic era. Medical social workers should stay updated on the latest guidelines and protocols related to dementia care in a post-COVID world. This may include incorporating telehealth and virtual communication tools to ensure continued access to care, especially for those who may face challenges in travelling or visiting health care facilities. (GAO, 57 years)

One participant emphasized the importance of self-care for medical social workers caring for people with dementia in Nigeria:

I would also emphasize the importance of self-care for medical social workers themselves. It’s crucial to prioritize self-care practices, seek support from colleagues, and engage in stress-reducing activities. By taking care of our own well-being, we can continue to provide the best possible care to those with dementia. (AYE, 42 years)

Discussion

This study is the first from Africa to document the experiences of medical social workers supporting people with dementia, particularly during a challenge like the COVID-19 pandemic. The roles of medical social workers are to navigate the complex emotional and social care of people with dementia and their families through assessment of their psychosocial needs, devising tailored care plans that consider individual circumstances.^49-52 They also facilitate effective communication between the health provider, patients, and families, by ensuring a holistic approach to care. They also address financial and legal concerns, they ease the burden on families. Medical social workers emerge as indispensable pillars of comprehensive care. ⁵³ In addition to this, medical social worker navigates the labyrinth of challenges posed by the pandemic to support individuals grappling with dementia. Findings of this study are an essential step toward unpacking resource needs gaps in dementia care in the context of medical social services in Nigeria and other African regions.

Participants described having to strictly adhere to public health protocols, which also include social distancing and masking. These findings align with social workers’ experiences working with other client populations in hospitals.^16,54,55 Strict adherence to public health protocols, including social distancing and masking, reflects a broader pattern observed in social workers’ interactions with people with dementia and their families. Given the vulnerability of individuals with dementia, maintaining strict protocols becomes paramount to protect their well-being, emphasizing the significance of tailored and unwavering infection control strategies in dementia care settings. Participants reported the challenges of conveying public health protocols to families of people with dementia and managing grief associated with its progression. This is consistent with a longitudinal survey of social workers supporting older adults with dementia in the United Kingdom, which revealed adverse mental health outcomes from intensified work demands of social workers in the country. ⁵⁶ A similar report from the English West Midland region indicated that social distancing, anxiety, and emotional labor were enforced among health care workers and social workers during COVID-19. ⁵⁷ Relatedly, as dementia progresses, families are constantly in need of creative ways to cope with the challenging situation of caring for dementia and the COVID-19 pandemic. ⁵⁸ Hence, the parallel enforcement of social distancing, anxiety, and emotional labour among healthcare and social workers underscores the collective strain within the sector. The evolving needs of families dealing with dementia amid the pandemic highlight the necessity for innovative coping while maintaining the well-being and comfort of older adults with dementia in Nigerian hospitals.

Although our findings indicated that COVID-19 safety protocols were enforced to prevent COVID-19 transmission with people with dementia in the hospital, participants expressed how COVID-19 prevention measures caused poor communication, diminished social interactions with colleagues in the work environment, and restricted family members from visiting loved ones with dementia. This implies that social distancing and masking, though essential for safety, pose challenges to effective information exchange, collaboration in dementia care, and the overall cohesiveness of the dementia care team in Nigeria.^11,37 Therefore, social workers in dementia care should think of innovative communications such as enhanced use of digital communication tools or structured team meetings, which could mitigate challenges during a pandemic. A similar study indicated that restricted social interactions pushed social workers in hospital settings, to take up virtual resources for meetings; however, ward rounds with older adults with conditions like dementia were limited. ⁵⁹ The camaraderie and support that often arise from social interactions in the workplace play a crucial role in maintaining a positive and collaborative work environment. ⁶⁰

Participants expressed that family members were restricted from visiting loved ones with dementia, which added another layer of complexity. Although these restrictions aim to minimize virus transmission risks, they have profound emotional and psychological effects on the person with dementia and their families. These findings are consistent with the international report from the Lancet Commission, which indicated that family caregivers experienced significant worries and anxieties about their loved ones with dementia during COVID-19. ⁶¹ This findings is consistent with an international study which revealed that family caregivers who previously visited a person with dementia before COVID-19 but became more concerned during the visitation-ban than those who had gone less frequently. Also, family caregivers who used to visit the person with dementia daily but only saw them once a week during the guest ban were less concerned. ⁶² The discerned constraints on familial visitations for individuals with dementia amid the COVID-19 pandemic carry profound implications. Despite the ostensibly protective intent of these restrictions in minimizing viral transmission risks by government, these manifest significant emotional and psychological repercussions for both the individuals living with dementia and their familial caregivers. Intervention strategies are warranted to facilitate sustained interpersonal connections and mitigate the pronounced loneliness experienced by individuals with dementia and their families in the wake of restricted visitations.

The participants’ narratives illuminate the challenging landscape of healthcare provision within Nigerian hospitals, characterized by a preexisting atmosphere of heightened stress. This already strained work environment becomes even more arduous when tasked with the care of individuals with dementia and their families, a circumstance compounded by the prevalent constraints of limited resources. Notably, these findings resonate with the experiences of social workers in analogous low and middle-income country settings globally, where the confluence of stress and restricted resources imparts an additional layer of complexity.^1,63 This parallel underscores a pervasive global phenomenon, wherein the exigencies of the pandemic further amplify the struggles faced by medical social workers in delivering comprehensive and timely care to individuals with dementia and their families in resource-constrained environments. Hence, there is need for increased resource allocation to healthcare facilities in large countries like Nigeria, by specifically focusing on provisions for dementia care. This could include funding for training programs, hiring additional staff, and ensuring the availability of necessary equipment and facilities., Although medical social services departments in hospitals were considered essential during COVID-19 pandemic, medical social workers caring for people with dementia experience significant burnout, and are overwhelmed with completing tasks, including balancing work and life. This finding is in tandem with the view Agwu et al. and Isangha et al. that that burnout and inability to complete a task are associated with a high workload, emotional exhaustion, and a sense of not being able to meet the demands of the job.^16,64 While the aforementioned studies may not explicitly address the realm of dementia care, recogniting these stressors and their potential impact on the mental well-being and job satisfaction of medical social workers is pivotal. This recognition is imperative due to the consequential nature of burnout, which has the propensity to compromise the overall quality of care furnished to patients. Further, participants reported feeling overwhelmed with completing tasks, suggesting systemic issues may contribute to the strain on social workers caring for people with dementia could be related to understaffing, inadequate resources, or unrealistic expectations regarding communicating difficult information about dementia and COVID-19.^16,64 This observation underscores the multifaceted nature of the challenges faced by medical social workers and suggests a critical need for systemic interventions to address structural issues within the healthcare framework, thereby fostering a more supportive and sustainable environment for those tasked with the demanding responsibility of dementia care. The majority of participants recommended that the government should improve the capacity of the system to meet the emerging demands of those with chronic health conditions like dementia and support for their families during the COVID-19 pandemic in Nigeria. For example, a study suggested more funding is required for enhanced health and social services system support capacity. ⁶⁵ Furthermore, building professional development for medical social workers supporting people with dementia in Nigeria in practice during a lengthy crisis like COVID-19 (eg, techniques for helping socially isolated people with dementia, negotiating powerful emotions from family members, support for working in a traumatic situation) might receive particular emphasis. The discerned findings accentuate the pivotal role that medical social workers may assume, not only as advocates for individuals with dementia within hospital settings but also as agents advocating for broader programmatic and systemic transformations in the healthcare landscape of Nigeria. This collective call to action underscores the necessity for proactive measures and strategic investments to fortify the healthcare infrastructure and ensure the holistic well-being of individuals grappling with chronic health conditions amidst unprecedented health crises.

Limitations

This study included a small group of medical social workers in Nigerian hospitals in Nigeria’s southwestern region, and resource constraints hence, sample size/power analysis was not conducted. Future research using participatory action research and more extensive and more varied samples, encompassing medical social workers in all 36 states in Nigeria (eg, government, nonprofit, and private) might be important, as might an evaluation of interdisciplinary staff influences. Notably, the research was conducted during the COVID-19 pandemic; hence, more study is needed to determine the pandemic’s long-term effects on social workers supporting people with dementia in future pandemics.

Implication to Policy and Practice

The study underscores critical implications for policy and practice in the care of persons with dementia during the COVID-19 pandemic. Policies should prioritize mental health support for medical social workers, integrating resources for stress management and emotional well-being even in future pandemic. Training and guidelines are necessary to navigate evolving COVID-19 protocols, ensuring worker competence and safety particularly for individual with dementia. Effective communication strategies with families, facilitated by policies and communication skills training, are essential for quality dementia care. Addressing work–life balance challenges through policy initiatives and flexible work arrangements is crucial. Long-term sustainability of social services necessitates policy-driven resource allocation and career development opportunities. Finally, incorporating lessons from the study into pandemic preparedness plans is vital for a resilient healthcare system. In all, findings from could enhance the support system, professional well-being, and overall quality of care for individuals with dementia, emphasizing the importance of proactive policies and practices in healthcare settings.

Conclusion

In this study, we expand on the experience of medical social workers caring for persons with dementia during the COVID-19 pandemic. Critical challenges noted in the study include negotiating COVID-19 preventive protocols, handling complex communications with families, and managing significant pressure while providing medical social services to people with dementia and their families. These findings highlight that addressing burnout and work–life balance challenges among social workers in hospital social services is crucial for maintaining the quality of care for people with dementia, supporting the well-being of healthcare professionals, and ensuring the long-term sustainability of essential social services in dementia care with the ultimate goal of preparing for future pandemics.