Health care workers’ risk behaviors and health status: Hidden realities or new paradigms?

Abstract

Healthcare workers (HCWs) and health systems comprise one of the most critical, diverse, and largest industries globally. Healthcare and public health research is often focused on population disease prevention and management, health and disease risks among the public, patient treatment and outcomes, drug and device in-novations, healthcare costs, quality, and utilization. Not much is written about the health of HCWs despite the fact that their health is an indirect and major determinant of population health and health system functioning. This editorial proposes focus categories to examine and understand the determinants of the health of HCWs. We are also calling for more research on this topic and submissions to this journal on the extent and nature of health risk and protective factors among HCWs, the determinants of various health problems among HCWs, and interventions or initiatives as real-world examples of what works in improving various dimensions of the health of HCWs.

Background

Healthcare workers (HCWs) are the backbone of healthcare systems. HCWs are fundamental in delivering essential healthcare services to individuals, families, and communities worldwide. They provide health education, preventive care, diagnostic services, therapies and treatment, rehabilitation, and palliative care making profound contributions to the well-being and quality of life of populations [1,2]. HCWs also play a crucial role in improving population health outcomes, addressing disparities, responding to emergencies and disasters, strengthening health systems, and serving as advocates for public health practice and research [1,2]. Recent estimates suggest that there are more than 50 million HCWs worldwide. If the social services sector is included (given the close alignment in nature of work with HCWs), currently there are more than 100 million health and social sector workers worldwide [1–3]

HCWs are instrumental in disease management and motivating patients to adopt healthier lifestyles and prevent diseases. The general public often holds HCWs in high esteem, may view them as modelers of healthy behaviors, considers them knowledgeable on health-related topics, and anticipates the best care or advice on disease prevention and risky behavior reduction from HCWs [4–10]. However, are HCWs able to meet these expectations given that many of them engage in high-risk behaviors or do not enjoy the best health? Do we focus enough on the health of HCWs? Were HCWs always at a higher risk for specific health problems or did the COVID-19 pandemic change the way HCWs engage in health risk behaviors or maintain their health? Above all, why are HCWs at risk for certain unhealthy behaviors and health problems?

The health of healthcare workers: trends and impact

Before the COVID-19 pandemic, collective evidence suggested that HCWs are at a higher risk for certain injuries (e.g. needlestick), various exposures (e.g. chemicals or radiations), chronic health issues (e.g. sleep and musculoskeletal disorders), infectious diseases (e.g. COVID-19 or influenza), psychological trauma and burnout (e.g. depression or anxiety), violence (e.g. verbal or physical; between and against HCWs), lack of social support and isolation, just to name a few [1,3,6,9–12]. While these were primarily occupational hazards, a plethora of studies before the COVID-19 pandemic also indicated risk behaviors among HCWs, such as not following safety protocols and infection prevention behaviors (e.g. handwashing), neglecting prevention recommendations (e.g. screenings for disease or adhering to dietary guidelines), and high rates of obesity, self-harm, smoking, and alcohol and substance use [4,6,8, 11–14]. Many of these studies indicated that the rates of health problems and risk behaviors could be similar, if not higher, among HCWs as compared to the general population. A global review from before the COVID-19 pandemic found a significantly higher risk of suicides among physicians (varying by specialty) compared to the general population and a recent analysis of the U.S. workforce from 2008 to 2019 found that the sex-and age-standardized suicide rates were significantly higher among HCWs as opposed to their non-healthcare counterparts [14,15]. While the pandemic brought the plight of HCWs under intense focus, the health of HCWs remained neglected and often poor even before the pandemic.

The COVID-19 pandemic changed lives and societies around the world. The group of professionals that was disproportionately affected as it relates to health and safety were HCWs. During the early and acute phase of the COVID-19 pandemic, there were numerous reports of fear and burnout, depression and anxiety, loneliness and isolation, sleep problems and reduced quality of life, pessimism and exhaustion, psychological distress and trauma among HCWs [15–18]. After the first year of the pandemic, several reviews and studies highlighted unhealthy lifestyles (e.g. suboptimal diet quantity and quality and inadequate exercise), poor or maladaptive coping with stress, excess alcohol, tobacco, and drug use in this population [18–20]. More recently, reports about violence against HCWs during the pandemic have also been published where it has been estimated that COVID-19 may have exacerbated this problem [21]. For COVID-19 infection prevention, numerous studies highlighted inadequate infection prevention practices and vaccination hesitancy in HCWs [7,22–24]. For contracting COVID-19 infection, the evidence is scattered, but studies estimated higher risk among HCWs with infection rates as high as 50 % or more for HCWs serving on the frontlines [23–27]. Similarly, there are no comprehensive global data for rates of hospitalization or complications due to COVID-19 infection among HCWs, but the rates could be as high as 25 % or more [26–29]. Recent studies also estimate that less than a tenth to more than half of the HCWs infected with COVID-19 may experience long-COVID or post-COVID conditions [29–32]. The worst manifestation of health risk among HCWs during the pandemic was in the form of excess mortality. Conservative estimates by the summer of 2021 suggested that more than 100,000 HCWs worldwide and more than 3000 HCWs in the U.S. may have died due to COVID-19 infection (with a higher risk of mortality among frontline, older, and minority HCWs) [33,34]. We believe that most of these problems are underestimated and need better data estimates.

The impact of a sick and unhealthy workforce of HCWs is well documented [6,10–12,20,32,35,36]. These impacts can be categorized by impact on HCWs and their coworkers, patients, and health systems. For instance, disengagement and reduced productivity, lower quality of life and morale, absenteeism and morbidity, financial burdens, and dissatisfaction are impacts upon HCWs. For patients, poor health of HCWs may lead to reduced time with patients or the spread of disease, poor quality of care, medical errors and healthcare safety issues, lack of counseling on healthy behaviors, errors in diagnosis/treatment, unfavorable health outcomes or lower satisfaction among clients, reduced trust, higher care costs, unfulfilled patient medical, social, and emotional needs. For health systems, the most profound and direct impact of poor health of HCWs relates to financial losses (e.g. higher costs due to turnover, staff shortages, or lower efficiencies and system productivity) [6,10–12,20,32,35,36]. Unfortunately, the vast majority of the member states of the World Health Organization do not have policy instruments or national programs for managing occupational health and safety of health workers.

Why are healthcare workers unhealthy?

Health risk behaviors and health problems of HCWs are fairly well documented along with the impacts of an unhealthy workforce of HCWs [16–36]. However, the reasons for health problems among HCWs have not been systematically examined and in published literature, the reasons mostly surround issues such as higher stress and poor coping. Also, the published studies mostly focus on a select group of HCWs such as nurses or physicians ignoring the health and risk behaviors of other types of HCWs. This was especially observed during the COVID-19 pandemic when the vast majority of studies related to HCWs’ health focused on mental health and psychological distress among selected groups of HCWs. There are many topics to be explored further (e.g. beyond mental health) and more research is needed on the determinants of poor health among HCWs (including those groups who have not been well studied). We believe that there is a comprehensive, tailored, and lifespan approach needed to understand the determinants of unhealthy behaviors, health risks, and diseases among HCWs as outlined below.

Population norms and foundational years

In the formative years and for a large part of their life, HCWs are not a unique group. HCWs have grown up adhering to the same norms and behaviors and they are products of the same societal contracts that mold the general population. Their formative years have been subjected to the same health routines, risky behaviors, sociocultural influence, and lifestyles as the general population. Interestingly, while many students/trainees select health-related fields for their careers due to family members’ preferences, occupations, and motivation, it is also known that family members/parents profoundly influence lifestyles and behaviors in young people [35,37]. As we emphasized earlier on smoking, alcohol use, and obesity, it is noteworthy that a significant proportion of adults today who engage in these behaviors adopted these behaviors during adolescence [38–42]. For example, the vast majority of current smokers in the world initiated this behavior between the ages of 14 and 25 years, and a fifth or more of the smokers began smoking during adolescence [38]. Similarly, various studies estimate more than a fifth of adults and adolescents around the world are current drinkers and the average age for alcohol use initiation is in early adolescence [39]. Recent estimates also suggest that the global average for the diagnosis of first mental illness is now less than 18 years of age [40]. Experimentation with drugs, engagement in risky sexual behaviors, consuming unhealthy diets, and acquiring sedentary behaviors are other examples of health risks that are frequently acquired before young adulthood or entering the workforce [38–42]. It would be imprudent to assume that HCWs suffer from diseases or engage in unhealthy behaviors after joining the workforce. It would also be unwise not to offer services commonly sought by patients to trainees and future HCWs (e.g. smoking cessation, psychotherapy, weight and stress management, etc).

Preparations and trainings

HCWs are trained in colleges and universities about various health topics, including the human body or pathophysiology, risk identification or diagnosis, and disease prevention or treatment. However, managing personal health, maintaining well-being, and coping with stress on an individual level requires a different level of skill, training, and understanding of strategies to maintain health. Training on health-related topics may not lead to healthier behaviors. Several studies with practicing and trainee HCWs have found high rates of avoidance of preventive or medical care, hesitancy in seeking help for mental health issues, denial or neglect of advice and guidance on health, poor coping and stress management, engagement in risky behaviors, and a greater tendency for self-diagnosis and self-medication among future and current HCWs [11–13,19,25,35,43–47]. Given the wide spectrum of students and trainees in the healthcare field and the lack of published literature, it is unclear what the nature, level, and extent of training is for these students on topics of personal health management and well-being promotion. While the traditional curricula may not cover such topics, hundreds of investigations worldwide have been conducted in the form of interventions for students and trainees in the health field across disciplines and colleges globally. These interventions and initiatives that focus on students of health fields indicate a dominant focus on mental health, stress and coping, substance use prevention and sleep hygiene, building resilience, or general wellness [44–47]. A general limitation highlighted in published studies has been the absence of an evaluation of the long-term impacts of such interventions on health of students in health related fields. Another major constraint is that the training schedules are often intense and may last a few years to more than a decade, leaving little opportunity for personal fitness and health regimes. Beyond a lack of personal health management training, students and trainees in the health field are often also poorly equipped for future professional challenges. Financial literacy and work-life balance, mentoring and communication with others, legalities or ethical challenges, violence from patients and coworkers, the ever-changing landscape of healthcare systems, administrative work or research obligations, and continuing professional development are some of the topics that may directly or indirectly affect the health of HCWs [35–37,44–49]. Still, HCWs may not have received adequate preparation for these challenges

People, personalities, and professions

After training and preparation, HCWs obtain employment in various settings. The healthcare workforce is probably one of the most diverse industries worldwide. There are differences among individuals in this workforce based on education, training, skills, responsibilities, practice settings, working shifts/timing, and roles. Additional differences are based on gender, age, race and ethnicity, employment status, income, childhood experiences, personality types, sexual orientation, and other sociodemographic characteristics. These differences are related to health risk behaviors, health status, probability of work-related sickness, or occupational diseases among HCWs [17–22,27,35,43,47,50,51]. Such diversity and heterogeneity challenge accurate assessments of the total number of HCWs worldwide, their most common health risks, health behaviors, and occupation-related diseases or injuries. However, it is well known that within the healthcare workforce, those with lower education and income, involvement in direct patient care or frontline work, in high-stress or fast-paced occupations, and women and minorities are at the highest risk of certain unhealthy behaviors or health risks (e.g. violence, injuries, poor mental and physical health)[3,9,10,12,17, 21,43,47]. Again, assuming that all HCWs maintain the highest level of health would be imprudent if we solely base our observations on HCWs who live the longest or have the highest incomes (e.g. male physicians in certain specialties). Further research is needed on health risks and diseases specific to various groups of HCWs and how sociodemographic or occupational differences play a role. Additionally, detailed regional and global data collection on HCWs’ social, economic, occupational, and health conditions is needed with stratification and categorization based on the aforementioned differences among HCWs.

Professional demands, occupational risks, and organizational challenges

HCWs may not always have the liberty to control work schedules and job demands (as seen among many other occupations). Some of the known stressors among HCWs are long or irregular work hours (e.g. shift work), dealing with high-stress and complex situations (e.g. life and death decisions), practicing in fast-paced environments (e.g. emergencies), strenuous mental responsibilities or physical demands, experiences of work overload and effort-reward imbalance (e.g. due to workforce shortages or inadequate compensation), experiencing mistrust or poor communication (E.g. from clients and coworkers), fear and moral dilemmas, or higher risk of hazardous exposures (e.g. physical, chemical, biological, and ergonomic) [6,10,12,17,50–53]. These are critical factors known to directly and indirectly influence HCWs’ health. For organizational issues affecting the health of HCWs, beyond the stressors and exposures at work, there are ever-changing systems and technologies, financial compulsions and legal/regulatory demands, inadequate access to healthcare or health promotion services, workplace violence and lack of good leadership, discrimination and lack of resources, unclear guidelines/policies and poor communication, lack of training for HCWs and human resource management inadequacies [52–60]. As a result, several experts and scholars have proposed a business case for HCWs’ well-being and suggested increasing investments in safe and healthy workplaces for health professionals [36, 37,53–55]. However, the major challenge remains in understanding what works and how to improve the health and safety of a diverse population of HCWs. While the literature is awash with workplace wellness interventions, most do not focus on HCWs or healthcare settings. Also, the interventions implemented in healthcare settings are localized to a healthcare facility or region and may not be universally valuable and effective due to challenges of replicability and sustainability given the global diversity in types of HCWs and their work characteristics [50–55].

Call for research

Since the beginning of this journal, we have constantly looked out for and received quality submissions on the health and work of HCWs [56–63]. In the first issue, a study by Olasupo found that emotional exhaustion positively predicted turnover intention, and workplace health promotion programs for nurses could help reduce the negative effects of job demands [58]. In the current issue, a study by Ndong and colleagues found that among Senegalese practitioners managing abdominal surgical emergencies, the prevalence of high burnout (at least in one dimension) was 46.2 % [59]. In contrast, another study in the current issue by Maple and colleagues describes HCWs’ perceptions of strategies that could support their mental health [60]. In this study from Australia, more than 5000 HCWs responded to an open text question “What strategies might be helpful to assist frontline healthcare workers during future crisis events like pandemics, disasters, etc.?”. Four major themes emerged: workplace structures to support a healthy work environment; supportive leadership and management; strengthening a sense of community to support mental health; and organizational culture normalizing mental health support [60]. Other studies in the current and previous issues of this journal have also touched upon topics such as physician shortage and burnout, policies and workforce trends for HCWs, the determinants and impact of technology use on HCWs, lack of training or guidelines, shortage of supplies or determinants of medical errors by HCWs, etc [56–63].

Recognizing that HCWs’ health and well-being are key to the overall health of the population, the editors of this journal are committed to further facilitating research on the health of HCWs. First, we seek submissions on the prevalence and nature of health risk factors and diseases among HCWs as well as submissions that extend beyond the traditionally well-examined health issues (e.g. stress and burnout) among selected groups of HCWs (e.g. nurses). Second, we are keenly interested in submissions that address the determinants of various health problems among HCWs (e.g. personality types vs. social influences vs. work settings). Finally, we encourage submissions on interventions and initiatives providing real-world examples of what works in improving various dimensions of the health of HCWs. For all these submissions, we are committed to expedited and high-quality reviews to facilitate research in this area and highlight the health issues among HCWs who are the backbone and lifelines of our health systems.