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Psychological resilience, fragility and the health workforce: lessons on pandemic preparedness from Liberia and Sierra Leone
  1. Laura Dean1,
  2. Janice Cooper2,
  3. Haja Wurie3,
  4. Karsor Kollie4,
  5. Joanna Raven1,
  6. Rachel Tolhurst1,
  7. Hayley MacGregor5,
  8. Kate Hawkins6,
  9. Sally Theobald1,
  10. Bintu Mansaray3
  1. 1Centre for Health Systems Strengthening, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
  2. 2Carter Center, Monrovia, Liberia
  3. 3University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Western Area, Sierra Leone
  4. 4Neglected Tropical Disease Programme, Ministry of Health, Monrovia, Liberia
  5. 5Institute of Development Studies, Brighton, Brighton and Hove, UK
  6. 6Pamoja Communications, Brighton, UK
  1. Correspondence to Laura Dean; Laura.Dean{at}

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  • Health workers in fragile settings are constantly exposed to stressors that become exacerbated in times of crisis; the scarcity within which they operate is now increasingly globally acknowledged.

  • Many providers—whether based in facilities or communities—may still carry unresolved trauma from earlier shocks.

  • Health systems resilience may require fundamental changes in resources and other structural factors, but also key to this is facilitating health workers access to long-term psychological support to enable them to navigate psychological distress.

  • Psychological support during shocks should be available for all health workers early, consider needs across cadres (including close to community providers) and respond to cumulative and historic trauma as well as associated stigma.

  • Health system planners need to design context-specific responses that are informed by close to real-time data and systematic research focused on improving understanding of healthcare workers stresses and mental health needs.


COVID-19 presents a time to redefine vulnerability; however, in discussions of vulnerability, the health workforce, particularly in regard to their psychosocial well-being, is often forgotten.1

Healthcare workers (HCWs) in fragile settings are constantly exposed to health system shocks, including; conflict, disease outbreaks and natural disasters, which compound the everyday challenges of working in an under-resourced health system. Based on a commitment to serve their communities, they often cope with repeated shocks and protracted crises through innovation and creative thinking.2 However, they also experience repeated acute and chronic stressors that can lead to psychological distress. For some, prolonged exposure to risk of psychological distress can lead to personal growth, for others, continuous exposure to chronic stress and uncertainty can lead to psychological injury.3

Psychological impact cannot be reduced to personal resilience, rather it becomes linked to dynamic interactions between an individual and the structural and social circumstance within which they live and work; as well as the level …

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