Evaluation of a comprehensive health check offered to frontline health workers in Zimbabwe

Health workers are essential for a functioning healthcare system, and their own health is often not addressed. During the COVID-19 pandemic health workers were at high risk of SARS-CoV-2 infection whilst coping with increased healthcare demand. Here we report the development, implementation, and uptake of an integrated health check combining SARS-CoV-2 testing with screening for other communicable and non-communicable diseases for health workers in Zimbabwe during the COVID-19 pandemic. Health checks were offered to health workers in public and private health facilities from July 2020 to June 2022. Data on the number of health workers accessing the service and yield of screening was collected. Workshops and in-depth interviews were conducted to explore the perceptions and experiences of clients and service providers. 6598 health workers across 48 health facilities accessed the service. Among those reached, 5215 (79%) were women, the median age was 37 (IQR: 29–44) years and the largest proportion were nurses (n = 2092, 32%). 149 (2.3%) healthcare workers tested positive for SARS-CoV-2. Uptake of screening services was almost 100% for all screened conditions except HIV. The most common conditions detected through screening were elevated blood pressure (n = 1249; 19%), elevated HbA1c (n = 428; 7.7%) and common mental disorder (n = 645; 9.8%). Process evaluation showed high acceptability of the service. Key enablers for health workers accessing the service included free and comprehensive service provision, and availability of reliable point-of-care screening methods. Implementation of a comprehensive health check for health workers was feasible, acceptable, and effective, even during a pandemic. Conventional occupational health programmes focus on infectious diseases. In a society where even health workers cannot afford health care, free comprehensive occupational health services may address unmet needs in prevention, diagnosis, and treatment for chronic non-communicable conditions

Exploring COVID-19 vaccine uptake among healthcare workers in Zimbabwe: A mixed methods study.

With COVID-19 no longer categorized as a public health emergency of international concern, vaccination strategies and priority groups for vaccination have evolved. Africa Centres for Diseases Prevention and Control proposed the '100-100-70%' strategy which aims to vaccinate all healthcare workers, all vulnerable groups, and 70% of the general population. Understanding whether healthcare workers were reached during previous vaccination campaigns and what can be done to address concerns, anxieties, and other influences on vaccine uptake, will be important to optimally plan how to achieve these ambitious targets. In this mixed-methods study, between June 2021 and July 2022 a quantitative survey was conducted with healthcare workers accessing a comprehensive health check in Zimbabwe to determine whether and, if so, when they had received a COVID-19 vaccine. Healthcare workers were categorized as those who had received the vaccine 'early' (before 30.06.2021) and those who had received it 'late' (after 30.06.2021). In addition, 17 in-depth interviews were conducted to understand perceptions and beliefs about COVID-19 vaccines. Of the 3,086 healthcare workers employed at 43 facilities who participated in the study, 2,986 (97%, 95% CI [92%-100%]) reported that they had received at least one vaccine dose. Geographical location, older age, higher educational attainment and having a chronic condition was associated with receiving the vaccine early. Qualitatively, (mis)information, infection risk perception, quasi-mandatory vaccination requirements, and legitimate concerns such as safety and efficacy influenced vaccine uptake. Meeting the proposed 100-100-70 target entails continued emphasis on strong communication while engaging meaningfully with healthcare workers' concerns. Mandatory vaccination may undermine trust and should not be a substitute for sustained engagement

Prevalence of chronic conditions and multimorbidity among healthcare workers in Zimbabwe:Results from a screening intervention

Non-communicable diseases (NCDs) are the leading causes of death globally, with most deaths occurring in low and middle income countries [1]. In particular, diabetes, hypertension, and their consequences, are among the top five causes of death and disability, with their prevalence and impact projected to increase dramatically in the coming decades. In southern Africa, the rapidly increasing impact of NCDs on mortality and years lived with disability is occurring in a context of ongoing high prevalence of HIV, tuberculosis (TB) and nutritional disorders, and a persisting substantial burden of other infections [2]. This presents considerable challenges to fragile health systems.Shared social and structural risk factors, together with shared biological pathways, mean that chronic conditions coexist within individuals: this phenomenon of multimorbidity, commonly defined as two or more physical or mental health conditions of long duration, magnifies the physical, psychological, social and financial consequences of ill health [3]. The last decade has seen growing awareness of multimorbidity with a suggestion of high prevalence of multimorbidity in Africa (pooled prevalence among adults 28% from a systematic review) [4]. However, population-based data are only available from a few countries and have usually relied on self-reported conditions [4,5], an approach which is likely to underestimate prevalence given that many conditions are undiagnosed [6,7].The healthcare workforce is the core of any health system: maintaining staff wellbeing is critically important for population health generally, for achieving Sustainable Development Goals, and for our ability to combat future pandemics [8]. Africa faces a healthcare workforce crisis, with a projected shortfall of 6.1 million healthcare workers by 2030 [9]. Alongside a severe HIV epidemic, Zimbabwe has experienced a sustained economic crisis that has severely impacted the health system and resulted in a mass exodus of health workers [10]. The infrastructure for identifying and managing NCDs is weak, resulting in underdiagnosis and undertreatment [11]. As a result of a depleted healthcare workforce, Zimbabwe has been added to the WHO health workforce support and safeguards list [12].It is likely that chronic diseases and multimorbidity impact on the ability of healthcare workers to continue to work, resulting in illness-related absences, requiring adjustment of work roles, or leading to early retirement. In countries affected by economic migration, staff who remain are generally older and therefore likely to be at higher risk of multimorbidity; increasing the impact of multimorbidity on human resources for health [13]. There are no studies on the prevalence or impact of multimorbidity among healthcare workers in Africa nor of multimorbidity among the general Zimbabwean population. One small study reported on the prevalence of hypertension among healthcare workers in Africa; whilst more reports have considered mental health in the context of the COVID-19 pandemic. Zimbabwean NCD prevalence estimates are either almost 20 years old or restricted to people attending HIV clinics [14].In the context of the COVID-19 pandemic, we implemented comprehensive health check-ups for healthcare workers in Zimbabwe, to provide access to SARS-CoV-2 testing and to address underlying risk factors for severe COVID-19 (ICAROZ [Impact of the COVID-19 pandemic on healthcare workers and the healthcare system in Zimbabwe]). In this analysis, we aimed to describe the epidemiology of both multimorbidity and the prevalence of individual chronic conditions, among healthcare workers in Zimbabwe

Prevalence of known and screening-detected chronic conditions and multimorbidity.

Prevalence of known and screening-detected chronic conditions and multimorbidity.</p

Inclusivity questionnaire.

The burden of non-communicable diseases (NCDs) in southern Africa is expanding and is superimposed on high HIV prevalence. Healthcare workers are a scarce resource; yet are vital to health systems. There are very limited studies on the burden of chronic conditions among healthcare workers in Africa, and none exploring multimorbidity (≥2 chronic conditions). We describe the epidemiology of infectious (HIV) and non-communicable chronic conditions, and multimorbidity, among Zimbabwean healthcare workers. Healthcare workers (≥18 years) in eight Zimbabwean provinces were invited to a voluntary, cross-sectional health-check, including HIV, diabetes, hypertension and mental health screening. Statistical analyses described the prevalence and risk factors for multimorbidity (two or more of HIV, diabetes, hypertension or common mental disorder) and each condition. Missing data were handled using multiple imputation. Among 6598 healthcare workers (July 2020–July 2022) participating in the health-check, median age was 37 years (interquartile range 29–44), 79% were women and 10% knew they were living with HIV. Half had at least one chronic condition: 11% were living with HIV, 36% had elevated blood pressure, 12% had elevated HbA1c and 11% had symptoms of common mental disorder. The overall prevalence of multimorbidity was 15% (95% CI: 13–17%); 39% (95% CI: 36–43%) among people aged 50 and older. Whilst most HIV was diagnosed and treated, other chronic conditions were usually undiagnosed or uncontrolled. Limiting our definition of multimorbidity to two or more screened conditions sought to reduce bias due to access to diagnosis, however, may have led to a lower reported prevalence than that found using a wider definition. Half of healthcare workers screened were living with a chronic condition; one in seven had multimorbidity. Other than HIV, most conditions were undiagnosed or untreated. Multisectoral action to implement contextually relevant, chronic disease services in Africa is urgently needed. Specific attention on health workers is required to protect and retain this critical workforce.</div

Euler diagrams illustrating prevalence and clustering of chronic conditions by age categories, in multiply imputed dataset (N = 6598).

* indicates prevalence ≤1%. Conditions are indicated by colour and line type. Non-intersecting white circles = no conditions; yellow circles with dotted lines = HIV; blue circles with dashed lines = elevated blood pressure (BP); green circles with dot/dash lines = elevated HbA1c; purple circles with solid lines = common mental disorder.</p

Disease control status of chronic conditions and multimorbidity, in multiply imputed dataset (N = 5215 women / 1383 men).

Clients were considered to have a condition if they either self-reported or screened positive during the study. Screening positive was defined as follows. Hypertension: Systolic BP ≥140mmHg or diastolic BP ≥90mmgHg. Diabetes: ≥6.5%. Common mental disorder: Shona Symptom Questionnaire Score ≥8. In the plot of multimorbidity (right panel), included conditions are HIV, diabetes, hypertension, and common mental disorders. Multimorbidity is defined as two or more conditions coexisting in an individual (orange, yellow or red). Disease control is defined as having a previous history of the condition, but a normal result during screening (e.g., known diabetes but HbA1c <6.5% on testing). HIV control was not assessed, HIV on treatment is included as a ‘controlled’ condition in the multimorbidity figure.</p

Supplementary methods, results and completed STROBE checklist.

Supplementary methods, results and completed STROBE checklist.</p

Univariable and multivariable risk factors for multimorbidity and its component conditions, after multiple imputation (N = 6598).

Univariable and multivariable risk factors for multimorbidity and its component conditions, after multiple imputation (N = 6598).</p

Characteristics of study population (N = 6598).

The burden of non-communicable diseases (NCDs) in southern Africa is expanding and is superimposed on high HIV prevalence. Healthcare workers are a scarce resource; yet are vital to health systems. There are very limited studies on the burden of chronic conditions among healthcare workers in Africa, and none exploring multimorbidity (≥2 chronic conditions). We describe the epidemiology of infectious (HIV) and non-communicable chronic conditions, and multimorbidity, among Zimbabwean healthcare workers. Healthcare workers (≥18 years) in eight Zimbabwean provinces were invited to a voluntary, cross-sectional health-check, including HIV, diabetes, hypertension and mental health screening. Statistical analyses described the prevalence and risk factors for multimorbidity (two or more of HIV, diabetes, hypertension or common mental disorder) and each condition. Missing data were handled using multiple imputation. Among 6598 healthcare workers (July 2020–July 2022) participating in the health-check, median age was 37 years (interquartile range 29–44), 79% were women and 10% knew they were living with HIV. Half had at least one chronic condition: 11% were living with HIV, 36% had elevated blood pressure, 12% had elevated HbA1c and 11% had symptoms of common mental disorder. The overall prevalence of multimorbidity was 15% (95% CI: 13–17%); 39% (95% CI: 36–43%) among people aged 50 and older. Whilst most HIV was diagnosed and treated, other chronic conditions were usually undiagnosed or uncontrolled. Limiting our definition of multimorbidity to two or more screened conditions sought to reduce bias due to access to diagnosis, however, may have led to a lower reported prevalence than that found using a wider definition. Half of healthcare workers screened were living with a chronic condition; one in seven had multimorbidity. Other than HIV, most conditions were undiagnosed or untreated. Multisectoral action to implement contextually relevant, chronic disease services in Africa is urgently needed. Specific attention on health workers is required to protect and retain this critical workforce.</div