Does prolonged stress enhance coping? Nigerian healthcare providers and COVID-19-related stress management

‘When the going gets tough, the tough get going’ appears to fit the response to difficult situations by many healthcare personnel (HCP) in Nigeria. Healthcare workers globally have experienced increased challenges during the COVID-19 pandemic. These include heavier workload, burnout, incommensurate compensation and isolation, which are all potential psychological stressors.^[1,2] The novelty of the pandemic and the relentless media reporting heightened trepidation with a profound effect on mental health. Increased rates of anxiety, depression, and suicides have been reported among HCP with^[3,4] some quitting their jobs or planning career changes.^[5,6]

The Nigerian HCP faces additional stress of unmet basic physiological needs of food, clothing, shelter, and security in their struggle to fulfill the fundamental needs on Maslow’s hierarchy ladder as previously described by Abiola.^[7] The expectation may be for these Nigerian HCP to have a higher risk of depression, anxiety, and other manifestations of stress during the COVID-19 pandemic. However, the study by Mokogwu in this issue of JPATS paints a slightly different picture.^[8] In their study among quarantined HCP in a tertiary hospital in South-South Nigeria conducted early in the pandemic, the frequency of anxiety and depression was 23.2% and 22.8%, respectively, when compared with 44.6% and 50% from a study by Lai et al. in China.^[8,9] As opined by Mokogwu, the Nigerian HCP may have built up psychological buffers to stress that mitigate these expected outcomes.^[8] This seems to be a harsh stance, but could it have helped them develop more effective coping muscles? Physiologically, constant or hyperstimulation can produce numbness due to the theory of attaining the threshold where further stimulation produces no more reaction.^[10,11] Perhaps, the constant or increasing daily stress faced by Nigerian HCP has caused a numbing of some sort or reduced their ability to respond to further noxious stimuli, helping them ‘cope’ with new stress.

Croghan et al. discussed resilience in healthcare workers as being influenced by multiple factors at the individual, organizational and societal levels.^[12] At the individual level, the ability to communicate face to face or virtually was uppermost in the coping strategy employed by Nigerian HCP with 90.6% frequency in the study by Mokogwu compared with 26% of talk therapy and 16% of virtual support groups in a New York study.^[8,13] Nigerians usually have a strong network of family and friends who provide social support, helping them cope with psychological challenges.^[14] This form of non-professional counseling has been shown to reduce the need for professional counseling which is not readily sought in Nigeria and other low- and middle-income countries.^[8,15] It lends credence to the phrase that ‘a problem shared is a problem halved’.

A similar finding was reported by Couper et al. among rural Canadian doctors; sharing information with peers and discussing it with family was a common coping tool.^[16]

Lower rates of anxiety and depression among HCP in Nigeria should, however, not be construed as a positive outcome because it may only be the ‘calm before the storm’ as this numbness could lead to worse psychological problems in the future.^[17] Therefore, a combination of coping strategies needs to be provided to mitigate stress in HCPs. Despite the positive effect of non-professional counseling, access to professional counseling must be provided for HCP in a safe and confidential manner. Mokogwu reported that about half of the respondents sought professional help during quarantine.^[8] Religious activities/praying and meditation were also commonly employed by the Nigerian HCP with a few using physical activity/exercise. This contrasts with the situation among HCP in New York who relied mostly on physical activities.^[13] Therefore, access to spiritual support and opportunities for physical activities should be prioritized in the workplace to promote stress management.

In conclusion, it is possible that prolonged stress could enhance coping skills as shown by these Nigerian HCP. However, its potential for further unpleasant outcomes that could jeopardize health and healthcare delivery makes it detrimental. The high rate of brain drain among HCP in Nigeria is a clear example of how stressful working conditions could negatively impact public health. We strongly recommend improvement in working conditions, and social and psychological support for HCP in Nigeria, recognizing that their perceived resilience is neither infinite nor innocuous.