Culturally-tailored Peer Support for Doctors and Nurses of Indian Origin

The mental health and well-being needs of healthcare workers have risen sharply, fuelled by the current COVID-19 pandemic. Migrant healthcare workers are affected not only by events in the country where they work but also by events in countries where their family and friends reside. Despite, increase in psychological distress, migrant HCWs don’t use the existing resources to support their needs. This paper summarises discussions from the workshop focusing on reasons/barriers in uptake of mental health and well-being resources in the UK, the scope of peer support initiatives and its boundaries in supporting colleagues in the UK and India. Finally, it makes recommendations on the governance structure and checklist when organising peer support for healthcare workers.


Background
The COVID-19 pandemic saw over 3.4 million lives lost and over 170 million people infected around the world, as of May 2021, according to figures from the World Health Organization [1]. Healthcare systems were under incredible strain with the overwhelming pressures. Healthcare workers (HCWs) across the world adapted rapidly in response to the crisis -even, at times, at cost to their physical and emotional wellbeing.
Immigrant doctors and nurses in the UK (making up between 22-37% of the NHS workforce) were hit hard by the pandemic in their home countries despite planned easing of restrictions in the UK, with many loved ones affected by illness and mortality secondary to COVID-19. As a result, feelings of distress, helplessness and anger prevail amongst these colleagues [2]. Despite ongoing emotional turmoil and psychological distress, only a small proportion of these HCWs are utilising the health and wellbeing resources within the NHS [3]. The consequential impairment of wellbeing does impact on the ability of staff to cope with workload and may impair their ability to provide compassionate care [4]. Given that waiting times are amongst the longest recorded in recent history of the UK NHS, this is a serious cause for concern [5].
Mental health well-being of HCWs in India is compounded with lack of poor infrastructure and huge shortage of trained professionals leading to large treatment gap [6]. The pandemic has worsened the health and well-being status and various psychological resilience framework are proposed [7,8]. As we prepare to tackle the aftermath of the pandemic, addressing staff fatigue and wellbeing should be a key

Problem statement
Surveys of HCWs found that the prevalence of depression was 51%, anxiety disorders 45%, insomnia 34% and post-traumatic stress disorder (PTSD) 73% post-pandemic [9]. A British Medical Association (BMA) analysis in April 2020 revealed that 30% of the 16,000 doctors surveyed reported a worsening in psychological and mental health since the start of the pandemic [10]. A further survey by the Nursing Times in May 2020 suggested that 33% of staff reported their overall mental health and wellbeing as "bad" or "very bad" and 50% described themselves as "a lot" more anxious or stressed than usual [11]. The Doctor's Association UK (DAUK) undertook a poll of 1,758 doctors across the UK -65% of respondents reported they would be leaving the NHS in the next three years and 45% cited the impact of the pandemic on their mental health as a driving factor in their considerations [12].
In August, NHS Providers surveyed 140 leaders from NHS Trusts and Foundations across England and almost all (99%) said they were either moderately or extremely concerned by the current level of burnout across the workforce [13]. Researchers at King's College London surveyed staff in nine intensive care units across England about how they coped during the pandemic -45% of the 709 respondents met the threshold for probable clinical significance for at least one of the following: PTSD (39%), severe anxiety (11%), problem drinking (7%) and severe depression (6%) [4]. There is no dearth of evidence demonstrating the negative impact that COVID-19 has had on the mental health of UK-based HCWs and the need for decision makers to take measures to address these both morally and from a productivity [14].

Peer support
Peer support is an inexpensive and effective approach in improving clinical care of chronic conditions [15]. As defined by the Mental Health Foundation, "Peer support is the help and support that people with lived experience of mental illness or a learning disability can give to one another' [16]. As defined by senior research associate for Advocates for Human Potential Inc., "a 'peer' is an equal, someone with whom one shares demographic or social similarities… 'Support' expresses the kind of deeply felt empathy, encouragement, and assistance that people with shared experiences can offer one another within a reciprocal relationship'' [17].
Previous studies have demonstrated the importance of cultural competency in peer support programs, given that participants cite a sense of estrangement and insufficiently diverse composition (of peers) as reasons for not using the program [18]. The study also recognized the need of outreach and engagement strategies for the ongoing success of peer support programs. It is fundamental, therefore, that those providing peer support are trained and adequately supported.
The British Association of Physicians of Indian Origin (BAPIO) and its arm's length body, the British Indian Nursing Association (BINA) have a network extending their reach to many doctors and nurses based in the UK and in India. In collaboration with the National Forum for Health and Wellbeing (NFHW), the three groups have launched the i-Peer Support initiative aimed at defining, developing and delivering virtual peer support with following key objectives: 1. Exploring reasons for poor uptake of current health and wellbeing resources within the NHS 2. Defining culturally tailored peer support approaches 3. Defining boundaries of peer support both in the UK and India 4. Assessing the impact of the proposed peer support initiative

Methodology
Service development approaches were utilised with key stakeholders' participation. A multidisciplinary team (MDT) focus group with doctors and nurses from various specialties (N=15) explored causes of poor utilisation of the current health and wellbeing resources in the NHS. Subsequently, a workshop (N= 29) with breakout discussions centred on the four aforementioned objectives was conducted, exploring the issues to great depth. Multidisciplinary participants (13 Male, 16 Female; 26 from South Asain background) were invited from all the three organisations (details of their role given in list of delegates). All participants contributed voluntarily and gave feedback to the final report. During the workshop, facilitator on each group made notes on what was discussed and then analysis was undertaken by two independent (SD and VV) members.

Reasons for poor uptake of current health and well-being resources in the NHS
Participants expressed varied views on this; some felt this was a sensitive issue, both personally and culturally. References were made to upbringings where psychological health is not given the same priority as physical health and seeking help is considered taboo. Furthermore, these issues are compounded by mistrust and a poor perception of the existing infrastructure as well as an inability to relate to providers on a cultural level. Although cognizant of the significance of mental wellbeing, HCWs are not immune to the stigma associated with seeking help, fear of been judged and negative perception of colleagues. However, a safe and confidential space is considered imperative. The system may additionally lack a sensitive and understanding approach, with normalization of burnout and fear which is driving colleagues away from accessing resources.
HCWs from minority ethnic backgrounds are less comfortable seeking help for themselves out of a sense of stoicism. Awareness and navigation of the system is also poorly understood. Emotional and mental health awareness is still not the norm and managers may feel out of depth in addressing these issues.

Defining culturally tailored peer support approaches
Peer support should be a comfortable approach. Ability to connect with the listener who can understand the person's journey and values is important. Ability to relate culturally is the key, as better understanding and awareness of cultural norms is important. Poor perception of provider or support system by colleagues is an additional barrier. The current resources are felt either remote or too aligned to organisational objectives and not meeting their needs.

Defining boundaries of peer support
Discussions on boundaries of peer support in India and UK had commonalities in terms of delivery aspects but there were specific challenges in context of India (detailed later).

3a. General consideration (applicable to UK and India)
Remit of Peer support and essential skill sets were discussed. The listening strategy facilitates those seeking support to reflect whilst encouraging and empowering them to come up with answers or solutions. When offering peer support to colleagues, the approach needs to be one of empathy and collectivism devoid of intimidation. This, however, could pose a challenge to those delivering the service unless trained to safely share their lived experiences, reinforcing once again the need to have proficiency and coaching for the providers.
Participants suggested highlighting at the start of any discussion what exactly we offer i.e., ease of access, confidentiality, an outside perspective or out-of-the-box thinking coupled with an ability and willingness to share personal lived experiences. There was a consensus that acknowledgement and validation of feelings is essential. Participants also highlighted the importance of placing emphasis on the fact that this is not a mental health service or a substitute for counselling.
Participants also discussed in detail the need for safeguarding mechanisms, particularly if someone is in acute distress and appears to be at risk to themselves or to others; it was suggested to signpost them appropriately, including writing to their health and wellbeing services at their employer or general practice or via private discussions with a peer who works in mental health services (e.g., psychiatrist, psychologist or a mental health nurse) with the individual's consent.

Quotes from participants around cultural aspects:
"A person having gone through similar experiences and values can understand the feelings and be kind to the person seeking help. Moreover, the person seeking help get connected to a listener instantly".

Quotes from participants around boundaries of peer support:
"A problem shared is a problem halved" and 'emotional well-being of HCWs is everyone business.'' "The approach taken by those delivering [peer support] should not be that of a 'know-it-all' individual but that of a modest, friendly colleague willing to share their own experience through listening and contributing sensibly".

3b. Specific consideration for offering peer support to colleagues in India
In the context of settings in India specifically, there are no studies on peer support -this lack of data and evidence is a significant barrier. Participants expressed concerns about ability to support colleagues in India virtually and risks with not having clear and reliable signposting to resources or support network. Some suggested that it may be easier setting something on an institutional level rather than in the community initially. It was suggested that enlisting the help of psychiatrists from India and other support mechanisms in India beforehand is a priority of high importance.

Assessing the impact of the proposed peer support initiative
Impact assessment is paramount to appreciate the efficacy and many different potential methods were discussed. Subjective Unit of Distress Scale (SUDS) was suggested to assess intensity of feelings, with a rating of 0 corresponding to "bad" and a rating of 10 corresponding to "very good"-this was considered a simple option for administration and adherence [19]. This could be assessed individually before and relate the change following the sessions.
More detailed approaches such as a general health questionnaire (GHQ) that comprises 12 questions and the Harvard PAVING wheel to assess progress in wellbeing components were also suggested [20,21]. These could be useful tools in longitudinal self-assessment at regular intervals. However, such linked data at personal level cannot be obtained and analysed to assess the impact of peer support, as it is classified as sensitive information and goes against principle of confidentiality. This can only be done in research domain but can be used by individuals for self-evaluation over time.

Discussion
Support for HCWs has taken centre stage in the NHS Mental Health Implementation Plan 2019/20 and Health Education England is supporting this with the development of new roles and a competency framework for Peer Support Workers as a result. Peer support provision will serve as an important bridge between people facing psychological distress and mental health services and can reduce hospital admissions [22]. HCWs are experiencing high degrees of emotional distress for myriad reasons, which are further intensified due to the pressures of the COVID-19 pandemic. Additionally, immigrant HCWs are affected due to circumstances in their native countries, leaving them with feelings of anger, helplessness and guilt (when unable to provide direct help and support to their loved ones). Despite the need for and availability of health and wellbeing services at all NHS trusts, these are poorly accessed because of similar barriers to those faced by the general population [3]. There are also concerns that we are not adapting sufficiently quickly to meet mounting demands of the mental health and wellbeing crisis [23]. Peer support initiative for mental health is underutilised and many challenges exists in India [6].
A peer support network and associated programs can be cost-effective and are efficient resources secondary to their provider's relatability and trustworthiness. Most people in psychological distress require low levels of support, with few needing specialist services as outlined by the Stevenson/Farmer review of mental health and employers [24]. Several studies have demonstrated the success of peer support programs in Quotes from participants around boundaries of peer support: "The lack of infrastructure and under-resourcing of healthcare systems poses a challenge to introducing structured peer support models in India". "It's time for a change and if we see an active increase in demand for peer support due to the pandemic, this might act as a catalyst".
"How do we make sure their wellbeing is protected without access to necessary resources?" responding to medical crises [25,26]. More recent initiatives have been launched in the UK; nurses set up the Nurse Lifeline organisation with a view to offer 24/7 peer support to nurses and midwives. The British Medical Association (BMA) also launched a similar program for doctors and medical students [27].
We have conducted this workshop to establish a culturally sensitive peer support program for doctors and nurses of Indian origin through the collaborative efforts of BAPIO, BINA and NFHW, all three of which have a history of working with HCWs of South Asian communities. This paper ultimately describes the consensus position around various aspects of delivering such an initiative drawn from focus group and workshop discussions.
We make the following recommendations: 1. The execution of this support network must be culturally tailored and based on peer support principles by bringing together colleagues with lived experience.
2. The initiative should provide a safe space with confidentiality (except in extreme circumstances to safeguard lives). The safe space will not ask for details of workplace, nor will any personal, sensitive or identifiable information be recorded or stored.
3. Provision should be voluntary, flexible with maximised accessibility in line with needs of colleagues 4. Provision can be virtually (via videoconferencing platforms) or face-to-face, taking into consideration pandemicrelated restrictions and comforts/preferences of users 5. When using existing NHS or third party mental health and wellbeing resources (such as mental health hub or board or private companies), it is important to have a collaborative approach with clear terms of reference/ memorandum of understanding (MOU) so as to incorporate the peer support groups within the safety of existing governance framework.
6. Good communication skills, particularly those of listening and reflective learning, would be essential for Peer support facilitators. If these are not part of their routine roles or they would like to refresh, they will be signposted to training courses by the BAPIO Training Academy.
7. The peer support initiative do not include provision of mental health services (no counselling or treatment offered), however: a. The presence of a competent and trained mental healthcare professional in each session is required. This could be a psychologist or a medical/nursing colleague from the mental health services. b. Identification of appropriate signposting and resources are required beforehand, for anyone who may require specific treatment or help. c. Prior consent will be sought before formal referral for specialist intervention (counselling or treatment).
8. To complement peer support, a workbook will be developed to enable self-evaluation e.g., with the GHQ-12 and PAVING wheel exercises. The workbook will also list additional resources and signpost further help.
9. Impact of Peer Support sessions will be assessed by Subjective Unit of Distress Scale (SUDS).