Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review
Open accessAbstract
BACKGROUND: Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. The World Health Organization (WHO) has warned about the potential negative impact of the COVID-19 crisis on the mental well-being of health and social care professionals. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these. OBJECTIVES: Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. SEARCH METHODS: On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions. SELECTION CRITERIA: We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together. MAIN RESULTS: We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies). Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout. Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the find
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Pollack et al. found no high-quality studies and only six moderate-quality studies since 2002 on interventions for frontline worker resilience and mental health.
“Pollack et al. identified no studies of high quality and only six of moderate quality since 2002.”
From Overview of sleep management during COVID-19. (2022) · cites this paper as [44]
The Certainty/confidence in the evidence section says there were no high-confidence findings and six moderate-confidence findings—not six moderate-quality studies. The Objective 2 qualitative evidence synthesis section also rates four studies as having no or few methodological limitations, contrary to the claim that no studies were of high quality. No page numbers were provided in our copy. (LLM, conf=0.87)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredDuring the pandemic, approximately 40% of healthcare workers experienced anxiety and approximately 37% suffered from depression.
“For instance, a comprehensive systematic review and meta-analysis revealed that during the pandemic, approximately 40% of healthcare workers experienced anxiety, while approximately 37% suffered from depression, highlighting the significant impact of the crisis on this group [8].”
From Mental Health in Healthcare Workers Post-COVID-19: A Latin American Review and Insights into Personalized Management Strategies (2024) · cites this paper as [8]
The Background (page unavailable) says healthcare workers are at risk of mental health problems during infectious disease outbreaks, supporting the general concern. It does not give the claimed 40% anxiety or 37% depression figures. The Objective 1: review of effectiveness section (page unavailable) also says the included study had no data suitable for meta-analysis, so this review did not produce the attributed pooled estimates. (LLM, conf=0.85)
Experimental — accuracy not yet measuredPrevious studies relate cognitive fusion and depression to emotional exhaustion, and low levels of resilience with burnout.
“This is consistent with previous studies that relate cognitive fusion (54) and depression (49, 52) to emotional exhaustion, and low levels of resilience with burnout (55, 56).”
From Evolution of burnout syndrome in Spanish healthcare professionals during and after the COVID-19 pandemic: psychosocial variables involved (2025) · cites this paper as [56]
The Background, “Description of the condition” (page not available), contrasts resilience with burnout, supporting a broad relationship between the concepts. It does not report that people with lower measured resilience have higher burnout. This citation is attached to the resilience–burnout part of the sentence, not the cognitive-fusion or depression claims. (LLM, conf=0.78)
Experimental — accuracy not yet measuredDisordered sleep is not expected to resolve once infection is controlled, so interventions are urgently needed.
“Disordered sleep is not expected to disappear with control of infection, making interventions acutely necessary.”
From Overview of sleep management during COVID-19. (2022) · cites this paper as [44]
The Background discusses possible long-term mental health problems, and Implications for research calls for research on long-term intervention outcomes. Neither passage says that disordered sleep persists after infection is controlled or that this makes sleep interventions urgently necessary. Searches for sleep persistence and infection control found only references to sleep-related works; the available copy is truncated. (LLM, conf=0.72)
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Flagged first, then by citations
Research works printed but not linked: 8
- Higgins 2020b Higgins JP, Eldridge S, Li T, editor(s). Chapter 23: Including variants on randomized trials. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). Cochrane, 2020. Available from www.training.cochrane.org/handbook.
- key or frontline or front-line) adj3 (staff or workerInterventions to support the resilience and mental health of frontline health and social care professionals during and a er a disease outbreak, epidemic or pandemic: a mixed methods systematic review (Review) Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Cochrane Database of Systematic Reviews 19. or/12-18 20. disease outbreaks/ or epidemics/ or pandemics/ 21. (((health$ or disease$) adj5 (disaster$ or catastrophe$ or crises or crisis)) or outbreak$ or pandemic$ or epidemic$).tw.
- or #-#72} #: [Disease Outbreaks] this term only #75 MeSH descriptor: [Epidemics] this term only #76 MeSH descriptor: [Pandemics] this term only #77 (((health* or disease*) near/5 (disaster* or catastrophe* or crises or crisis)) or outbreak* or pandemic* or epidemic*):ti,ab,kw (Word variations have been searched) MeSH descriptor: [Ebolavirus] this term only #79 MeSH descriptor: [Influenza, Human] this term only #80 MeSH descriptor: [Severe Acute Respiratory Syndrome] this term only #81 MeSH descriptor: [Pneumonia, Viral] this term only #82 MeSH descriptor: [Coronavirus Infections] explode all trees #83 MeSH descriptor: [Meningitis, Bacterial] this term only #84 MeSH descriptor: [Cholera] this term only #85 MeSH descriptor: [Influenzavirus B] explode all trees #86 MeSH descriptor: [Influenzavirus A] explode all trees #87 MeSH descriptor: [Influenzavirus C] this term only #88 MeSH descriptor: [Chikungunya Virus] this term only #89 MeSH descriptor: [Chikungunya Fever] this term only #90 MeSH descriptor: [Dengue] explode all trees #91 MeSH descriptor: [Ri Valley Fever] this term only #92 MeSH descriptor: [Yellow Fever] this term only #93 MeSH descriptor: [Zika Virus Infection] this term only #94 MeSH descriptor: [Lassa Fever] this term only #95 MeSH descriptor: [Hemorrhagic Fevers, Viral] explode all trees #96 MeSH descriptor: [Coronavirus] this term only #97 MeSH descriptor: [Betacoronavirus] this term only #98 MeSH descriptor: [Middle East Respiratory Syndrome Coronavirus] this term only #99 MeSH descriptor: [SARS Virus] this term only #100 MeSH descriptor: [Monkeypox] this term only #101 MeSH descriptor: [Smallpox] this term only #102 MeSH descriptor: [Henipavirus] explode all trees #103 MeSH descriptor: [Henipavirus infections] this term only Interventions to support the resilience and mental health of frontline health and social care professionals during and a er a disease outbreak, epidemic or pandemic: a mixed methods systematic review (Review) Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. #105 (chikungunya or cholera or smallpox or small pox or monkeypox or plague or tularaemia):ti,ab,kw (Word variations have been searched) #106 ((avian or bird or fowl) near/5 (influenza or flu or plague)):ti,ab,kw (Word variations have been searched) #107 ((bacterial near/2 meningitis) or (meningococcal near/2 diseas*)):ti,ab,kw (Word variations have been searched) #108 (severe acute respiratory syndrome or SARS or coronavirus or ((atypical or influenza or viral or virus) near/3 (pneumonia or bronchopneumonia or infection))):ti,ab,kw (Word variations have been searched) #109 (coronavirus* or corona virus* or HCoV* or ncov* or covid* or sars-cov* or sarscov* or sars-coronavirus*):ti,ab,kw (Word variations have been searched) #110 {or #74-#109} #111 #32 and #73 and #110 with Cochrane Library publication date Between Jan 2002 and May 2020. Appendix
- chikungunya or cholera or smallpox or small pox or monkeypox or plague or tularaemia).tw. Interventions to support the resilience and mental health of frontline health and social care professionals during and a er a disease outbreak, epidemic or pandemic: a mixed methods systematic review (Review) Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. S17 TI (nurs* or midwife* or midwives* or (health N2 visitor*) or (art N2 therapist) or chiropodist
- Mr James Chan, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford; Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust Dr Mark Delicata, Victoria Hospital, Kirkcaldy, NHS Fife, UK Dr David Gillespie, Royal Infirmary Edinburgh, NHS Lothian, UK Dr Sohil Khan, Griffith University, Australia Dr Terry Quinn, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
- Dr Abi Sriharan, Dalla Lana School of Public Health, University of Toronto Prof Balendra Pratap Singh, King George's Medical University, India Dr Ali Zamlout, Tishreen University, Latakia, Syria Text from the 'EPOC Qualitative Evidence synthesis: protocol and review template' has been used within this protocol (EPOC 2019). Declarations of interest Alex Pollock: grant holder on funding from the Chief Scientist Office, Scottish Government to support this review. Employed within a post at the NMAHP Research Unit which is supported by the Chief Scientist Office, Scottish Government. No other known conflict of interest. Pauline Campbell: grant holder on funding from the Chief Scientist Office, Scottish Government to support this review. No other known conflict of interest. Joshua Cheyne: no known conflict of interest.
- Julie Cowie: grant holder on funding from the Chief Scientist Office, Scottish Government to support this review. No other known conflict of interest. Bridget Davis: no known conflict of interest. Kris McGill: no known conflict of interest.
- Andrew Elders: grant holder on funding from the Chief Scientist Office, Scottish Government to support this review. No other known conflict of interest.
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Labrague, L. J., & de los Santos, J. A. A. (2021) · Applied Nursing Research · doi:10.1016/j.apnr.2021.151476 · Cited by 221 · see citing works
Zaçe, D., Hoxhaj, I., Orfino, A., Viteritti, A. M., Janiri, L., & Di Pietro, M. L. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.02.019 · Cited by 105 · see citing works
The Molecular Basis of Resilience: A Narrative Review
Ryan, M., & Ryznar, R. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.856998 · Cited by 65 · see citing works
Anger, W. K., Dimoff, J. K., & Alley, L. (2024) · American Journal of Public Health · doi:10.2105/ajph.2023.307556 · Cited by 67 · see citing works
Blake, H., Gupta, A., Javed, M., Wood, B., Knowles, S., Coyne, E., & Cooper, J. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18073626 · Cited by 53 · see citing works
Overview of sleep management during COVID-19.
Becker, P. M. (2022) · Sleep Medicine · doi:10.1016/j.sleep.2021.04.024 · Cited by 51 · see citing works
“Management and interventions must occur before chronicity, substance abuse and suicide increase [10], particularly since disordered sleep does not return to base rates even after control of infection [44].”
BackgroundRosales Vaca, K. M., Cruz Barrientos, O. I., Girón López, S., Noriega, S., More Árias, A., Guariente, S. M. M., & Zazula, R. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.114501 · Cited by 51 · see citing works
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How can we help healthcare workers during a catastrophic event such as the COVID-19 pandemic
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- Authors
- Pollock, A., Campbell, P., Cheyne, J., Cowie, J., Davis, B., McCallum, J., McGill, K., Elders, A., Hagen, S., McClurg, D., Torrens, C., & Maxwell, M.
- Affiliations
- Glasgow Caledonian University (GB)
- University of Edinburgh (GB)
- University of Stirling (GB)
- ORCID
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2020-11-05
- Volume
- 2020
- Issue
- 11
- Pages
- CD013779-CD013779
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC8226433
- OpenAlex
- W3096168896
- Cited by
- 631
- References
- 170
- Citations by year
- 2026: 28 · 2025: 79 · 2024: 119 · 2023: 140 · 2022: 153 · 2021: 104 · 2020: 5 · 2019: 1 · 2017: 1
- FWCI
- 7.86
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Edinburgh Research Explorer (University of Edinburgh) (acceptedVersion, other-oa)
- ResearchOnline (acceptedVersion, other-oa)
- Stirling Online Research Repository (University of Stirling) (submittedVersion, public-domain)
- ResearchOnline (Glasgow Caledonian University) (submittedVersion, other-oa)
- Funders
- Maudsley Charity
- Government of the United Kingdom
- University of Oxford
- National Research Foundation of Korea
- Topics
- Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
- Health Sciences › Health Professions › General Health Professions › Healthcare professionals’ stress and burnout
- Health Sciences › Health Professions › Occupational Therapy › Occupational Health and Burnout
- Keywords
- mental health, resilience, psychological intervention, workplace interventions, psychological support, pharmacological interventions, burnout, anxiety, depression, stress, COVID-19 pandemic, outbreak, pandemic, implementation barriers and facilitators, workplace mental health, mental health promotion, mental health screening, mental health education, mental health services, mental health policy
- MeSH terms
- Social Workers, Psychosocial Support Systems, Betacoronavirus, COVID-19, SARS-CoV-2, Burnout, Professional, Disease Outbreaks, Health Personnel, Humans, Mental Health, Pneumonia, Viral, Bias, Occupational Health, Workplace, Coronavirus Infections, Hemorrhagic Fever, Ebola, Needs Assessment, Severe Acute Respiratory Syndrome, Resilience, Psychological, Epidemics, Pandemics
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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