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Abstract

Background

Hospital workers have borne a large burden of the COVID-19 pandemic, exposed to risks of infection, while enduring elevated workloads, increased workplace stress, prolonged hours in uncomfortable working conditions, and public stigmatisation.

Objectives

In this cross-sectional study, we examined the psychological stressors of COVID-19 on hospital essential services workers and their needs at a tertiary hospital in Singapore. Methods: We conducted a study of 246 outsourced essential workers comprising housekeeping, maintenance staff, and porting staff. Psychological distress was measured by the Kessler-6 scale. We also surveyed respondents through a questionnaire on the main concerns that worried them, supportive resources available, and additional resources that would most help them.

Results

Among the survey respondents, concerns related to employment, finances, accommodation, transportation, and likelihood of receiving medical attention for COVID-19 were significantly associated with moderate to severe psychological distress (p<0.05). Stress from isolation and fear of COVID-19 infection constituted the greatest psychosocial burdens. Respondents felt that main supportive resources came from their employers and social circles. They also listed enhanced individual ability to cope, and additional financial aid from their employers and the government would help them the most.

Conclusions

Financial and accommodation-related stressors reflect structural factors that exacerbated the psychosocial burdens faced by non-medical hospital workers. Most respondents tended to individualise their coping strategies, which point towards the need for stronger social protections and mental health provisions for hospital essential services workers.

Keywords

Mental health essential workers hospital COVID-19 Singapore

Introduction

The coronavirus pandemic 2019 (COVID-19) has resulted in tremendous human, economic, and social costs around the world. In addition to the huge loss of lives, the COVID-19 pandemic also resulted in significant psychological impact. Multiple systematic reviews have revealed increased rates of anxiety, depression, insomnia, stress, and loneliness globally due to public health measures and the economic disruption of the COVID-19 pandemic.^1–3 Despite the growing availability of COVID-19 vaccines, subsequent waves of COVID-19 sub-variants prevent a complete return to a pre-COVID normalcy,⁴ suggesting that the psychological impacts of the pandemic could be prolonged.

Of increasing concern is the psychological impact on healthcare workers who bear the brunt of the increased need for clinical services, while at the same time, struggling to adapt to the social disruptions brought on by COVID-19. Healthcare workers face higher risks of COVID-19 infection, while enduring elevated workloads, increased workplace stress, prolonged hours in uncomfortable personal protection equipment (PPE), and public stigmatisation.^5–7

While this growing literature highlights the mental health impacts on healthcare workers, less attention has been directed towards hospital essential services workers, who also perform public-facing roles and are exposed to increased risks of COVID-19 infection, poor working environments, and high socioeconomic vulnerability. More importantly, hospital essential services workers are distinct from medical healthcare workers in employment and social status. For instance, physicians, nurses, and other healthcare workers are generally hired by hospitals as full-time staff with employment benefits such as medical and vacation leave. Additionally, these staff generally enjoy higher wages, alongside a degree of respect and prestige as frontline healthcare workers. In comparison, hospital essential services workers such as housekeeping or maintenance staff tend to be undervalued by society due to the menial and low-wage nature of their jobs.^8–10

Despite their key role in infection prevention and control in hospital environments, such hospital essential services workers are an “invisible workforce”,¹¹ “systemically devalued, ignored, and relegated to the bottom of the socioeconomic hierarchy”.¹² Moreover, hospital essential services workers are generally outsourced from private firms. Such outsourcing models may increase the vulnerability of hospital essential workers to poor working conditions. For example, writing in the Canadian context, Zuberi highlights how the outsourcing of workers has enabled hospitals to enjoy cost-savings, at the expense of the working conditions of workers such as housekeeping, maintenance, or food services employees, who may be overworked, underpaid, exposed to workplace hazards, or do not receive adequate training and PPE.¹³ In Singapore, while there are labour regulations governing low-wage jobs such as cleaning, poor enforcement, depressed wages, and the low socioeconomic status of employees continue to leave them vulnerable to poor working conditions.⁸

Yet, such hospital essential services workers tend to be under-represented in studies, especially in a healthcare setting. Most systematic reviews on healthcare workers tend to focus on physicians, nurses, allied healthcare professionals, and other clinical support staff. For instance, Tan et al’s (2020) study sought to study the psychological impacts of the pandemic on healthcare staff in a Singapore hospital, measuring incidences of anxiety, stress, depression, and post-traumatic stress disorder.¹⁴ While they found a higher incidence of anxiety among non-medical healthcare workers, the technicians, clerical, and administrative staff in their sample only comprised 23.2% of the total. In this exploratory study, we aim to examine the psychological stressors and needs of hospital essential services workers supporting the housekeeping, maintenance, and portering services in a tertiary hospital in Singapore during the COVID-19 pandemic. Because this is a relatively understudied population, understanding their concerns and needs in a pandemic situation will enable more effective organisational and policy responses to mitigate undesirable impacts.

Method

Setting and participant recruitment

This cross-sectional study was conducted among outsourced hospital essential services workers – housekeepers, porter, and maintenance services staff in a tertiary hospital from 15^th September to 30^th October 2020. We define “outsourced workers” as employees not directly employed by the hospital, but deployed by a third-party to perform specific tasks on hospital grounds. Participants were recruited according to the following criteria; (a) above 21 years old, (b) were outsourced essential workers in the hospital, (c) had the ability to give written informed consent. Participants who were under 21 years old were excluded from the study. None of the participants had a history of previous mental disorders.

Survey instrument and data collection

We sent invitations to all 580 housekeeping, porter, and maintenance services staff in the hospital through their respective companies to attend the briefing sessions about the study. Data was collected using both online and paper-version self-administered questionnaires. Emails containing a link and a QR code to the online survey were distributed to the outsourced staff through their employers. The online questionnaire was hosted on the Quadrics platform. Briefing sessions were also held by the research team to explain the study to the workers. For workers who faced difficulty filling up electronic surveys, paper questionnaires were provided on request. It took approximately 15 – 20 min for respondents to complete the questionnaire, which was translated into seven languages: English, Chinese, Malay, Hindi, Tamil, Bengali, and Burmese by bilingual in-house staff and independently verified by another bilingual staff.

Socio-demographic information was also collected, and considered alongside the results of the K-6 and open-ended survey: age, gender, ethnicity, marital status, resident status, income, primary language, years of experience, religion, housing type, perceived health status, and proximity to COVID-19 infection.

Psychological distress was measured by the Kessler-6 distress scale (K-6). The K-6 was developed to detect general psychological distress, has demonstrated good reliability and validity, and was used in the WHO World Mental Health surveys.^15–17 For the Kessler-6 distress scale, we used available official translations of Chinese (Mandarin), and Malay (adapted from K-10).¹⁸ For other languages in which an official translation was not available, we used the translated versions on the Web site of the Government of New South Wales.¹⁹ Mental well-being was assessed by the Kessler-6 distress scale (K-6). There are five response options for each question, ranging from “none of the time” to “all of the time” and a score of zero to four was assigned to each response respectively. A total score was calculated by summing up the responses to each question. We used a cut-off point of ≥5 to identify moderate to severe mental distress.²⁰ We excluded missing responses from the analysis.

Concerns among essential workers were surveyed by the following prompt: “In the past 4 weeks, how much you have been worried about the following”. Responses were captured by a 5-point Likert scale ranging from “not at all worried” to “extremely worried” across the following options: loss of employment, finance, contacting COVID-19, your loved ones contacting COVID-19, family conflicts, aggression by family members, accommodation, transportation, and getting treatment for conditions not related to COVID-19. In addition, three open-ended questions: “What is your biggest burden during this pandemic?”, “What is your biggest supportive resource during this pandemic?”, and “What would help you most during this pandemic? were asked to better understand the concerns of respondents.

Ethics statements

Ethics approval was obtained from the SingHealth institutional review board (CIRB Ref: 2020/2757). Written informed consent was obtained from each participant before participating in the study.

Analysis

Descriptive analysis was used to summarise data in Tables 1 and 2. Independent t test was used to compare the mean scores across respective concerns and psychologically distressed respondents (Kessler score ≥ 5) (Table 3). Statistical analyses were performed using Stata 15.²¹ Content analysis was performed on responses from the open-ended questions (Tables 4 to 6). Content analysis is a common technique for coding and analysing qualitative data. This approach is useful in describing and categorising the characteristics and meaning of textual data.^22,23 Given the dearth of studies on the concerns of hospital essential services workers, we used an inductive approach to interpret participants’ responses, which gave us the flexibility to accommodate emerging themes. Some responses were submitted in Mandarin. These were translated to English by a bilingual staff. One co-author read and re-read the responses to sort the responses into preliminary codes. These codes were then assigned into categories, before grouped into broader domains. These domains were discussed among the study team over several iterations of analysis, and further refined.

Table 1.

Characteristics of the study population (n= 246).

Age (mean±SD)	45.24 ± 15.6
Gender (N, %)
Male	129 (52.4)
Female	117 (47.6)
Ethnicity (N, %)
Chinese	74 (30.1)
Malay	61 (24.8)
Indian	68 (27.6)
Others (Bengali, Myanmar, Vietnamese, others)	41 (16.7)
Missing	2 (0.8)
Marital status (N, %)
Never married	80 (32.7)
Currently married	140 (57.1)
Separated but not divorced/divorced/widowed	25 (10.2)
Missing	1 (0.4)
Resident status (N, %)
Locals	118 (48)
Foreign workers	125 (50.8)
Missing	3 (1.2)
Job category (N, %)
Housekeeping staff	109 (44.5)
Maintenance staff	31 (12.7)
Porter	94 (38.4)
Others	11 (4.5)
Missing	1 (0.4)
Accommodation (N, %)
Public housing	133 (54.1)
Private housing	59 (24)
Hotel	12 (4.9)
Dormitory	11 (4.5)
Missing	31 (12.6)
Proximity to COVID-19 infection (N, %)
Level 0	166 (67.5)
Level 1	14 (5.7)
Level 2	60 (24.4)
Missing	6 (2.4)
Year of experiences in current position (median, IQR)	2 (1,5)
Have religion (N, %)	202 (83.1)
Have chronic disease (N, %)	36 (14.7)

Table 2.

Concerns among essential workers.

	Not at all worried	A little worried	Somewhat worried	Very worried	Extremely worried
Your loved ones contracting COVID-19 virus	37 (18.2)	42 (20.7)	35 (17.2)	43 (21.2)	46 (21.2)
Contracting COVID-19 virus	34 (16.4)	72 (34.8)	38 (18.4)	36 (17.4)	27 (13.0)
Finance	61 (29.2)	56 (26.8)	36 (17.2)	34 (16.3)	22 (10.5)
Family conflicts, divorce, or parenting difficulties	77 (41.4)	37 (19.9)	23 (12.4)	30 (16.1)	19 (10.2)
Loss of employment	87 (41.4)	47 (22.4)	30 (14.3)	26 (12.4)	20 (9.52)
Aggression by family members	83 (46.1)	32 (17.8)	25 (13.9)	27 (15.0)	13 (7.22)
Accommodation	115 (56.7)	37 (18.2)	21 (10.3)	14 (6.9)	16 (7.88)
Transportation	115 (56.7)	37 (18.2)	26 (12.8)	12 (5.91)	13 (6.4)
Getting treatment for medical conditions not related to COVID-19	102 (53.4)	37 (19.37)	30 (15.71)	15 (7.85)	7 (3.66)

Table 3.

Association between concerns and psychological distress.

	Psychological distress		P value
	No	Yes
	168 (75.34)	55 (24.66)
Your loved ones contracting COVID-19 virus	3.10 ± 1.51	3.11 ± 1.16	0.98
Contracting COVID-19 virus	2.74 ± 1.37	2.83 ± 1.06	0.67
Finance	2.39 ± 1.36	2.90 ± 1.18	0.02
Family conflicts, divorce, or parenting difficulties	2.22 ± 1.45	2.64 ± 1.30	0.10
Loss of employment	2.11 ± 1.36	2.73 ± 1.30	0.01
Aggression by family members	2.03 ± 1.37	2.74 ± 1.15	< 0.01
Accommodation	1.71 ± 1.23	2.46 ± 1.22	< 0.01
Transportation	1.70 ± 1.19	2.33 ± 1.17	< 0.01
Getting treatment for medical conditions not related to COVID-19	1.76 ± 1.14	2.26 ± 1.05	0.01

Table 4.

Summary of codes and quotation of essential workers' biggest burden during pandemic (n=171).

Domain	Category	Subtotal	%	Domain total	Sample quote
Psychosocial	Lack of recreation	35	20.5	88	“Feel don’t have much freedom”
	Fear of COVID-19 infection	27	15.8		“Worried to be contacted with the COVID-19 sickness”
	Separation from family	18	10.5		“I always work round the clock and been separate from my family in Malaysia. My children [are] unable [to transfer] school from [Johor Bahru] to Singapore. Family [communicates less] and easily [gets frustrated].”
	Job insecurity	8	4.7		“Hard to find new job”
Physical	Increased workload	15	8.8	25	“More work, [need] more time to sanitise”
Physical	Discomfort from Covid-related precautions	10	5.8		“Always have to put on face mask”
Economic	Financial burden	22	12.9	22	“Financial problems [paying] off home loans and other bills.”
Others	No burden	36	21.1	36	“I didn't feel anything as a burden”

Table 5.

Summary of codes and quotation of essential workers' biggest supportive resource during pandemic (n= 189).

Domain	Category	Subtotal	%	Domain total	Sample quote
Employer	Benefits and welfare	26	15.1	64	“Logistical support and assistance from company”
	Employment-related	22	12.8		“At least still able to earn a living”
	PPE	16	9.3		“Get enough masks and disinfection supplies every day”
Social	Family	41	23.8	57	“Family members very supportive and we support each other in everything (own family and siblings)”
Social	Friends	16	9.3		“My big[gest] support is that special person in my life and also my workplace friends.... who are always there for my help.”
Government	Financial aid	22	12.8	22	“Extra support from government monthly”
Self	Healthy lifestyle	11	6.4	28	“Keep a good attitude, health is the most important thing!”
Religion	Religious support	1	0.6	1	“God the father Lord Jesus Amen!”
Lack of support	No supportive resource	17	9.9	17	“no supportive resources”

Table 6.

Summary of codes and quotation regarding resources that would most help essential workers during pandemic (n= 141).

Domain	Category	Subtotal	%	Domain total	Sample quote
Self-expectation	Healthy lifestyle	23	16.3	42	“Prayer, healthy diet, exercise and positive mindset”
Self-expectation	Hygiene discipline	19	13.5		“Safe distancing, hand wash, wear mask”
Employer	Benefits and welfare	24	17.0	37	“Kids childcare rules to [be] loosen as kids [are] prone to have typical normal flu and cough and the mother needs to work to support and feed them. Or have extra childcare leave if they fall sick on working days.”
	Financial aid	7	5.0		“Bonus and incentives”
	PPE	6	4.3		“Mask and hand sanitizer”
Financial	General aid	23	16.3	29	“If we can try to help us financially so that we can settle our bills and home loans.”
Financial	Government aid	6	4.3		“Government subsidy”
Social	Family support	13	9.2	26	“Family support and bonding”
Social	Support from friends	13	9.2		“My friends”
Medical	Medical attention	4	2.8	4	“Health treatment”
Religion	Religious support	3	2.1	3	“The power of faith”

Results

246 essential workers responded, and gave consent to participate in the study. 67% of participants completed the questionnaire online and 58% used the English version. Among them, 11 did not complete the survey. This yielded a response rate of 42.4%, and non-completion rate of 4.3%. Average age of participants was 45 years (Standard deviation, SD=15). Majority of participants were male (52.2%), foreign workers (51.4%), and currently married (57.1%). 61.8% had a monthly income lower than $1,400 (Table 1), which the Ministry of Manpower Singapore defines as low-wage workers.²⁴

The highest concern among essential workers was the fear of their loved ones contracting COVID-19 (41.4% in the category of very worried and extremely worried), followed by fear of contracting COVID-19 (30.4%); financial difficulties (26.8%); family conflicts, divorce, or parenting difficulties (26.4%); and loss of employment (21.9%) (Table 2).

The prevalence of psychological distress among our sample was 24.7%. Statistical analysis revealed that concerns related to employment, finances, accommodation, transportation, family aggression and conflict, and likelihood of receiving medical attention for conditions not related to COVID-19 were significantly associated with moderate to severe psychological distress (p<0.05) (Table 3). In-depth results and discussion on the prevalence of psychological distress and anxiety are detailed in a separate paper.²⁵

171 responses were collected for the first open-ended question: What is your biggest burden during this pandemic? Three key domains emerged from the analysis: psychosocial (51.5%), economic (12.9%), and physical (14.6). 21.1% of respondents indicated they had “no burden” (Table 4).

The psychosocial domain contributed the highest number of responses, amounting to 51.5% of the total, which was contributed by 49.7% unique respondents. Within this domain, respondents noted their biggest burden was the lack of recreation (20.5%), highlighting how movement restrictions and social distancing prevented them from accessing places of recreation and socialisation. Respondents conveyed a sense of frustration that they had no “freedom” to go wherever they wanted and experienced much “boredom”. Respondents also expressed fear of COVID-19 infection (15.8%), feelings of separation (10.5%), job insecurity (4.7%).

Economic burdens were mentioned in 12.9% of responses. Within this domain, respondents described challenges associated with fulfilling financial obligations such as feeding their family or paying rent and other bills (12.9%).

Physical burdens contributed 14.6% of responses, that related to heavier workloads due to COVID-19 related precautions or physical discomfort associated with wearing PPE.

189 responses were collected for the second open-ended question: What is your biggest supportive resource during this pandemic? six key domains emerged from the data: their employer, social groups, self, the government, lack of support, and religion (Table 5).

Their employer was highlighted by 37.2% of respondents as their biggest supportive resource. This support was most evident through the provision of benefits and welfare (15.1%), in the form of “relief supplies” and “free welfare items”, a regular salary (12.8%), and provision of PPE (9.3%).

Social groupings such as family and friends were the biggest supportive resource for 33.1% of respondents. Respondents described how being able to spend time with their family, as well as the help provided by friends and family, were their biggest supportive resource.

The Singapore Government (12.8%) and the self (6.4%) constituted smaller sources of support. 9.9% of respondents indicated they had no supportive resource.

141 responses were collected for the third open-ended question: What would help you the most during this pandemic? six key domains emerged from the data: Self-expectation, the employer, finances, social resources, medical attention, and religion (Table 6).

29.8% of respondents referred to themselves as the resource that would most help them. Respondents set expectations to take better care of themselves physically, mentally, and emotionally. This was expressed in terms of maintaining a healthy lifestyle (16.3%), and adhering to COVID-19 measures such as hygiene discipline and social distancing (13.5%).

21.2% of respondents indicated more employer support would most help them, in terms of family or childcare leave (17%), salary raises (5%), and PPE (4.3%).

20.6% of respondents indicated the need for more financial support. Most responses in this domain were general in nature, but 4.3% of respondents highlighted the role of the government in providing more financial help to the needy.

18.4% of respondents felt more social support from their family and friends would help them the most. Respondents highlighted time spent bonding with family, and encouragement from friends as the kinds of support they needed.

Discussion

In this study, we examined the psychological stressors of the COVID-19 pandemic on hospital essential services workers in a tertiary hospital in Singapore. In contrast to most of the literature on the concerns of healthcare workers during the COVID-19 pandemic, we have focused on outsourced workers, such as housekeeping, maintenance, and porting staff. This sub-population has tended to be neglected in studies investigating the mental health of healthcare essential workers. In our study, we administered a survey through online and physical outreach that provided us a cross-sectional perspective of the concerns of hospital essential services workers.

Our analysis reveals that psychosocial burdens were most salient for our respondents. Fear of COVID-19 infection, precarious employment and financial conditions, lack of recreation opportunities due to movement restrictions, family and parenting difficulties, and separation from family contributed to psychosocial burdens on hospital essential services workers. The predominance of fear of COVID-19 infection, and the fear of spreading the virus to their family among the worries reported by our respondents is likely due to working in proximity to COVID-19 patients and healthcare workers in close contact with them. These psychosocial challenges are certainly not unique to our respondents and have also been reported among clinical essential workers such as physicians, nurses, and other frontline healthcare workers.^14,26 Meta-analyses of healthcare workers’ experiences have reported the psychological toll of (self)isolation, exhaustion from elevated workloads, and stress from fear of infection, alongside other challenging work conditions.^27,28 However, compared to healthcare workers elsewhere, the hospital essential services workers in our study did not encounter a sustained shortage of PPE, which they attribute to the ability of their employers to provide.

The significant association between concerns about accommodations and psychological distress is likely to stem from uncertainties about accommodation among foreign workers. Such workers are typically housed in large-scale, purpose-built dormitories, where workers face cramped, unsanitary, and uncomfortable living conditions.²⁹ Due to outbreaks of COVID-19 across many dormitories in April 2020, most migrant workers were isolated within dormitories as authorities sought to isolate the growing COVID-19 clusters. However, some healthy individuals were moved to refurbished public housing, and employers explored alternative housing arrangements others.³⁰ It is possible that the uncertainty of their tenancy, anxieties over future housing arrangements, and prospects of returning to locked-down dormitories resulted in some degree of stress for migrant workers. Additionally, Malaysian workers (who may be foreigners or Permanent Residents) faced difficulties securing rental accommodation due to rigid tenancy duration, increasing rents, and the uncertainty of border restrictions with Malaysia.^31,32

Furthermore, we found that family and parenting conflicts, as well as aggression by family members were concerns raised by respondents. This is not surprising as the combined effects of high stress related to socio-economic and workplace anxieties, social isolation, and lockdown has resulted in increased rates of domestic violence around the world.^33,34 In Singapore, police reports related to domestic violence saw a 22% increase during the circuit breaker period compared to previous months.³⁵

Our respondents also highlighted the financial struggles they face during the pandemic (such as making rental payments and other daily expenses), even as they experienced increasingly challenging work environments. Many expressed concerns about being able to make ends meet, or the prospects of losing their job. Even before the pandemic, migrant workers who make up a majority of our respondents, faced precarious employment conditions due to the asymmetrical power relationship between them and their employer, and low awareness of their rights and labour regulations.³⁶ They are also disadvantaged in any negotiations with employers due to the heavy debts they likely owed to exploitative migration agents. In the context of the pandemic-induced recession, some migrant workers were reported to have been owed months of unpaid salaries as companies struggled to stay afloat.³⁷

While such livelihood concerns were evident prior to COVID-19, the socio-economic and psychological disruption brought on by the pandemic have exacerbated existing social and economic vulnerabilities among essential workers around the world.^38,39 In this regard, our findings highlight the economic vulnerability of outsourced essential workers, their financial burden, and the need for more financial assistance and stronger labour protections. In the Singapore context, essential workers such as cleaners are among the bottom 20^th percentile of wage earners due to their wages being depressed by outsourcing practices and availability of foreign labour.^40,41 Indeed, more than 60% of our respondents reported a monthly income lower than $1,400.

Interestingly, respondents from our study highlight the employer as their biggest supportive resource, as a source of financial resources, welfare, and PPE. Respondents’ positive evaluation of their employer could be related to improving workplace practices, combined with heightened public attention on the working conditions of essential workers brought on by the pandemic.⁴⁰ At the same time, a high number of respondents expressed a desire for more generous and flexible leave policies to better cope with individual or household contingencies, suggesting current workload and benefits policies do not adequately meet the needs of employees.

Our findings are also consistent with evidence showing that healthcare workers tend to eschew professional psychological services, in favour of relying on friends and family, and adopting individual lifestyle adjustments to cope with stressors.⁴² When asked what they needed the most to get through the pandemic, participants in our study responded with expectations of self-reliance on lifestyle and hygiene practices. While Muller et al (2020) suggest that healthcare workers have a tendency to underestimate their need for psychological help,⁴² our respondents’ attitudes towards individual coping strategies were most likely the result of a pragmatic assessment of their circumstances. Almost half of our respondents are migrant workers, typically housed in purpose-built dormitories, factory-converted dormitories, or rental housing. To maximise housing space, migrant workers are usually housed in overcrowded living arrangements that offer little privacy or hygienic conditions.³⁶ Local respondents tended to be older adults with low education qualifications who likely had little awareness of avenues for mental support or have the economic resources to access such services. Thus, despite the high level of awareness about social distancing and hygiene demonstrated by our respondents, and the role of non-governmental organisations in providing mental care services,⁴³ it is likely they were constrained by structural factors, amplifying the need for self-reliance and individual coping strategies.

Concluding thoughts

To our knowledge, this is the first Singapore study examining psychological stressors and needs of hospital essential services workers during the pandemic. Our use of validated scales such as the Kessler K-6 distress allowed us to reach populations that may not have a strong command of English. We also managed to get a reasonable response rate of 42.4% with approximately equal proportions of local and foreign workers providing a multicultural perspective to stressors, and the experience of coping during the pandemic. However, we recognise that our single time-point cross-sectional study design without a control group has limited generalisability. Our sample is also vulnerable to bias as participants were self-selected.

The following recommendations can be made from the results of this study. Firstly, it is important to acknowledge that all classes of essential workers face challenging conditions, despite being vital to managing the impacts of the COVID-19 pandemic. The series of lockdowns brought on by the pandemic has sparked growing awareness of the inequalities essential workers face. Fundamentally, there needs to more expansive social protections for lowly-paid essential workers.^44,45 However, social protection in Singapore remains dependent on regular employment, highly targeted and differentiated by class and nationality, and limited in scope and duration to disincentivise reliance on social welfare.^41,46 As the public health narrative shifts towards living with an “endemic state” of COVID-19,⁴⁷ there is an urgent imperative to pre-empt such health inequalities from becoming entrenched, and exacerbating already-existing inequalities that perpetuate poverty traps for members of the lower socioeconomic strata.^41,46

Secondly, our findings highlight the need for greater awareness and normalisation of mental health support at the organisational level, especially for contract workers. The tendency of our respondents to individualise coping strategies, creating possibly unhealthy self-expectations for themselves is a recurring pattern among studies of healthcare workers.⁴² While our study did not provide more details about respondents’ perception of organisational support, it is likely that few avenues exist to support the mental or social needs of hospital essential services workers. As these groups of workers are highly distinct from conventional healthcare workers in demographic and employment terms, it is imperative that hospitals develop culturally-appropriate forms of mental and social support. Although these workers are not directly employed by the hospital, given the important role they play in supporting clinical services, there needs to be greater scrutiny of the contractual standards for these workers. National manpower policies and regulations also need to be improved and enforced appropriately to ensure that the needs of these essential workers are not neglected.

Footnotes

Acknowledgments

We thank Rebecca Ong and Pwee Keng Ho for helping us improve the clarity of an earlier draft.

Author contributions

NEEK, LCS, SSP, OHC conceptualised the study and methodology. NEEK, OHC, E.H was involved in project administration. NEEK, LCS, SSP, OHC performed visualisation of the data. NEEK and E.H was involved in data curation, and performed the analysis. E.H wrote the initial draft. All authors reviewed and edited the manuscript, and approved the final version of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Ethics approval (include full name of committee approving the research and if available mention reference number of that approval) was obtained from the SingHealth institutional review board (CIRB Ref: 2020/2757).

Informed Consent

Written informed consent was obtained from each participant before participating in the study.

Trial Registration (where applicable)

N/A.

ORCID iD

Ezra Ho

Data availability Statement

The analysed during the current study are available from E.H.

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Psychological stressors and needs among essential workers at a Singapore hospital during the COVID-19 pandemic

Abstract

Background

Objectives

Results

Conclusions

Keywords

Introduction

Method

Setting and participant recruitment

Survey instrument and data collection

Ethics statements

Analysis

Results

Discussion

Concluding thoughts

Footnotes

Acknowledgments

Author contributions

Declaration of conflicting interests

Funding

Ethical approval

Informed Consent

Trial Registration (where applicable)

ORCID iD

Data availability Statement

References