Long-term impact of attacks on health care on mental health and workforce retention among healthcare workers in protracted emergency settings: East of the Democratic Republic of Congo

BACKGROUND: Healthcare workers (HCWs) in the Democratic Republic of the Congo (DRC) are frequently subjected to attacks on healthcare (AHC), with potentially serious implications for their mental well-being and employment stability. This study provides estimates of the prevalence of serious mental health symptoms and intent to leave employment among HCWs in relation to their exposure to AHC. METHODS: An integrated mixed-method study conducted in 2023 where sociodemographic characteristics, AHC exposure, and mental health status were assessed using Self-Reported Questionnaire-20, WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings, and the Post-traumatic stress disorder (PTSD) Checklist version DSM-5. The analysis centered on estimating adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) for the impact of AHC on mental health symptoms and workforce retention using robust Poisson regression. RESULTS: In our sample of 407 HCWs, the median time of AHC exposure was 2.5 years, with no gender difference. Among HCWs exposed to AHC, 71% exposed for over 2.5 years showed general mental health risks, compared to 60% for those exposed ≤2.5 years and 7% for the non-exposed. AHC exposure increased the prevalence of serious mental health symptoms, particularly fear (aPR 1.89; 95% CI 1.40-2.55). AHC exposure significantly elevated PTSD symptoms (aPR 1.12; 95% CI 1.01-1.26). In addition, AHC exposure increased the likelihood of HCWs absenteeism (aPR 1.32; 95% CI 1.05-1.66) and of leaving their jobs (aPR 1.75; 95% CI 1.22-2.50). AHC categories of violent searches and obstruction were associated with higher rates of PTSD (aPR 2.12; 95% CI 1.70-2.64) and job turnover (aPR 1.56; 95% CI 1.19-2.04), respectively. CONCLUSIONS: The study provides rare findings on the high burden of probable serious mental health and the associated risk of workforce turnover due to long-term exposure to AHC among HCWs in South Kivu, DRC. The findings thus highlight the critical need for mental health interventions and workforce retention strategies in conflict-affected regions. Further investigation is warranted to inform the development of targeted support programs and policies to address these challenges.