Throughout the COVID-19 pandemic, many frontline workers in service positions have suddenly had the spotlight shone on them. Healthcare professionals, transit system operators, waste collectors, and other essential workers have not been able to physically distance or move their work online. Many of their jobs have required them to face the dangers of exposure as they interact with people and materials that carry unknown risks. On top of this, many service workers work rotating shifts. This has been connected to negative health outcomes even outside of pandemics.1,2 The reality for many frontline workers right now is complex and uncertain. However, by leveraging social and agency-based theories of behavioral change, we can provide the people who support us with their own support system.
COVID-19 and shift work
COVID-19 is a novel pandemic, so research on its effects is still emerging. What has been found so far in relation to front-line workers has focused mainly on healthcare professionals. Many of these individuals have reported excessive workloads, unreasonable hours, inadequate social support, and inadequate personal protective equipment (such as masks and gowns), all in addition to increased risk of COVID-19 exposure.3 These outcomes have been associated with increased stress, anxiety, depressive symptoms, insomnia, and development of trauma, all of which negatively impact health and productivity.
A significant number of these healthcare professionals work shifts. Due to their rotating schedules, these workers experience more disruption to their biological systems than workers who have regular daily schedules. Sleep and diet are two prime examples. Disruptions to these systems can drive changes in the body that lead to the development of diseases such as stroke, coronary heart disease, certain cancers, and type two diabetes.1,9 The health of frontline workers, even beyond the scope of the pandemic, is clearly an issue that needs attention. While COVID-19 has disrupted all of our lives in different ways, its effects have interacted with pre-existing difficulties that are structural.
There are components of people’s health that depend on the environment around them. This is where leveraging behavioral science can make a great impact.
Interventions can take on a number of forms. There has been some success with those that take into account frontline workers’ hierarchy of needs.4 Maslow’s hierarchy of needs is a framework that posits that human health depends on satisfying physiological and psychological needs in a specific order. A General Theory of Behavior, recently updated by Dr. David Marks in 2018, has explained this hierarchy in terms of physiological and psychological balance.4 Workers will constantly be preoccupied by their need to regain balance when their sleep and diet schedules are disrupted, contributing to psychological problems such as stress if left unsatisfied. According to Maslow’s hierarchy, physical needs such as sleep and nutrition need to be satisfied first.
Supporting physiological health
Shift workers, especially those who are frontline workers in the pandemic, tend not to maintain good sleep, diet, or exercise habits.1,5 As such, these should be the first areas employers target for intervention.
A popular intervention method for improving the physiological health of shift workers in healthcare contexts has been knowledge dissemination. Educating workers about how to monitor their health by forming better sleep, diet, and exercise habits can feel empowering. Many educators assume that, with the appropriate knowledge, people will make the best decisions for themselves. This kind of education assumes and celebrates learner agency. Evaluations of informational interventions, though, show that they are not very effective. Information alone is not enough to change behavior.6 What can be done?
The concept of nudging shows promise. In a nutshell, nudging can be described as providing small pushes toward a desired behavioral outcome. Agency is never disrupted, as workers are still able to make their own choices. By repositioning healthier choices as easier, faster, or cheaper, workers can be gently pushed toward better health outcomes.
For example, providing dedicated nap or rest spaces that are conveniently located can nudge workers to take much-needed breaks. Dedicated exercise spaces are also an idea.1,7 When it comes to food, sources that support healthy dietary choices are vital for workers to be able to attend to their health at the workplace.1,7 Most workers need to source their own food and vending machines seem to be the quickest way for them to do so. By providing healthier options in vending machines or placing healthier food sources closer to food court entrances, workers can be nudged to choose healthy options.8,9
In terms of more immediate work environments, some smartphone apps (e.g., the myCircadianClock app), wearable technologies, and artificial intelligence are being developed to make managing sleep, diet, and other behaviors related to biological functioning easier. The benefits of such technologies are that they are personalizable and convenient. Knowing that an app is tracking them can cause smartphone users to change their behaviors.10 Users form persistent habits from simple reminders and explicit accountability to their commitments.
Being part of a group can strengthen an individual’s commitment to better health behaviors.6 If there is a healthy food choice that is more conveniently available, but all of your friends decide they want to go for an unhealthy food choice, it is likely that you will follow. The social aspect of behavior is important to consider in interventions. Forming social support groups can increase individual accountability, for example.1,3
Beyond small groups, institution-wide communication of policy can be just as effective. In a 2011 study, researchers Grant and Hofmann found that healthcare workers were incentivized to change their hand-washing behaviors when messaging about hand hygiene highlighted consequences for other people.11 Drawing attention to the social components of decision making resulted in meaningful behavioral changes. As such, official organizational communications can benefit from subtle rewording. When policies are created or changed, appealing to the group is more effective than appealing to the individual.
To support the physiological health of frontline workers, it is important to design support structures that promote both their agency and interconnectedness. Workers’ decision making capabilities are adversely affected by both shift work and the current pandemic. These capabilities can be strengthened by strategically constructing the work environment and by focusing on developing social connectivity.
Supporting psychological health
Turning now to tools to support psychological health, researchers have uncovered that stress, burnout, and psychological flexibility processes are related.2 Psychological flexibility can be likened to creativity: it describes how well a person can cope with changes in circumstances. In the case of COVID-19, this would describe how well individuals and institutions can think of multiple novel solutions. When individuals are stuck in bad thinking habits, they can reinforce their stress and exacerbate it. To counter these near-automatic processes, interventions that target psychological flexibility can mitigate stress and burnout.2
Some examples of these kinds of interventions are group workshops, regular socials, mentorships, and one-on-one therapy. Encouraging workers to practice responding to stressful scenes is a way to train psychological flexibility. Similar to what we saw for physiological health, groups can influence decision making behaviors. Therefore, forming official groups and/or creating dedicated time and space for social meetings can be very effective ways of supporting front line workers in their training. Indeed, someone may benefit from hearing about strategies that they wouldn’t have thought of by themselves.
Mindfulness-based interventions further nurture worker resilience by allowing workers to practice disrupting harmful thinking habits. For some, individual therapy sessions are particularly effective at this, while for others group sessions are more effective.2 Workers with higher levels of mental health problems have been found to generally be more interested in developing self-help skills from therapy sessions, while workers with lower psychological disturbances have preferred informational media.3
Recommendations for institutions include providing as many support systems as possible and providing information on how workers can access institution-external supports. In addition, dedicated psychological health teams that provide support to front line workers have been found to be effective for crisis intervention during COVID-19.3 These specialized teams could provide services that can also be extended to patients. Regularly screening workers for evidence of psychological distress can tell teams—and institutions more broadly—what kinds of interventions would benefit the greatest number of workers. Screening would also provide evidence policymakers can use to create or update psychological intervention guidelines.
Physiological health has often taken precedence over psychological health in crisis responses.3 Both needs are important to satisfy in order to attain balance. Although time and funds need to be invested in the short-term, psychological interventions will support long-term worker health, productivity, and performance.1
Every individual is different when it comes to what kinds of support most benefit them. It is important, therefore, for individuals and larger institutions to pay attention to behavior. The key to supporting our frontline workers is to make many options available and work with many different teams. It is particularly important to continue this work beyond the pandemic, as strong systems may prevent the same thing from happening again in the future.