Remote Psychological First Aid (rPFA) in the time of Covid-19: A preliminary report of the Malaysian experience.

Dear Sir,

The Covid-19 outbreak originated in Wuhan, Hubei province in December 2019, and fast became a global pandemic. The virus responsible was named 2019 novel coronavirus (2019-nCov). On the 11th of February 2020, the disease caused by 2019-nCov was termed coronavirus disease 2019(Covid-19) (Sun et al., 2020). Similar to the severe acute respiratory syndrome (SARS), the spread to humans is postulated to be from exotic wild animals. Eventually, human-to-human transmission occurred by means of contact and droplet transmission, leading to a pneumonia-like illness. The current pandemic has led to increased psychological distress and poorer mental health outcomes among both healthcare professionals and the lay public (Spoorthy, 2020; Rajkumar, 2020).

In view of its deleterious mental health outcomes, it is imperative to implement effective psychological interventions to improve mental health outcomes, particularly among front-line health care workers (subsequently referred to as front-liners in the text). Psychological First Aid (PFA) is one such measure recommended by the World Health Organization in ameliorating distress during an infectious pandemic (World Health Organization and World Vision International & UNICEF, 2014). PFA is distinct from mere counselling or therapy as it involves an integral and humanistic support for survivors of a disaster, consisting of three components: look, listen and link. Though recommended (Maunder et al., 2008; Everly et al., 2014), data on PFA administration in pandemics, particularly in the South East Asian region, is still scarce. Moreover, there is a pressing need for more systematic data regarding the impact of Covid-19 on mental health issues in Asia (Tandon, 2020). As such, the authors present their experience in developing a remote PFA module among frontline healthcare workers.

Development of a remote PFA (rPFA) module in a tertiary university hospital

University Malaya Medical Centre (UMMC) is a tertiary hospital in heart of the Malaysian capital, Kuala Lumpur. At the time of writing, there were 6482 positive cases in Malaysia, with 1378 cases detected in Kuala Lumpur (Department of Statistics Malaysia, 2020). As such, it was declared a Covid-19 hospital and tasked to treat and manage patients with the illness. With time, there was a need to develop a mental health module to help front-liners cope with their psychological distress and burnout. In line with the WHO’s recommendation in disaster situations, we decided to develop a rPFA module for our front-liners. In keeping with the need to limit face-to-face consultation to reduce the risk of transmission of Covid-19(Kavoor et al., 2020), a remote method of PFA was devised.

The initial step was assembling a mental health team trained in PFA who then trained other psychiatrist, psychologists and counsellors. Training was done over a period of one day, consisting of both didactic and interactive learning using the principles prescribed by the International Federation of Red Cross and Red Crescent Society (International Federation of Red Cross and Red Crescent Societies, 2020). In particular, the mental health team were educated on the principles of look, listen and link in the context of remote administration. Remote administration of PFA was made possible by using the ‘Whatsapp’ application and phone call platform to reach out to consenting front-liners.

rPFA administration and flow

Once the training was completed, the rPFA module was formally rolled out. Front-liners were identified and referred by three organizations tending to front-liners: Department of Public Health, Staff Health Clinic and Occupational, Safety and Health Environment Department. The referring criteria was front-liners treating and managing Covid-19 patients who answered yes to the screening question sent via the ‘Whatsapp’ application:

“Are you feeling distressed or upset in any way handling Covid-19 patients?”

The Central Data Collation Unit (CDCU), a unit consisting of counsellors and psychologists, were tasked with collating mental health data in the form of the Depression, Anxiety and Stress Scale (DASS) and Copenhagen Burnout Inventory (CBI). The CDCU then referred clients to the mental health team, consisting of psychiatrists, psychologists and counsellors, on a 1:1:1 ratio. They were administered rPFA via phone call for a total duration of 4 weeks. The frequency of the rPFA phone calls were based on a case-to-case basis. Severity of the cases was decided based on clinical judgement of the mental health team and the pre-rPFA DASS and CBI scores. The most distressed front-liners were given twice-weekly rPFA, followed by weekly rPFA for those less severe, and fortnightly for those with mild severity. Frontliners needing further help were then scheduled for follow-up remote consultation. The workflow is summarized in Fig. 1 .

Fig. 1

Diagram depicting the workflow of rPFA administration in University Malaya Medical Centre, Kuala Lumpur, Malaysia.

rPFA: remote Psychological First Aid.

CDCU: Central Data Collation Unit.

* Psychiatrists, psychologists and counsellors.

At the time of writing, the rPFA was on going and the data collection process in progress. Early feedback from both the rPFA administrators and recipients were encouraging.

Conclusion

In conclusion, the authors describe the rPFA module used in their setting. rPFA is an important tool in the armamentarium of mental health interventions. The relative short training required coupled with its broad applicability makes it a unique and attractive option in a pandemic situation.

Financial disclosure

None.

Ethical statement

1) This material is the authors' own original work, which has not been previously published elsewhere.

2) The paper is not currently being considered for publication elsewhere.

3) The paper reflects the authors' own research and analysis in a truthful and complete manner.

4) The paper properly credits the meaningful contributions of co-authors and co-researchers.

5) The results are appropriately placed in the context of prior and existing research.

6) All sources used are properly disclosed (correct citation). Literally copying of text must be indicated as such by using quotation marks and giving proper reference.

7) All authors have been personally and actively involved in substantial work leading to the paper, and will take public responsibility for its content.

Declaration of Competing Interest

None.