Future role aspirations, achievement motivations and perceptions of personal help-seeking among humanitarian aid trainees

In comparison to the general population, international expatriate and local national HA workers experience elevated levels of trauma and significantly higher rates of posttraumatic stress disorder (PTSD), depression, and anxiety (Connorton et al. 2012). A post-deployment survey of 376 national Ugandan HA workers (Ager et al. 2012) working locally in high conflict areas, and across 21 organisations, found 68% of respondents scored at or above established cut-offs on validated measures of depression and anxiety (The Hopkins Symptom Checklist, Derogatis et al. 1974), whilst 26% reported clinically significant symptoms on the Los Angeles Symptom Checklist for PTSD (King et al. 1995; Ager et al. 2012).

Aid workers also appear to experience occupational mental health effects at a higher rate than other professions exposed to potentially traumatising events. Studies of PTSD among military and police personnel have found prevalence estimates of 8.3% (Defence Health 2016) and 10–12% (Rose et al. 2002) for these populations respectively, compared with 4–6% of the general population (Cooper et al. 2014). Whilst studies of HA workers have generally relied on questionnaire measures rather than structured clinical interviews (producing estimates of “probable PTSD” rather than formal diagnoses), indicative rate estimates for PTSD among national and international expatriate HA workers range between 17 and 30% in the available literature (Eriksson et al. 2001; Armagan et al. 2006; Putman et al. 2009; Zhen et al. 2012).

Distinct differences in training protocols between HA workers and other professions exposed to potentially traumatising events have been identified as a key factor underpinning differences in mental health outcomes between these populations (Burke and Shakespeare-Finch 2011). Review of the available HA literature indicates that pre-deployment training varies widely among organisations; it frequently involves international agencies training expatriate workers and is often very limited in nature (Connorton et al. 2012; Ehrenreich and Elliott 2004; McCall and Salama 1999). Whilst these studies present a fairly bleak view of HA worker training, the broad picture is suspected to be worse. Connorton et al. (2012) argue that as participation in the surveys was voluntary, it is possible that agencies where training is perceived to be adequate were more likely to have returned surveys, thereby affecting the findings.

Inadequate training leaves workers with underdeveloped knowledge and skills, including potentially unrealistic expectations of roles and achievements. These factors may predispose them to adverse mental health outcomes including depression, anxiety, occupational burnout and PTSD (Mollica et al. 2004; Cardozo et al. 2005; Dahlgren et al. 2009). Conversely, training that specifically targets the risk and resilience profile of those who choose a profession is thought to produce workers who are more resilient to career challenges, thereby reducing the risk of adverse mental health outcomes (Burke and Shakespeare-Finch 2011). For example, it has been found that police officers often cope well with potentially traumatising events. One explanation for this is that their training regimes have prepared them in advance for such exposures (Chan et al. 2003; Gist and Woodall 2000). Evidence of the health benefits of training has led the Australian Ambulance Service to provide comprehensive in-house training (Robinson 1993), which appears to equip workers with effective personal resources to mitigate the effect of stressful events, resulting in more effective trauma recovery and reduced sick leave (Van der Kolk and Fisler 1995).

Research addressing the risk profile of trainee HA workers is very limited. One study of agency-employed workers (Eriksson et al. 2012) found they commonly exhibit certain risk factors (e.g. avoidant coping styles) and resilience factors (high levels of social support), before they enter the field. A resilience factor is conceptualised as a trait or behaviour that is associated with a lower likelihood of adverse mental health outcomes or that reduces the negative impact of a potential risk factor after incident exposure (O’Connell et al. 2009). Conversely, a risk factor is defined as a trait or behaviour associated with an increased risk of future harm to the individual (Metcalfe et al. 2011). Greater literature regarding these factors exists in relation to HA workers with field experience. This provides some basis for understanding factors which will potentially affect future workers. A review of the area reveals three key factors which have the potential to support or undermine occupational wellbeing among HA workers and related groups. These include motivation/achievement, social support, and help-seeking.

Individuals who seek employment within HA are often highly motivated to achieve a particular goal (Eriksson et al. 2012). Research has found that altruistic individuals with high intrinsic motivation (i.e. based on personal values and outcomes) demonstrate good resilience against adverse effects on mental health, including burnout (Moreno-Jiménez and Villodres 2010). An individual’s expectancy of achievement can also mediate one’s risk. Within occupational settings, the theory of met expectations indicates that the higher the congruence between an individual’s expectations and the reality of their work, the greater satisfaction and adjustment one experiences (Wanous et al. 1992). This accords with previous research in occupational settings, which found that met expectations were associated with high job satisfaction, performance and longevity (Wanous et al. 1992). Conversely, when expectations are not met, levels of satisfaction and personal accomplishment decrease (Delgatty 2011; Lee 2008). Achievement expectations have not been specifically examined in HA worker populations, although related work has found that HA workers with high levels of motivation are less likely to suffer from burnout (Cardozo et al. 2012). Notably, however, Tassell (2009) found that a sub-group of workers with high, potentially unrealistic motivation (“obsessive passion”) for this work were significantly more likely to experience burnout.

Social support represents an important protective factor against adverse mental health effects for the general population, as it appears to provide an effective buffer against stressful experiences (Ager et al. 2012; Brooks et al. 2015; Cardozo et al. 2012; Eriksson et al. 2012; Musa and Hamid 2008). Social support is defined as emotional and instrumental social interactions that provide an individual with actual assistance or a belief that such assistance is available (Thoits 2011; Hobfoll 1988). Past studies in the HA field have found that strong social support may significantly decrease the risk of adverse mental health consequences for workers (Cardozo et al. 2012). Specifically, social support appears to positively predict worker wellbeing, satisfaction (Brooks et al. 2015) and resilience (Eriksson et al. 2009), as well as mitigate against adverse mental health consequences including psychological distress, burnout (Brooks et al. 2015; Cardozo et al. 2012; Musa and Hamid 2008), PTSD and depression (Eriksson et al. 2012).

One suggested mechanism by which social support acts as a resilience factor is through encouraging help-seeking; an adaptive response which counteracts the negative effects of stressful life events (Gourash 1978). Despite these apparent benefits, individual willingness to seek help from both personal and professional sources is often quite low (Zartaloudi and Madianos 2010). Individual factors associated with reduced help-seeking include the perceived need for self-reliance (i.e. believing one should deal with their own problems), social image concerns and lack of knowledge of mental health treatment effectiveness (Staniford et al. 2009; Fischer and Turner 1970). Research with HA workers found that such attitudes are associated with poorer trauma recovery (Connorton et al. 2012).

The available literature examining occupational wellbeing within the HA field focuses almost exclusively on worker populations with experience in the field. Only one study (Eriksson et al. 2012) has examined a pre-deployment training population, who were existing employees of an aid organisation, rather than a novice training group per se. Research conducted early in HA training and prior to agency experience can improve our understanding of the profile of those who pursue HA work, and the status of potential risk factors that may mediate future exposures.

Thematic analysis was used to identify patterns and commonalities across participant interviews regarding current experiences of social support, help-seeking attitudes and behaviours, and motivations and aspirations regarding HA work. Four major themes emerged regarding mental health risk and resilience factors for trainee HA workers in the current sample: (1) The goal of supporting people; (2) Humanitarian aid short-term, development long-term; (3) Social support based on likeness and (4) Help-seeking: a good idea that is not implemented. Interview excerpts have been selected based on their relevance and importance in illustrating emergent themes.

Trainee humanitarian aid workers were found to exhibit risk and resilience factors for occupational stress in the field. That is, before entering the field, the trainee group displayed attributes, behaviours and perceptions that have previously been shown to mediate mental health sequelae among HA worker populations, notably anxiety, burnout and PTSD (Ager et al. 2012; Brooks et al. 2015; Comoretto et al. 2015; Eriksson et al. 2012). This study found that the four factors, motivation and achievement, evolving ideas of HA, social support, and help-seeking attitudes and behaviours, represent potential mediating factors among these trainees.

The demographic profile of the current undergraduate sample shows a group that is predominantly female, of Anglo background, without a current second language, and recent high school graduates. Whilst most individuals had completed previous paid and/or volunteer work, paid work was typically casual whilst volunteer work was of short duration. The limited nature of work and life experience of these trainees may constitute an experiential risk factor for such populations. Whilst these are preliminary findings, they highlight the potential benefit of training within undergraduate programs to address issues such as cultural competence, occupational health and wellbeing, and the importance of both social and organisational support.

The present study found that through training and increased knowledge of the field, intentions regarding the type and duration of future roles in HA may change significantly. The current participants had only just begun their training within a 3-year undergraduate degree. However, initial exposure to the “basic” concepts of HA work and what it entails caused many to re-think their initial goals of a sustained career in the HA profession. Through their increased knowledge of the sometimes difficult nature of the work, potential incongruence between personal and organisational goals and the perceived potential to have a greater impact in development work, the most frequent intention became to seek HA roles in the short-term “for experience” before pursuing roles in development programs for a more prolonged, sustainable career. Arguably, this finding indicates a form of resilience within this trainee sample. The ability to adapt to new information, including actively selecting work environments which better support personal and professional goals, may be an important determinant of occupational health and longevity within this field. Whilst further research is needed, the present study contributes a novel insight regarding the implications of HA education on the intentions of future workers.

With regard to social support, the current results supported Benkel et al. (2009) finding that individuals prefer to seek support from their friends before their families during times of personal stress. Trainees also preferred to derive support from friends, due to their greater shared understanding and common experiences. The desire for support networks based on shared experiences and understanding also appears central to consideration of potential future work roles and relationships. This suggests a potentially important resilience factor for these future workers, who envision that colleagues may act as reliable sources of information and emotional support. This prior readiness to rely on colleagues in difficult circumstances when in the field, due to their perceived shared understanding, may prove to be a valuable protective factor that can be further supported and extended upon through training.

If HA workers are likely to seek support from their colleagues in the first instance, it may prove beneficial to equip both workers and trainees with mental health knowledge and skills. Mental Health First Aid training has been shown to increase knowledge of mental illness and treatments and provide individuals with appropriate strategies to support others in need (Aakre et al. 2016; Jensen et al. 2016). Such training in workplace settings has been found to increase individual willingness to provide support to others, a greater likelihood of advising others to seek professional help, and improvement in the mental health of the those who underwent the training themselves (Kitchener and Jorm 2004). Providing HA workers with such knowledge and skills may support similar outcomes, including positive mediation of mental health responses to field exposures.

The present study also examined specific attitudes towards personal help-seeking. This is an area scarcely recognised in the current HA literature, despite the known mental health sequelae within this population. When looking at the broader research base on help-seeking and mental health, the present findings contrast previous research that found a positive relationship between help-seeking attitudes and actual help-seeking behaviour (Zartaloudi and Madianos 2012). Respondents in the current study reported strong intentions towards future help-seeking with work colleagues, in the context of distress, and perceptions that such actions would be beneficial. Whilst the translation of these help-seeking intentions to future behaviours remains unclear, evidence from experimental psychology shows that high intent and high perceived positive outcomes predict high levels of behavioural translation (Azjen 1991; Cooke and French 2008). Against this, however, is the finding that current positive perceptions of help seeking with friends generally do not translate to help seeking attempts in this population. As these findings are based upon different samples, however, it is difficult to compare. One explanation for this difference may relate to trainees’ high motivation to support others. This high level of altruism and related self-image may indicate that participants are more likely to put others’ needs ahead of their own and are therefore unwilling to be seen as needing support themselves. A similar phenomenon was observed in 911 workers in the USA who were found to be highly motivated by altruism, but unlikely to seek help for personal stress, seeing it as “just part of the job” (Shuler and Sypher 2000). Tassell (2009) found that HA workers with high altruism were vulnerable to disillusionment and more likely to experience burnout. The specific relationship between help-seeking intentions and behaviours in a HA work context requires further research. Arguably, however, education programs with trainees could highlight the potential benefits of appropriate help-seeking in occupational contexts.

Nonetheless, the finding that participants perceive field-based needs as qualitatively different from their current lives (i.e. potentially risking personal health and wellbeing) appears to legitimise help-seeking, including that from health professionals. Such statements must be viewed with caution, since behavioural intentions are not strongly predictive of future behaviours (Thirlaway and Upton 2009). Also, professional help may not be as readily available in the field as participants may perceive and a high “response effort” for such help could simply reinforce pre-deployment ideals of foregoing personal help-seeking for the sake of helping others. However, this is a notable finding in that it suggests mental health literacy related to this work role may provide the conditions under which help-seeking, in the context of heightened stress, would be viewed as being “acceptable”. Whilst further research is needed regarding this relationship, this finding highlights the potential role that mental health education, and messages during training, may have in increasing help-seeking and self-care practices among workers.

Compassion, a core element of altruism can have both positive and negative impacts upon individual efficacy and longevity within such professions. Compassion fatigue, a potentially negative outcome of compassionate commitment, increases financial costs to organisations due to increases in sick leave, turnover (White 2006) and lower worker morale and productivity; all of which are indicative of burnout (Stamm et al. 2002). On the other hand, individuals who experience compassion satisfaction, are less likely to experience symptoms of burnout as the individual feels as though they are performing their job competently and have the right social supports in place to do so (Stamm 2002). As Maslach (1982) highlights, burnout is not a problem of people, but rather the environment in which people work. Therefore, in order to decrease such negative perceptions of individual help-seeking observed in the current sample, it may be useful to look at ways to foster work and training environments that encourage compassion satisfaction rather than fatigue.

Despite finding low current help-seeking behaviour in this sample, participants perceived they would be more likely to seek help when in the field. Such future intentions to seek help may be explained by trainee recognition that proactive help-seeking in an occupational context would be an appropriate and likely beneficial response. Whilst these findings may reflect demand characteristics, it is notable that several participants indicated that formal help-seeking (i.e. health professionals or within the organisation) would be warranted given their understanding of specific mental health risks associated with aid work. Future research could test this relationship to determine whether perceived assistance needs of field workers are acted upon (and the circumstances that make this “acceptable”), or whether they are consistent with non-occupational contexts where help is often avoided or negated (Mackenzie et al. 2006). Therefore, although participants reported that help-seeking in their current lives is limited due to such things as not wanting to be a burden, it appears that with increased field-based mental health literacy, help-seeking with future colleagues may be seen as more acceptable. Thus, the implementation of training that further fosters this way of thinking may build upon worker resilience in the field. Help-seeking and its relationship with mental health remains an underrepresented area in the HA literature. Research is needed to better understand both the attitudes and behavioural skills that allow workers to successfully elicit appropriate support when needed, and potential restraints such as altruistic self-image and perceived stigma. Such research could examine the development of help-seeking intentions, and whether greater mental health literacy (e.g. Mental Health First Aid training), including symptom recognition and assistance “thresholds”, can change access rates to formal and informal sources of support.

A reflexive approach was maintained throughout the research process. That is, whilst care was taken to ensure representativeness and validity of the identified themes, the researcher assumes an active role in the interpretative process (Braun and Clarke 2006). As such, it is recognised that context, knowledge and beliefs play a role in the extraction of themes from the data and thus are shaped by researcher reflexivity. This is not a limitation of the current study as the results and subsequent interpretations were grounded in the data and further justified through the use of a co-rater. The use of an independent co-rater ensured the dependability of findings through establishing inter-rater reliability and also increased the credibility of findings as all themes were confirmed via the inter-rater process (Golafshani 2003).

As the present study employed a purposive sample within a qualitative study, the findings cannot be generalised further than the sample employed in the analysis. The study also focused on an undergraduate university sample and, as such, its findings are most relevant to this HA trainee sub-population. Whilst purposive sampling of students from one university may also restrict the transferability of findings, subsequent research may employ the same methodology on samples from other institutions at similar stages in training. Such re-testing may provide further confirmation of the present findings.

The findings from the present study are important insofar as they provide a preliminary insight into the potential risk and resilience factors present in trainee HA workers. The major findings indicate two areas of resilience and one area of risk within this population. Social support based on likeness, and the evolving ideas of HA work indicate flexibility within the current population through the reported ability to adapt to new physical, emotional and social environments. Conversely, the contradictory nature of help-seeking indicates an area of potential risk. The reported lack of help-seeking in the context of high personal stress warrants further research attention, as a failure to seek help has been linked to increased mental health problems in the general population (Rickwood et al. 2007), and may similarly mediate mental health outcomes among HA workers. Recent occupational health literature suggests a pathway from such risk factors to occupational burnout and to conditions such as depression and PTSD (Brooks et al. 2015; Musa and Hamid 2008). Whilst factors such as coping style and poor social support are recognised contributors to burnout among HA workers (Brooks et al. 2015), the relationship between help-seeking and burnout has not been investigated in this population. Future research investigating this pathway, and the potential role of help-seeking attitudes and skills, may support important developments in training and self-care practices among these professionals. A follow-up study assessing the risk and resilience trajectories and how future training fosters such factors within the current sample is recommended as such information may be invaluable for future training programs.