An exploration of female healthcare workers’ experiences during the COVID-19 pandemic in Bindura, Zimbabwe

Abstract This study explores the experiences and coping strategies of female frontline healthcare workers (HCWs) fighting the COVID-19 pandemic in resource-constrained settings. Female frontline HCWs face an elevated risk of contracting the COVID-19 infection and infecting their loved ones because when they return from work. The study adopted a qualitative approach to explore the experiences of female frontline HCWs working in high-volume departments at Bindura provincial hospital in Zimbabwe. Using purposive sampling, 15 participants were recruited. HCWs were asked to share their views and perspectives on COVID-19 and their work environment. The study focused on HCWs’ experiences of stigma and discrimination once infected; access to treatment; understanding of transmission; and life experiences of living with COVID-19. The findings suggest that female HCWs working in high-volume departments experience a higher risk of exposure to infection, barriers to assessing personal protective equipment (PPE) and stigma, which impact their mental health. However, despite the complex interrelated challenges female frontline HCWs face in Zimbabwe, there are limited interventions to ameliorate this burden, a knowledge gap this research aims to illuminate.


PUBLIC INTEREST STATEMENT
The research showed that HCWs working in high volume departments experience a higher risk of exposure to infection, barriers to assessing personal protective equipment (PPE) and stigma. Women comprise 70% of healthcare workers globally hence, the impact of health-related crises is predominately felt by female HCWs. The risk is even worse for female healthcare workers in Zimbabwe, a country grappling with persistent problems such as HealthCare workers and resource shortages that is already straining the public health system. Our research has confirmed and reiterated the importance of addressing gender issues when examining the experiences of individuals in particular contexts.

Introduction and background
Throughout the COVID-19 pandemic, healthcare workers (HCWs) have been experiencing additional risks, thus compounding their health and well-being. Such additional risks include increased vulnerability to infection and stress emanating from illness or death of friends, loss of many patients or colleagues, long shifts combined with unprecedented population restrictions, fear of transmission to family members, including personal isolation which have affected their ability to cope (Mehta et al., 2021;Ulfa et al., 2022). This study explores the experiences of frontline female HCWs, emphasising their feelings and practices thus providing a subjective and insider perspective on the challenges they faced. The risk was profound, especially among this cohort partly due to the additional demands primarily borne by women, which include childcare and eldercare responsibilities (Ahinkorah et al., 2021). Unpaid care responsibilities generally fall on women due to their multiple identities as mothers and caregivers in patriarchal societies such as Zimbabwe. The responsibilities of frontline female HCWs who continued to go to work even during the lockdown period were magnified due to the interruptions of school, facilities, and other services. As such, there were no support structures available to relieve them of the burden of domestic care. The impact of COVID-19 was even worse for HCWs in Zimbabwe, a country grappling with persistent problems such as HCW and resource shortages that strain the public health system (Chimene et al., 2021). Therefore, this article explores the experiences of frontline female HCWs during the peak of the COVID-19 pandemic, and how these shaped their different experiences in executing healthcare work.
Globally, women comprise 70% of healthcare workers; hence, the impact of health-related crises is predominately felt by female HCWs (OECD, 2020). For example, during the outbreak of Ebola between 2014 and 2015, studies from West African countries suggested that women suffered the crisis more than men, partly due to their roles as caregivers, resulting in higher infection rates (Menéndez et al., 2015;Nkangu et al., 2017). In addition, evidence suggests that as of April 2020, some female HCWs were battling burnout or emotional fatigue due to work-related stress caused by the outbreak of COVID-19 (Ulfa et al., 2022). Furthermore, research further indicates that intimate partner violence increased in Zimbabwe during the peak of the COVID-19 pandemic as noted from the increase from 43.1% in 2015 (Iman'ishimwe Mukamana et al., 2020) to 47% in 2021 (Muchemwa & Odimegwu, 2021). As a result, of the shifting gender roles in households, tensions also affected female HCWs whose services were in demand during the pandemic (Muchemwa & Odimegwu, 2021).
While consensus prevails that "COVID-19 does not discriminate . . . knows no racial, ethnic, gender, or national borders" (Ho & Dascalu, 2020, p. 1), its impacts are not the same across the working sector. Research has demonstrated that HCWs are at a higher risk of contracting COVID-19 than those in other work spaces, particularly because of shortage of PPE, patient contact, and suboptimal hand hygiene. HCWs are more than 10 times likely to be infected with COVID-19 and likely to be killed by the disease than the general population (Dzinamarira et al., 2022). The impact of COVID-19 was severe in low-income and middle-income countries where more than 10 000 HCWs were infected (WHO, 2020a). Between 80 000 and 180 000 HCWs died from COVID-19 since January 2020 (UN, 2021). World Health Organization (WHO) initially pronounced COVID-19 as an emergency global health challenge in early 2020 and a global pandemic on 11 March 2020 (Shumba et al., 2020). Given the shortages of healthcare personnel in most developing countries, the threat of COVID-19 is worrisome and tends to cripple the health sector in its delivery of universal healthcare access (Mehta et al., 2021). The impact of COVID-19 on the well-being of families, communities and HCWs is severe (Coaches & Mentors Association of South Africa [COMENSA], 2020). Therefore, it is significant to explore the effects of the COVID-19 pandemic on the mental and physical health of female HCWs working with many people since they are characterised by an elevated risk of contracting the COVID-19 infection, and infecting their families because of their role as caregivers.
With a complex political historical setting, an ongoing social crisis, patriarchal traditions of male dominance, and gender inequality (O'Brien & Broom, 2013), Zimbabwe offers a relevant site for exploring the challenges faced by frontline female HCWs. While chronic drug shortages have been troubling the country's healthcare system in the past eight years, COVID-19 has exacerbated the situation in public healthcare facilities, including provincial hospitals such as Bindura Hospital (Makoni, 2020). Drugs reported to be in short supply were Diazepam and Morphine, and important medical equipment such as pulse oximeters and syringe pumps. Furthermore, Zimbabwe experienced a critical shortage of personal protective equipment (PPE), and some HCWs were even unaware of the correct WHO COVID-19 control measures, placing themselves, their families, and patients at an elevated risk of being infected (Makoni, 2020). Additionally, at least 58 nurses in Mashonaland Central provinces resigned within the first 90 days of the COVID-19 pandemic, citing fear, anxiety and physiological distress (WHO, 2020b). Bindura Provincial Hospital is a hybrid referral hospital located in Mashonaland Central where all the cases of COVID-19 were referred to as it was a quarantine centre. There is very little research on the impact of COVID-19 on the well-being of many vulnerable groups in Zimbabwe, especially female HCWs because of the dilemma emanating from the question on how best they can take care of themselves and their families, simultaneously grappling with emotions of dealing with infected individuals (Santarone et al., 2020).
Participants are multiple-case samples recruited from Bindura Provincial Hospital, the study's geographical location is an understudied research area. Although evidence denotes that the health sector has been heavily affected due to COVID-19, little has been done to understand the impact of COVID-19 among female HCWs in Zimbabwe, particularly in Mashonaland Province. Bindura is located in Mashonaland Central, which ranked fourth on the list of areas most affected by COVID-19 in Zimbabwe's 10 provinces (Ministry of Health and Child Care, 2022). Bindura is located about 88 kilometres north-east of Harare. There is a high volume of human traffic between the two cities, mostly comprising vendors, who thrive on the informalisation of the economy (Schlyter, 2003). Travelling especially using congested public transport increased people's risk of contracting the COVID-19 infection. Progress in Mashonaland Central has been worrying, especially with the country sweating with the surge in new infections due to low temperatures in winter. Therefore, respiratory infections are high because people are more frequently inside and interact in close proximity (WHO, 2021). This has led this research to better understand the situation of female healthcare professionals during the COVID-19 pandemic with the aim of, where applicable, providing recommendations given the scale of mental trauma and the increased working hours necessitated by the COVID-19 pandemic.
Beyond epidemiological data, the novel coronavirus has shed light on a silent gender gap that research must reflect on. As such, this study seeks to explore the experiences and realities of frontline female HCWs during the COVID-19 pandemic, focussing on Bindura Provincial Hospital. Despite a growing body of research on HCWs during the COVID-19 pandemic, there is a dearth of research on how gender shapes the experiences of HCWs. Within the context of research on health systems, gender is understood as a critical social stratifier that influences the positioning of women and men within healthcare structures and their experiences within that location. The objectives of the study were to: (i) Explore the gendered effects of the COVID-19 pandemic on the mental and physical health of front-line female healthcare workers, and (ii) Examine how the COVID-19 pandemic affects the supply of healthcare workers and the quality of care in resource-constrained settings such as Zimbabwe.

Theoretical framing
This study used the Socio-Ecological Approach to health, which was first coined in about 1970 by Urie Bronfenbrenner but has continuously been revised until 2005. The Social-Ecological Approach to health maintains that individuals' experiences of health and illness are influenced by factors within and beyond the individuals themselves (Feldacker et al., 2011). The challenges of frontline female HCWs must be viewed within the context of intersectionality, that is, the community, structure, and environment in which they interact (Viner et al., 2012). We therefore, argue that adopting an integrated social-ecological approach designed to understand the effects of COVID-19 on the performance of HCWs could open up avenues for interventions that respond not only to their biophysical being but also to their environmental circumstances. This is particularly relevant, given that public healthcare institutions often fail to consider the welfare of health practitioners. The consistent failure by government institutions to consider the employees' social environment when making interventions, even though it is clearly linked that the success of the health system is inevitably connected to a larger social ecosystem, limits our ability to mitigate challenges faced by healthcare personnel, which eventually affects their performance (Grzywacz & Fuqua, 2000). Thus, the Socio-Ecological Theory more suitably enables an understanding of the link between the experiences and environmental circumstances of HCWs, which can help the government to identify areas requiring improvement in the context of HCWs.

Selection of participants
Initially, access to the participants was negotiated through the Hospital Superintendent, who then introduced the researcher to the participants. Ethical clearance for this study was granted by Midlands State University. The study protocol was then submitted to MRCZ and authority was granted (MRCZ/B1794).A purposive sampling strategy was used to recruit registered nurses (RGN). Data saturation was reached during the 15 th interview (Burmeister & Aitken, 2012). We also used objective sampling to select the maternal ward, Family and Community Health (FCH) Department, Outpatient Department (OPD), and COVID-19 Isolation Ward or Quarantine Centre where COVID-19 patients were isolated. These departments were purposely selected because they have a high volume of clientele visits, while the COVID-19 isolation department was selected because of the risk of infection associated with it.

Data collection
Considering the ongoing COVID-19 pandemic, CJ conducted all the interviews telephonically. The duration of the interviews ranged from 45 to 60 minutes. Data were collected from 15 March to 30 April 2022. After a thorough literature search was conducted to establish the research gap, an interview guide was generated. The interview schedule constituted the data collection tool. The interviews were conducted in Shona, the dominant local language in Mashonaland Central, and were then recorded and transcribed verbatim. The participants were assigned pseudonyms drawn from common vernacular names used in Zimbabwe. Digitally recorded data were encoded to guarantee the anonymity of the participants. Transcripts were later entered into NVivo (QSR International, Melbourne, Australia) software for coding. Thematic analysis was used to analyse data (Braun & Clarke, 2006). An inductive approach based on the socio-ecological model was used to define themes.
Verbatim quotes were first coded and then grouped into major themes (Braun & Clarke, 2006). Major themes are constitutive of the most important points mentioned voluntarily, while minor points are less well developed by all the participants in a cross-sectional manner. Additionally, minor themes are secondary, as they are not fully developed by some participants.

Data analysis
The first step entails researchers' familiarisation with data (reading and rereading transcribed data while generating initial codes). All the researchers independently engaged in the process. Secondly, meetings were held to harmonise the themes and decide on the major and secondary themes to be retained, and their regrouping into subject categories (defining and naming definitive themes). The analysis was validated by two authors, CJ (male, MSocSc Psychology) and RK (female, Anthropology PhD). Validation was then done by all the five authors CJ (reference author, male), KST (male, Social Sciences Education PhD), RK (female, Anthropology PhD), KS (male, Health Promotion PhD), and KG (male, Professor Research Psychologist, PhD). The main part of the final write-up was done by the reference author (CJ), while RK and KST wrote part of it. KS reviewed and edited the first draft while KG directed the research. Differences of interpretation were resolved by discussion and a consensus was reached. Member checking was conducted, and data were sent back to participants for authentication. Participants were informed that citations from their discourse could be used (translated to English) to illustrate the results of the study in a scientific publication, and all the participants signed informed consent forms prior to participation in the study.

Description of the study participants
The sample comprised 15 female HCWs. Of these, five (33.3%) were recruited from the Quarantine Centre, the other five (33.3%) were drawn from the FCH department. The remaining three (20%), and two (13.3%) were working under the Maternity Ward and OPD, respectively. Only two participants were not married, and these hailed from the Quarantine centre and FCH department. The rest of the participants indicated that they were married and stayed with their families. All the participants reported that they had been vaccinated for COVID-19. Three participants (60%) from the Quarantine centre reported that they had been infected with COVID-19. Similarly, two (67%) participants from the Maternity Ward reported the same. Participants were aged between 20 and 45 years; hence, the mean age was 32.5%. Participants also cited 5 to 10 years of work experience, hence the mean years of experience was 7.5 years. All the participants cited poor socio-economic status, exacerbated by low incomes.

Vulnerability to infection (concern for self and family)
Findings reveal that frontline female HCWs working in high-volume departments were always fearful and concerned about getting infected with the novel coronavirus. Some of them reportedly refused to work in high-volume departments where chances of being infected were quite high. These were reported to be from Family and Community Health (FCH) Department, Outpatients Department (OPD), and the Maternity Ward. One participant reported: "We are short-staffed, as some staff members refuse to work in this department. To make up for this shortage, we take up double shifts. As a result, we are overwhelmed. When you are tired, you are bound to make mistakes and therefore the risk of infection is high" (HCW Chitando, FCH).
In addition to being short-staffed, participants mentioned that PPE was uncomfortable and cumbersome, especially the heavy N95 masks. This was exacerbated by long working hours. Some participants reported that they would pull the mask aside just for a few seconds to get some air thus risking getting infected. Additionally, some HCWs had a negative attitude towards COVID-19 and N95 masks in particular, which constituted the best PPE in reducing respiratory infections. One female HCW who was wearing a surgical mask instead of the N95 mask said: "I prefer these surgical masks because the N95 mask suffocates me, especially if I wear it for a long time" (HCW Tubwa, OPD). Therefore, the above responses suggest that some of the HCWs only wore PPE in compliance with the national COVID-19 protocols despite the risk associating with working in high-volume departments.
Although HCWs negative attitudes toward N95 masks contributed to new COVID-19 infections, some were infected due to their passion for work. One participant explained: The above sentiment shows how some HCWs' positive attitudes put them at risk of being infected with COVID-19. Despite their limited access to PPE, their commitment to serve increased their risk of getting infected.
The risk of infection was higher for HCWs working in the COVID-19 isolation centre, as they were working directly with patients infected with the Sars-Cov-2 virus, compared to their counterparts in other departments. One HCW working at the Quarantine Centre reported that: "There is a high risk of infection because we work directly with patients infected with the Sars-Cov-2 virus. Though we are supposed to be one week in and one week off, we are always here because some of our colleagues detest working here" (Tongogara, Quarantine Centre).
Another participant, who also reported being in direct contact with COVID-19 patients, said: "There is direct contact with pregnant mothers during child birth. You must swab the patient, thus coming into contact with her. Furthermore, our catchment area has increased because Chiwaridzo and Chipadze Clinics in the high-density suburbs charge maternity service fees. Hence, pregnant women opt for hospitals that offer free services and as such, we face a higher risk of being infected with COVID-19 than most of our colleagues because we work with large numbers of people" (Zimba, Maternity Ward).
Being in direct contact with COVID-19-infected patients was reported to be the main spreader of the Sars-Cov-2 virus to participants' spouses and family members. Recent evidence suggests that the virus spreads mainly between people who are in close contact with each other, typically within the radius of one metre. A person can be infected upon inhaling aerosols or droplets containing the virus or when these come into direct contact with an individual's eyes, nose or mouth (WHO, 2021).

Shortage of PPE and the lack of standard infrastructure
Limited access to PPE, such as gloves, surgical masks, goggles or face shields, gowns, and N95 masks, all of which have demonstrated efficacy in reducing the COVID-19 infection among HCWs, was a common concern. Bindura Hospital was not an exemption. All the HCWs from the hospital's various departments reported inadequacy of PPE.
"Ideally, when working with patients, one must be protected. The need for protection is even more pertinent because of the COVID-19 pandemic. However, PPE is usually inadequate. There is always a shortage of gloves, gumboots and masks in the wards. The hospital management prioritises those HCWs working at the isolation centre. However, we are also working with a lot of people and the same can be said for OPD and FCH" (Tsitsi, FCH).
When asked if it was the right call to prioritise HCWs in such departments, as one participant argued that every department must be prioritised, one participant said: "Every point must be prioritised. People come in the FCH department and you do not know whether or not they have a history of travel. At OPD, nurses also face the same risk since it is a referral department that attends to all emergencies. The same obtains at the Paediatrics, Opportunistic Infections (OI) Clinic, and Eye Unit. All the people accessing these units must be tested because not all of them are negative. We may have so many positive cases, even when they do not seem to show any symptoms. At one point, a patient later tested positive for COVID-19 when he was about to go to the theatre for an operation, and that put other patients and nurses in the ward at risk" (Tsitsi, FCH).
The above findings were also reported in other studies (McMahon et al., 2020;Ranney et al., 2020). In another study, HCWs who did not have enough resources (PPE) compared themselves to firefighters who spout fires without water or soldiers who go into combat with cardboard body armour (Cohen & Rodgers, 2020).
Although the challenge of shortage of PPE was reported, participants identified other resources that were in short supply. For example, test kits used to detect Sars-Cov-2 were inadequate. One participant said: "We used to test everyone who came to these departments, but because we do not have enough resources, such as polymerase chain reaction (PCR) and antigen test kits, we are now testing people who come showing symptoms only because the test kits were running out fast" (Tomwe, OPD).
Notably, the lack of PPE in Zimbabwe puts HCWs at an elevated risk of contracting the COVID-19 infection.
Another participant highlighted that the infrastructure that lacked minimum standards of operation also exposed HCWs to the risk of contracting the COVID-19 infection. One participant said: "Unfortunately, we do not have showers. We are supposed to bathe before leaving for the parking area or the bus stop outside. There is lack of adequate infrastructure. We mix a lot with people working in other departments, especially the kitchen. We need improved infrastructure to avoid mixing HCWs with other workers. For instance, those who work in the Isolation centre and those in the theatre department must not mix with the rest. So, those in high-risk areas must be restricted to try and curb the spread of COVID-19. There is no infrastructure meant for COVID-19; there must be secluded entrance and exit to avoid exposing patients and other HCWs to COVID-19" (Choguti, Quarantine Centre).
According to WHO (2022), up to 65% of Africans have been infected with COVID-19. Exposure to COVID-19 for people working with infected individuals was associated with a high risk in this study.

Fear of infecting family members
It emerged that HCWs were in constant fear of infecting their family members. A participant said: "On arrival at home, my children rush to hug me. The younger one, who is 15 months old, refuses to be held or fed by his nanny in my presence. So, l must step in. The dilemma of wanting to protect your children while showing them physical affection and coming from a high-risk space kills me. What if they get infected? They do not understand why mummy cannot hug them. At some point, I even contemplated resigning, but I needed money for my children's upkeep" (Chirisa, Maternity Ward).
The participants were juggling their roles and responsibilities as mothers, wives and HCWs. Increased demand and exposure to the virus affected their family responsibilities, and their inability to carry out these family responsibilities affected them emotionally (expressed as feeling sad or losing their temper). The pressure exerted by COVID-19 may have increased work-family conflict for the HCWs. In some cases, the HCWs mulled over resigning from their jobs.
Some participants reported an increase in intimate partner violence (IPV) during the lockdown period. They reported that since they did not have personal cars, they had to use public transport to and from work. Because of lockdown regulations, public transport was not always available and therefore, they often reached home late. This caused tension between them and their partners, as some of them were accused of infidelity and, sometimes, the violence was physical. One participant narrated: "I finished my shift at 18h00; however, there was no transport to take me home. I finally got a lift from a stranger. I reached home at around 21h00. My husband was furious and accused me of cheating on him. He argued that the distance between my workplace and home was not a three-hour journey. He accused me of having been to some other place before reaching home. We had a heated and ugly argument that night. For some weeks, he even refused being intimate with me for the fear of getting infected with an STI" (Nyasha, Maternity Ward).
Healthcare work demands increased fear and anxiety among female HCWs who were torn between their duty as nurses and their responsibilities as family women. The participants reported being accused of infidelity by their husbands, which further impacted their mental health.

Experiences of loss
Constraints related to the lack of resources resulted in participants grappling with psychological effects. They reported experiencing feelings of helplessness and remorse that they could have done better to save their patients.
"There was a patient whom we had stabilised the night before going home for the day. The next morning, l was told that he had a cardiac arrest that night and had passed away. I couldn't help but wonder if there was something we could have done to prevent his death. There were instances when we had to turn patients away owing to a shortage of oxygen. This made me feel helpless, as l could not do anything to help them" (Chirasa, Quarantine Centre).
The participants were often unable to provide the level of care they felt professionally and morally obliged to provide, and many felt the government betrayed them. This was a risk factor for mental health problems and could be particularly damaging in the context of the COVID-19 pandemic. This was aggravated by seeing colleagues (some of them very young) suffer and die from COVID-19. Participants reported feelings of fear and anxiety concerning the next casualty. This was exacerbated by daily media reports of exponentially increasing statistics of people getting infected and succumbing to COVID-19.

Ethical dilemma
The competing obligations that the participants felt between providing good patient care and protecting their own physical safety were noted. For example, HCWs who were assigned to duty without adequate PPE were at high risk of being infected, and could infect their families and clients as well. This violated the "no harm to others" or "non-maleficence" ethical principle. However, the HCWs reported that they saw their work as an act for the greater good. Despite not having enough PPE, frontline female HCWs reported that they had to improvise because they could not leave patients unattended. One participant reported: "Sometimes, the PPE is made specifically for males who usually have bigger frames" (Tubwa, OPD).
As such, female HCWs had to improvise the PPE that fitted them.

Stigma towards COVID-19
Participants reported being stigmatised. The stigma associated with COVID-19, in the present context, could be understood as a social process aimed at excluding those perceived as potential sources of the disease, thus posing a threat to effective social living. One participant reported: "At home, we share a boundary fence with our neighbours. The fence is made of wire. Their 5-year-old daughter befriends my daughter of the same age and the girls often chatted through the fence. My neighbour would call her daughter back telling her not to play with my child because she would risk getting infected because l brought COVID-19 from my workplace. This affected my daughter because she could not understand why her friend could not play with her" (Chitsiga, OPD).

Coping strategies
The participants indicated that they adopted a plethora of strategies to avert the spread of COVID-19. These are described below:

Vaccinations
Vaccines are medical products that are given to individuals (both children and adults) to protect them against serious and sometimes deadly diseases. The perceptions of HCWs towards the vaccine are reported below. When asked what they thought about the vaccines, all the HCWs reported positive outcomes. One participant explained: "It's useful and effective as those who are vaccinated suffer less than the unvaccinated. There are few cases of hospitalisation or severe illness among the vaccinated. After being vaccinated, one may also get sick but they can quickly recover as compared to the unvaccinated" (Chidoko, FCHD).
All the participants confirmed the efficacy of vaccines. When they were asked about the importance of vaccines, the participants agreed that they served a good cause by reducing the chances of severe illness and hospitalisation. For example, one participant said: "After vaccination, one may still get sick, but vaccination reduces the chances of one becoming a severe case, and that cannot be said for those with weaker immune systems" (Chidoko, FCHD). Therefore, despite receiving the recommended doses of Sinopharm or Sinovac, one may still be infected with Sars-Cov-2. However, all the participants agreed that there were higher chances that fully vaccinated individuals may recover, when compared to those that were unvaccinated.

The use of home remedies (Herbal concoctions)
Various home-based remedies, including steaming, were believed to cure COVID-19. For instance, the famous Zumbani (Lippia javanica) was believed to cure COVID-19. The participants explained that they believed in the medicinal properties of Zumbani tea in treating COVID-19. They reported that steaming using Zumbani and other remedies such as lemon leaves, onions, ginger, and tsunami offered an effective remedy.
One participant explained that: "We also steam using a heated stone. We then pour hot water on the stone and by so doing, the stone produces more steam. We also use tsunami or ginger. We do not know whether this works or not because it is not scientifically proven. We are just trying" (Chirasa, Quarantine Centre).

Another participant said:
"We take all the WHO precautionary measures to protect ourselves. These include sanitising our hands regularly. However, maintaining social distance is a challenge in our department" (Zimba, Maternity Ward).
Steaming was described by all the participants as an effective remedy. One of the HCWs who once got infected with COVID-19 explained that she would steam, which helped to clear her throat. The treatment comprised regular steaming using hot water mixed with ginger and tsunami or Zumbani. One participant reported that she had a toxic experience with the use of raw onions, tsunami and ginger. The participant advised against the use of such remedies. Steaming was reported to be very useful in relieving congestion or cold in the upper respiratory tract. In addition, to steaming and using a mixture of home remedies (concoction), Roxithromycin and Paracetamol drugs were found to be effective in reducing pain.
The study focussed on how HCWs, especially married mothers with children who wanted motherly care, protected their loved ones, that is, family. Most HCWs (6 out of 10 = 60%) females noted that they would avoid mixing with their families, though it was reported to be difficult. One HCW said:

"The first thing that I do when I reach my place is to sanitise my hands, and then bathe with hot water. I also wash my clothes with hot water. I usually do not mix up with my children after work. I sometimes eat my meals in my bedroom" (Tubwa, OPD).
One participant also noted that when she suspected that she had been infected with COVID-19, she sent her children to their grandmother, fearing that she might have passed the virus on to them. The other HCW related how she suspected to have been infected by . At first, she tested negative using an antigen test. Later on, a PCR test was conducted, and she tested positive, hence putting other HCWs and her patients at risk. Clearly, PCR tests are more effective than antigens (Rohde et al., 2022).

Renting rooms to stay away from families
Another coping strategy meant to protect families against COVID-19 infection the participants adopted was renting rooms in locations that were far away from their families. This was especially common for those who stayed with the elderly and immunity-compromised family members. Participants reported renting rooms as groups of HCWs as they could not risk infecting their families. Working in high-risk areas meant that there were potential carriers of the novel coronavirus among the HCWs. However, this measure affected the female HCWs' mental health because they felt isolated from their loved ones, which increased their anxiety and caused depression due to limitless timelines regarding the end to the pandemic.
Furthermore, the participants that stayed in rented accommodation reported regular movements from house to house because their landlords continuously moved them feeling that they posed a risk to the rest of the tenants since they worked in hospital settings. This caused tension for female HCWs whose partners did not work in hospital settings. These female HCWs contemplated resigning from their jobs because they struggled to cope with the situation.

Positive attitude and self-motivation
Having faith in God was one of the ways through which the participants coped with the pain. HCWs believed that they would not be adversely affected since their faith would enable them to courageously deal with the crisis. This belief in God also helped them to maintain a positive attitude towards the provision of healthcare services in spite of the threatening COVID-19 pandemic. One female HCW intimated: "No one forced us to do this duty. It was our choice and therefore we have to do the best we can. We sometimes sing hymns and pray before assuming duty. That's how we cope" (Chirasa, Quarantine Centre).

Psychological support
Psychosocial support was reported to be a very effective strategy of dealing with the pandemic. In her exact words, one participant explained: "Psychosocial support is very important. Receiving phone calls from relatives and colleagues made me feel very happy because that signified that some people cared about me. Sometimes, some colleagues would come and maintain their social distance while wearing N95 masks and we would talk. This made me strong" (Choguti, Quarantine Centre).
From the above sentiments, it can be concluded that psychosocial support is key for people suffering from infectious diseases such as HIV and AIDS, as well as COVID-19. The findings replicate those of other studies conducted in Sub-Saharan Africa (SSA) (Jimu et al., 2021;Okonji et al., 2021).

Discussion
In this article, we explored the experiences of frontline female HCWs during the COVID-19 pandemic. The findings reveal that the specific effects of COVID-19 on female HCWs included exposure to infection, longer workdays and a bigger workload, which was harmful not only to the HCWs themselves but also to the quality of care they were providing. Female HCWs were concerned about their own physical safety and that of others. This concern was exacerbated by media reports on the virus, which some described as alarmist because they frequently announced deaths of colleagues, all amid inadequate PPE and other resources such as medical equipment. Stigma also strained HCWs' relationships with families, that situation was compounded by anxiety and stress. However, the experiences of female HCWs during the COVID-19 pandemic were without precedent, as they were comparable to those experienced during previous pandemics for instance HIV (Morgan et al., 2022;Nkengasong, 2022).
The study reveals how the maternal body can be a site of contestation between dominant maternal ideals and the demands of healthcare work. Being a wife, mother and employee placed working mothers in difficult positions. This was amplified by the gender expectations insisting on being a "good mother" and that was exacerbated by the need to be a dedicated employee during the COVID-19 pandemic. Although female HCWs were expected to be "good mothers", which implies prioritising one's children, work-related pressures were amplified during the COVID-19 pandemic. HCWs risked contracting the virus at work, which was equally risky for their children and the elderly (Chou et al., 2020). While fathers also made sacrifices during the COVID-19, they did not express the same emotions as their female counterparts. These findings reflect gender differences in socially prescribed parental and HCW expectations that can emotionally affect individuals.
The findings also show that caring for patients with COVID-19 created mental and social discomfort for female HCWs, which corroborate other international studies (Galehdar et al., 2020;Li et al., 2022). Frontline female HCWs struggled with experiences of loss. They reported feeling inadequate and overwhelmed, which affected them mentally, emotionally, psychologically, and physically. Such distress even affected their families. Participants felt distressed and powerless about how they could protect their families from COVID-19, given that they were frontline workers facing an elevated risk of contracting the infection. Physical fatigue, psychological vulnerability, health risks meted out to their families as well as lack of equipment and facilities further contributed to the participants' mental exhaustion. They were torn between doing their work-related duties and protecting their families from COVID-19. This underscores the need for increased mental health support, protection, material support, and gender equality in the workplace. These are the crucial elements in the maintenance of HCWs' mental well-being (Galehdar et al., 2020).
The research has highlighted female HCWs' unique needs during pandemics. The findings expose a feminised burden of care during COVID-19. The closure of schools and day care centres during the peak of the COVID-19 pandemic meant children's increased care and needs. In a society structured along patriarchal lines and gendered responsibilities, it is a woman's social responsibility to take care of all the things relating to the home and the welfare of her family. The lack of childcare support is particularly problematic for essential workers, including HCWs, who have additional care responsibilities. With social distancing guidelines and travel restrictions in place, working mothers were unable to call on support networks seeking childcare. Therefore, female HCWs shouldered the responsibilities of taking care of the home, children, the sick, and the elderly. This suggests that the home is a space for power manifestation, the feminisation of unpaid labour, violence, and the reproduction of patriarchy. This has implications for policy, an aspect that may have been overlooked. Response measures must prioritise maintenance of the continuity of care for children while also reducing the burden on women and girls. Targeted approaches that consider measures of intersectionality are urgently needed in the response efforts meant to decimate COVID-19. There is need for providing meaningful support to HCWs, considering the cultural expectations of female HCWs both as mothers and as employees. There is a need for gender-responsive interventions that specifically meet their mental health needs. Evidence indicates that supporting female HCWs' mental health during crises is an important factor determining recovery from disasters (Morgan et al., 2022).
Although inequalities are experienced in intensely personal ways, these have institutional sources. The increased demand for care during the COVID-19 pandemic deepened existing inequalities in gendered division of labour, placing a disproportionate burden on women and girls (Ahinkorah et al., 2021). The absence of social support, causes increased feelings of anxiety and distress. HCWs complained that people stigmatised them and their family members, often withdrawing from their circles because of their interaction with COVID-19 patients. As a result, they felt lonely and isolated. This has raised concerns about the need for social support for working women, especially HCWs during pandemics. In the absence of social support, breaking points will be reached with long-term consequences for women's health and well-being and that of their families (Behrendt et al., 2021). This emphasises the need for a new conception of motherhood that recognises the psychological tensions that working women experience as a result of the patriarchal standards that marginalise women rather than their own personal decisions (UN, 2022).

Domestic violence
Due to altered routine and increased workload for female HCWs, reports of domestic violence were a certainty. These findings are not unique to female HCWs; they are also reported in other studies (Magezi & Manzanga, 2019;Peitzmeier et al., 2022;Zero & Geary, 2020). An overall increase of over 75% of the cases of domestic violence was reported compared to the pre-lockdown trends reported in Zimbabwe, and 94% of the cases involved women (Magezi, 2020). This illustrates how intimate partner violence has remained a global challenge. There is a need to ensure that all GBV services (including shelters, Victim Friendly Units (VFUs) and help lines) are designated essential services and work with the police and judiciary services to protect women and girls to prevent impunity and ensure that female survivors continue accessing support and justice during pandemics.

Zimbabwean friendship bench model intervention
The Zimbabwe Friendship Bench (FB) project is an evidence-based intervention developed in Zimbabwe to bridge the mental health treatment gap. The FB aims to enhance mental wellbeing and improve quality of life using problem-solving therapy delivered by trained lay health workers, focussing on people who are suffering from common mental disorders, such as anxiety and depression (Chibanda et al., 2016). The Zimbabwean FB model has proved to be the best fit locally, particularly in terms of its ability to improve mental health (Chibanda et al., 2016). One of the strengths of the model is that it is an evidence-based intervention developed over a 20-year period bordering on community research in Zimbabwe. It uses an approach based on cognitive behavioural therapy offered at the primary care level to address "kufungisisa" -a local Shona word closest to depression and literally meaning "thinking too much". Thus, it can be argued that the Zimbabwean FB had contextual relevance to this study as it has local relevance. For example, trial patients with depression and anxiety but receiving problem-solving therapy using the friendship bench technique were three times more likely to have lower symptoms of depression after six months than their counterparts (14% compared to 50%). Our study found that participants reported depression and psychological distress, and therefore we recommend the adoption of the Friendship Bench model for female HCWs.

Strength and limitations
The most prominent strength of this research lies in its qualitative approach and its use of female narratives to document the lived experiences of female HCWs as they were impacted by gender and other aspects of participants' lives. Taking an inter-sectional stance in the analysis, the experiences of the HCWs in this research proved useful, as they contributed to the realisation that the marginalisation of women is a combination of several factors that converge to constitute violence against women. Highlighting and prioritising the female gender by analysing the personal experiences of female HCWs have added a valuable contribution to literature by amplifying voices that were previously muted. However, this study is not without limitations. The study was conducted at Bindura Hospital and is only relevant to that context; therefore, the applicability and generalisability of our findings are limited to that context. Again, the absence of men in our sample limited our ability to examine the unique experiences of this cohort, depriving us of engaging meaningfully in comparisons between men and women. Lastly, gender is a highly complex concept that is difficult to investigate through telephone-based interviews comprising only a handful of questions. Therefore, this study hardly provides a comprehensive account of the influence of gender on HCWs' experiences.

Conclusion
This paper has explored the lived experiences of frontline female HCWs during the COVID-19 pandemic when female HCWs have faced immense psychosocial pressures that ranged from unsupportive family norms to a hostile working environment. Our findings revealed that HCWs experienced feelings of apprehension while treating COVID-19 patients; HCWs' feelings towards COVID-19 patients; challenges facing female HCWs and coping strategies; confidence in government, healthcare administration, and self-reflection. Our research has confirmed and reiterated the importance of addressing gender issues when examining the experiences of individuals in particular contexts. Using a gender lens framework, we exposed how larger structural inequalities shape individual experiences and problems in meaningful, yet often inconspicuous ways.