Ethiotime1
The COVID-19 pandemic has been an ongoing global public health emergency that has burdened healthcare workers’ physical and mental well-being (HCWs) [1, 5]. Our review confirms the enormous magnitude of mental health impact of COVID-19 on healthcare workers in sub-Saharan Africa, and it is widespread, with significant levels of depression, anxiety, distress, and insomnia; especially those working directly with COVID-19 patients at particular risk [34,35,36,37, 39,40,41,42,43,44,45]. Out of the twelve articles reviewed, eight studies (66%) came from Ethiopia, and this has implications on the results (Table 1). This finding indicates few research published to date on the psychological impact of the pandemic on the mental health of HCWs in sub-Saharan Africa; a subregion that the COVID-19 pandemic has severely impacted.
Overview of the study sites
Studies in this review were conducted predominantly in hospital settings. We found only one study relating to primary healthcare workers or facilities [38]. This finding is of concern, as there is increasing evidence that many non-frontline HCWs continue to suffer psychological symptoms long after the conclusion of infectious disease epidemics [7, 8]. In addition, a significant mortality due to COVID-19 was due to excess morbidity, some of which were from primary care facilities. Given that this study is the first narrative review in sub-Saharan Africa, it would be helpful to briefly compare our findings with some published reviews and surveys from other regions (Table 2).
High prevalence of psychological disorders among participants
Investigators in this review found 16.3–71.9% HCWs with depressive symptoms, 21.9–73.5% had anxiety symptoms, 15.5–63.7% experienced work-related stress symptoms, 12.4–77% experienced sleep disturbances, and 51.6–56.8% PTSD symptoms [35,36,37,38,39,40,41,42,43,44,45]. This high prevalence of mental health symptoms among HCWs in our review is consistent with previous reviews conducted early in the pandemic in sub-Saharan Africa [31], Asia [17, 18, 26, 28], USA & Europe [15, 16], and supported by a batch of cross-sectional studies globally [11,12,13,14, 19, 27, 30]. We found mixed results with significant variations within and among regions and countries, as depicted in Tables 1 and 2.
Risk factors of psychological disorders among participants
Studies established that HCWs responding to the COVID-19 pandemic in sub-Saharan Africa were exposed to long working hours, overworking, exhaustion, high risk of infection, and shortage of personal protective equipment (Tables 3 and 4). In addition, HCWs had deep fear, were anxious and stressed with the high transmission rate of the virus among themselves, high death rates among themselves and their patients, and lived under constant fear of infecting themselves and their families with obvious consequences [35,36,37,38,39,40,41,42,43,44,45]. Some HCWs were deeply worried about the lack of standardized PPEs, known treatments and vaccines to protect against the virus. Many health workers had financial problems, lacked support from families and employers if they contracted the virus [34,35,36,37, 39,40,41,42, 44]. An additional source of fear and anxiety was the perceived stigma attached to being infected with COVID-19 by the public [36, 41]. Studies found that HCWs, especially those working in emergency, intensive care units, infectious disease wards, pharmacies, and laboratories, were at higher risk of developing adverse mental health impacts compared to others [34,35,36,37, 39,40,41,42,43,44]. This is supported by previous reviews [15,16,17,18, 26, 28] and cross-sectional studies [10,11,12,13,14, 20, 21, 23, 25, 30]. However, findings were inconsistent on the impact of COVID-19 on frontline health workers, with ten studies [35,36,37, 39,40,41,42, 44, 45] suggesting they are at higher risk than peers and two studies showing no significant difference in psychological disorders relating to the departments [38, 43].
The Mali’s study was conducted exclusively in primary care facilities among HCWs not involved in treating COVID-19 cases but still registered a very high prevalence of depression 71.9%, anxiety 73.6%, and insomnia 77.0% [39]. In contrast, two studies conducted among HCWs at COVID-19 treatment facilities in Ethiopia [36, 38] registered much lower prevalence of depression 20.2%, anxiety 21.0%, and insomnia12.4% [36], and 16.3%, 30.7% and 15.9% respectively, in the second study [38]. These findings show that not only frontline HCWs experienced mental health disorders during this pandemic but highlight the need for direct interventions for all HCWs regardless of occupation or workstation during this and future pandemics. The significant disparity in the studies could be due to structural, occupational, and environmental issues for example challenges faced by Mali’s healthcare systems, characterized by acute equipment shortages, lack of PPEs, human resources, lack of trained and experienced HCWs, ongoing nationwide insecurity, and terrorism compared to Ethiopia. Therefore, local context needs to be considered as contributing factor to mental health disorders among HCWs.
Regional variations of psychological disorders
Tan et al. found a higher prevalence of anxiety among non-medical HCWs in Singapore [27]. As previously noted, the prevalence of poor psychological outcomes varied between countries. Compared to sub-Saharan Africa and China, data from India [23] and Singapore [27] revealed an overall lower prevalence of anxiety and depression than similar cross-sectional data from sub-Saharan Africa [35,36,37,38,39,40,41,42,43,44,45] and China [9, 25, 30]. This finding suggests that different contexts and cultures may reveal different psychological findings and that, it is possible that being at different countries’ outbreak curve may play a part, as there is evidence that it is influential.
Tan et al. suggests that medical HCWs in Singapore had experienced a SARS outbreak and thus were well prepared for COVID-19 psychologically and infection control measures [27]. What can be deduced is that context and cultural factors play a role, not just the cadre or role of healthcare workers [16]. It also highlights the importance of reviewing evidence regularly as more data emerge from other countries.
One hospital in Ethiopia found that the thought of resignation was associated with higher chances of mental health disorders and that pharmacists and laboratory technicians who did not receive prior training exhibited higher symptoms of mental health disorders compared to others [36]. Work shift arrangement, considering a dangerous atmosphere presented by working in COVID-19 wards, was one which exacerbated or relieved mental health symptoms among HCWs, with shorter exposure periods being most beneficial [36]. Meanwhile, studies found that financial worries caused by severe lockdowns and erratic payment of salaries and allowances were also major stressors [35]. This finding is like studies in Pakistan [13] and China [30, 32].
In this review, HCWs who had contact with confirmed COVID-19 patients were more affected by depression, anxiety, and stress than their counterparts who had not [35,36,37, 40, 41, 43, 45]. This finding is like previous reviews [15,16,17,18, 26, 28, 31] and cross-sectional studies [9,10,11,12,13,14, 21, 23,24,25, 27, 30], which reported higher depression, anxiety, and psychological symptoms of distress in HCWs who were in direct contact with confirmed or suspected COVID-19 patients.
A study in Pakistan showed that 80% of participants expected the provision of PPE from authority [13], and 86% were anxious. Some respondents alluded to forced deployment, while in Mali, 73.3% were anxious, with the majority worrying about the shortage of nurses [39]. Therefore, prospects of being deployed at a workstation where one had not been trained or oriented contributed to fear among health workers. In the sub-Saharan African context, this scenario can best be represented in HCWs involved in internship who must endure hard work during their training. Tan et al. found that junior doctors were more stressed than nurses in Singapore [27].
Socio-demographic characteristics
Nearly all studies in our review suggest that socio-demographic variables for example age, gender, marital status, and living alone or with families contribute to the high mental disorder symptoms [35,36,37, 39,40,41,42,43,44]. We, the authors suggest that these observations are handled cautiously as several investigators of these reviewed articles did not entirely control the influence of confounding variables. An alternative explanation for this study’s findings may be the more significant risks of frontline exposure amongst women and junior HCWs, predominantly employed in lower-status roles, many of whom lacked experience and appropriate training within healthcare system globally. It is also important to note that respondents to all studies, when disaggregated by gender, and age, were predominantly younger or female, which may have impacted the outcomes of these findings [16]. In addition, the consistently higher mortality rates, and risk of severe COVID-19 disease amongst men would suggest that the complete picture regarding gender and mental health during this pandemic is still incomplete [16]. Moreover, in several studies, both younger and older age groups were equally affected by mental health symptoms but for different reasons. Cai et al. [32] in a Chinese study on HCWs for example observed that irrespective of age, colleagues’ safety, self and families’ safety, the lack of treatment for COVID-19 was a factor that induced stress in HCWs. Similarly, in our review, the lack of PPEs, high infection transmission rates, high death rates among HCWs, and the fear of infecting their families were the factors that induced stress in all HCWs [34,35,36,37, 39,40,41,42,43,44,45].
We, the authors propose that paying close attention to concerns of HCWs by employers would greatly relieve some stressors and contribute to increased mental well-being of participants. Compared with physicians, our review showed that nurses were more likely to suffer from depression, anxiety, insomnia, PTSD, and stress [35, 37, 39,40,41, 44, 45]. Workloads and night shifts in healthcare facilities, as well as contacts with risky patients, enhanced nurses’ mental distress risks [15,16,17,18, 26,27,28]. In addition, nursing staff have more extended physical contacts and closer interactions with patients than other professionals, providing round-the-clock care required by patients with COVID-19 and thus the increased risk [15]. On the one hand, we posit that most senior physicians are experienced and always keep well-informed with emerging medical emergencies. The majority become aware of emerging epidemic early and actively protect themselves from infections through regular scientific literature updates compared to their junior counterparts. Senior physicians also spend less time in emergency wards unless there is a need to conduct specific procedures which cannot be undertaken by senior housemen or general medical officers. Cai et al. [32] concluded that it is essential to have a high level of training and professional experience for healthcare workers engaging in public health emergencies, especially for the new staff. As a result, these findings highlight the importance of focusing on all the frontline HCWs sacrificing to contain the COVID-19 pandemic.
Regular monitoring of high-risk groups
There is a need to continue monitoring the high-at-risk groups, including nursing staff, interns, support staff, and all deployed in emergency wards. These high-at-risk groups should be encouraged to undertake screening, treatment, and vaccination to avoid the medium and long-term consequences of such epidemics [15, 16, 35, 37, 40, 44].
Social support and coping mechanisms
The effect of social support and coping measures is in the qualitative study [34] and three other quantitative studies [36, 41, 42] which concluded that respondents with good social support were less likely to suffer from severe depression, anxiety, work-related stress, and PTSD. The qualitative study identified several coping measures, including community and organizational support, family, and community networks, help from family, responsibility to society, and assistance from community members and strangers, including the symbiotic nature of assistance in the community [35]. Other measures include providing accommodation and food to employees [35].
Interestingly, no study examined the association of resilience and self-efficacy with sleep quality, degrees of anxiety, depression, PTSD, and stress. However, a Chinese study by Cai et al. [32] suggests that the social support given to HCWs causes a reduction in anxiety and stress levels and increases their self-efficacy. In divergence, Xiao et al. [46] found no relationship between social support and sleep quality.
Only two studies in our review examined the effects of stigma on the mental health of HCWs [36, 41] and found that HCWs with perceived stigma were more likely to be depressed, anxious, stressed, and prone to poor sleep quality [36, 41]. We, the authors suggest that better community sensitization by creating public awareness involving appropriate local community structures and networks are essential. The broader community in sub-Saharan Africa may have suffered severely from infodemics with severe consequences on their mental health, especially during the difficult lockdowns. In addition, removing discrimination/inequalities at the workplace based on race and other social standings have a powerful influence on the mental health outcomes of HCWs. Also, because emotional exhaustion is long associated with depression, anxiety, and sleep disturbances, none of the studies in our review examined burnout as an essential component of mental health disorders in HCWs in sub-Saharan Africa.
Protective and coping measures
In this review we have provided evidence about personal, occupational, and environmental factors that were important protective and coping measures against psychological disorders. Based on these factors we suggest some protective and coping measures which can help to reduce the negative effects of the pandemic on mental health of HCWs in sub-Saharan Africa. Organizations and healthcare managers need to be aware that primary prevention is key to any successful interventions to contain and control any epidemic. This should take the form of planned regular training, orientation and continuing medical education grounded on proven infection control measures. These measures need to be backed up by timely provision of protective equipment, drugs, testing facilities, vaccines, isolation facilities, clinical and mental health support, and personal welfare of HCWs [35,36,37, 42, 45]. The effect of community and organizational support and coping measures was shown by the qualitative study [35] and five other quantitative studies [36, 37, 41,42,43] indicating that respondents who had good social and organizational support were less likely to suffer from severe depression, anxiety, work related stress and PTSD. Prior experience with comparable pandemics and training are suggested as beneficial coping strategies for healthcare workers during this pandemic but also local social structural and geopolitical conditions appear to determine the pattern and evolution of mental health symptoms among HCWs [14, 15, 31, 32, 47]. In our case the high prevalence of all mental health symptoms in non-frontline primary health care facilities in Mali [39] which was already plagued with instability and weak healthcare systems prior to the pandemic is a case in point. Results are particularly consistent in showing that provision of PPEs, testing kits, orientation training of workers, work shift arrangements, provision of online counselling, provision of food and accommodation and prompt payment of allowances by employers were important protective measures [35,36,37,38,39, 41,42,43,44,45,46,47]. The feeling of being protected is associated with higher work motivation with implication for staff turnover [35, 38, 43, 45]. Hence, physical protective materials [14], together with frequent provision of information, should be the cornerstone of any interventions to prevent deterioration in mental health of HCWs (Table 5). Finally, provision of rest rooms, online consultation with psychologists/psychiatrists, protection from financial hardships, access to social amenities and religious activities are some important coping measures [35, 36, 38, 42, 45]. In this era of digital health care with plentiful internet and smartphones, organization can conduct online trainings, online mental health education, online psychological counselling services, and online psychological self-help intervention tailored to the needs of their HCWs [35, 37, 42]. In addition, it is essential to understand and address the sources of anxiety among healthcare professionals during this COVID-19 pandemic, as this has been one of the most experienced mental health symptoms [48]. Adequate protective equipment provided by health facilities is one of the most important motivational factors for encouraging continuation of work in future outbreaks. Furthermore, availability of strict infection control guidelines, specialized equipment, recognition of their efforts by facility management, government, and reduction in reported cases of COVID-19 provide psychological benefits [15, 32]. Finally, we call upon Governments (the largest employers of HCWs) in sub-Saharan Africa to do what it takes to improve investments in the mental health of HCWs and plan proactively in anticipation of managing infectious disease epidemics, including other expected and unexpected disasters.
Future research direction
There was no study that examined the association of resilience and self-efficacy with sleep quality, degrees of anxiety, depression, PTSD, and stress. Although emotional exhaustion has long been associated with depression, anxiety, and sleep disturbances, no study in our review examined burnout as an important component of mental health disorders in HCWs in sub-Saharan Africa. The impacts of infodemics, stringent lockdown measures, discrimination/inequalities at workplaces based on race, and other social standings on mental health outcomes of HCWs need to be investigated.
Future studies are needed on the above including other critical areas like suicidality, suicidal ideations, and substance abuse during the COVID-19 pandemic. In addition, there is a significant variation of related literature calling for more rigorous research in future. More systematic studies will be required to clarify the full impact of the pandemic so that meaningful interventions can be planned and executed at institutional and national levels in the Sub-Saharan Africa.
Limitations of this study
There are some limitations to this study. First, most of the studies are from one country, limiting the generalizability of the results to the whole African continent. Second, all the studies were cross-sectional and only looked at associations and correlations. There is a need for prospective or retrospective cohort or case–control studies on this subject matter. Longitudinal research studies on the prevalence of mental disorders in the COVID-19 pandemic in the sub-Saharan Africa are urgently required. Third, most studies reviewed did not adequately examine protective factors or coping measures of the health workers in their settings. In addition, most studies did not pay strict attention to confounding variables which could have led to inappropriate results and conclusions. Fourth, most sample sizes were small and unlikely representative of the population and yet larger sample sizes would better identify the extent of mental health problems among health workers in the region. Fifth, depression, anxiety, and stress were assessed solely through self-administered questionnaires rather than face-to-face psychiatric interviews. Sixth, these studies employed various instruments and different cut-off thresholds to assess severity. Notably, the magnitude and severity of reported mental health outcomes may vary based on the validity and sensitivity of the measurement tools. Seventh, there was no mention of mental baseline information among the studied population and therefore it was unknown if the studied population had pre-existing mental health illnesses that decompensated during the pandemic crisis. Eight, investigators did not give much attention to stigma, burnout, resilience, and self-efficacy among study participants.
Furthermore, our review did not employ systematic reviews or meta-analyses methods for the information generated. This narrative review paper precluded deeper insight into the quality of reviewed articles for this paper. Still, our observation was that investigators did not consider the strict lockdown measures, quarantine, and isolation imposed by many countries in sub-Saharan Africa as possible risk factors for mental health disorders among HCWs.
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