The COVID-19 pandemic has been an ongoing global public health emergency that has placed a heavy burden on healthcare workers' physical and mental well-being (HCWs) [1, 5]. Our review confirms the magnitude of the mental health impact of COVID-19 on health care workers in sub-Saharan Africa; it has been extensive, with significant levels of depression, anxiety, distress, and insomnia, with those working directly with COVID-19 patients at particular risk [34–37, 39–45]. Out of the 12 articles reviewed, most studies, 08 (66%), came from Ethiopia; this has implications for our results. The finding indicates that there is scanty research published on the psychological impact of the pandemic on the mental health of HCWs in sub-Saharan Africa, a sub-region in which COVID-19 has severely impacted the health workers' mental to date.
The studies included in this review were predominantly concerned with 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 pandemics [7, 8]. In addition, significant mortality due to COVID-19 was due to excess mortality, some of which could have occurred 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). Mainly, investigators in our review found (that 16.3–71.9%) of 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%) reported PTSD symptoms [35–41, 42–45].
This high prevalence of the 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], the USA & Europe [15, 16], supported by a slew of cross-sectional studies across the globe [11–14, 19, 27, 30]. The results have mixed significant variations within and among regions and countries, as depicted in Tables 1 and 2.
Studies established that HCWs responding to the COVID-19 pandemic in sub-Saharan Africa were exposed to long working hours, overworking, exhaustion, a high risk of infection, and a shortage of personal protective equipment.
In addition, HCWs had profound 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 [35–45]. Some HCWs were deeply worried about the lack of standardized PPEs, and the lack of known and available treatment and vaccines to protect against the virus. Many health workers feared financial problems and a lack of support for themselves and their families from their employers; if they contracted the virus [34–37, 39–42, 44]. An additional source of fear and anxiety among HCWs 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 [34–37, 39–44].
This is supported by previous reviews [15, 16, 17, 18, 26, 28] and cross-sectional studies [10–14, 20, 21, 23, 25, 30].
Findings were contradictory for front-line health workers, with ten studies [35, 36, 37, 39–42, 44, 45] suggesting that they are at higher risks than peers and two studies finding no significant difference in psychological disorders concerning the departments [38, 43]. The study from Mali was conducted exclusively in primary care facilities not involved in treating COVID-19 cases but still registered a very high prevalence of depression 71.9%, anxiety 73.6%, and insomnia 77% among HCWs [39]. In contrast, two studies conducted 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 among their respondents [38].
These findings show that front-line HCWs experience mental health disorders during this pandemic and highlight the need for direct interventions for all HCWs regardless of occupation or workstation during this and future pandemics. The significant disparity could be due to structural, occupational, and environmental challenges faced by Mali's healthcare systems, characterized by acute shortages of equipment, including PPEs, shortage of human resources, lack of trained and experienced HCWs, and ongoing nationwide insecurity and terrorism compared to Ethiopia. Therefore, local context also needs to be considered as contributing factor to mental health disorders among HCWs.
Tan et al. found a higher prevalence of anxiety among 470 non-medical HCWs in Singapore [27]. 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 [35–45] or China [9, 25, 30]. This finding suggests that different contexts and cultures may reveal different findings. It is possible that being at different points in their respective countries outbreak curve may have played a part, as there was evidence that this may be influential.
Tan et al. postulated that the medical HCWs in Singapore had experienced a SARS outbreak and thus were well prepared for COVID-19 psychologically and in their infection, control measures [27]. From the study, findings are that context and cultural factors are likely to play a role, not just the cadre or role of healthcare workers [16]. It also highlights the importance of reviewing the evidence regularly as more data emerge from other countries.
One hospital in Ethiopia found that the thought of resignation was associated with high mental health disorders and that pharmacists and laboratory technicians who did not receive training exhibited high symptoms of mental health disorders [36]. Work shift arrangements, considering the dangerous atmosphere presented by working in COVID-19 wards, were identified as 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 among the health workers in sub-Saharan Africa agrees with studies from 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 did not [35–37, 40, 41, 43, 45]. This review finding agrees with previous reviews [15–18, 26, 28, 31] and cross-sectional studies [9–14, 21, 23, 24, 25, 27, 30], which reported higher symptoms of depression, anxiety, and psychological distress in HCWs who were in direct contact with confirmed or suspected COVID-19 patients.
Studies in Pakistan revealed that 80% of participants expected provision of PPE from the authority [13], 86% of the respondents in Pakistan were anxious, and some respondents alluded to forced deployment. In contrast with the Mali study [39],73.3% of the respondents were anxious, with the majority worrying about shortages of nurses. Also, health workers' fears came from the prospect of being deployed at a workstation where there was no proper training or orientation. In the sub-Saharan African context, this scenario could be like what HCWs involved in an internship must endure during their training, although no study examined this group separately. Tan et al. found that junior doctors were more stressed than nurses in Singapore [27]. Almost all the studies in our review suggest that socio-demographic variables like age, gender, marital status, and living alone or with families could have contributed to the high mental disorder symptoms reported in our review [35–37, 39–44]. These mental health findings on health workers were influenced by confounding variables that many investigators did not correctly control. The findings should be treated cautiously in the context of the sub-Saharan situation.
An alternative explanation for this study's findings may be the more significant risks of front-line exposures amongst women and junior HCWs in the lower status roles, many of whom lack experience and appropriate training within healthcare 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 findings [16]. The consistently higher mortality rates and risk of severe COVID-19 disease amongst men would suggest that the whole 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 H et al., in a Chinese study of HCWs, observed that irrespective of age, the safety of colleagues, the safety of self and families, and the lack of treatment for COVID-19 were factors that induced Stress in all HCWs [32]. Similarly, in our review, the lack of PPEs, high transmission rates, high death rates among HCWs, and the fear of infecting their families were the factors that induced Stress in all HCWs [34–37, 39–45].
We advise that paying close attention to the above concerns of HCWs by their organizations/employers would greatly relieve some of the stressors and contribute to the increased mental well-being of the respondents.
In comparison with physicians, our review has indicated that nurses were more likely to suffer from depression, anxiety, insomnia, PTSD, and Stress than doctors [35, 37, 39–41, 44, 45]. Workloads and night shifts in healthcare facilities, as well as contact with hazardous patients, enhance nurses' mental distress risks [15–18, 26–28]. In addition, the nursing staff has more extended physical contact and closer interactions with patients than other professionals, providing round-the-clock care required by patients with COVID-19 [15].
We postulate that most senior Physicians are experienced and always keep abreast with emerging medical emergencies. In addition, the majority actively protect themselves from infections through constant 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 not undertaken by Senior Housemen or General Medical officers. Cai H et al. concluded that it is crucial to have a high level of training and professional experience for healthcare workers engaging in public health emergencies, especially for the new staff [32].
As a result, these findings highlight the importance of focusing on all the front-line HCWs sacrificed to contain the COVID-19 pandemic.
There is a need to continue monitoring the highly at-risk groups, including the nursing staff, interns, support staff, and all deployed to emergency wards. These high-risk categories must be encouraged to present themselves for screening and treatment to avoid the medium- and long-term consequences of such epidemics. [15, 16, 35, 37, 40, 44].
The effect of social support and coping measures is in the qualitative study [35] and three other quantitative studies [36, 41, 42], concluding that respondents with good social support were less likely to suffer from severe depression, anxiety, and 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 the employees [35].
No study examined the association of resilience and self-efficacy with sleep quality, degrees of anxiety, depression, PTSD, and Stress. In a Chinese study, Cai H et al. suggested that the social support given to HCWs caused anxiety reduction and stress levels and increased their self-efficacy [32]. In contrast, Xiao et al. found no relationship between social support and sleep quality [46].
Only two studies examined the effects of stigma on the mental health of HCWs [36, 41] and found that HCWs who perceived stigma were more likely to be depressed, anxious, stressed, and prone to have poor sleep quality [36, 41]. We suggest better community sensitization to create public awareness involving appropriate local community structures and networks. The broader community in sub-Saharan Africa may have suffered severely from infodemics with severe consequences for their mental health, especially during the hard lockdowns.
Removing discrimination/ inequalities at the workplace based on race and other social standings could have a powerful influence on the mental health outcomes of HCWs.
Although emotional exhaustion is associated with depression, anxiety, and sleep disturbances, none of the studies in our review examined burnout as a vital component of mental health disorders in HCWs in sub-Saharan Africa. Future studies on mental health and other critical areas like suicidality, suicidal ideations, and substance abuse during the COVID-19 pandemic among health workers are very much required.
The disparities observed within and among countries could be due to differences in sample sizes, assessment tools, cut-off values used to categorize outcomes, the time of research during the pandemic, the level of development of health services, cultural contexts, and structural contexts.
Prior experience with comparable pandemics and training of health workers are beneficial coping strategies for healthcare workers during this pandemic. However, local social structures and geopolitical conditions appear to determine the pattern and evolution of mental health symptoms among HCWs [15, 16, 27, 28, 31, 32, 46]. In our case, the high prevalence of all mental health symptoms in non-frontline primary health care facilities in Mali [39], with instability and weak healthcare systems before the pandemic, appears to be a case in point.
We posit that the patterns of mental health issues could be unique in Africa or at least vary across geographical regions [31]. This finding was in many studies; however, further investigations using rigorous research designs are needed [31].
Protective and coping measures
Despite the high prevalence of mental health disorders among HCWs, many overlook their psychological health. Some potential beneficial measures are suggested, including effective communication, tangible support from the administration/seniors, mental health problem online screening, and interventional facilities, making quarantine/isolation less restrictive. Others include ensuring interpersonal communication through the various digital platforms, proactively curtailing the misinformation/rumors spread by the media and strict legal measures against violence/ill-treatment of HCWs [8, 16, 19, 32, 34, 36, 41, 42, 43].
Several studies identified environmental factors as a protective theme, including support and recognition from the healthcare team, government, and community. Social support, flexible work-shift arrangements, standardized infection control measures, and regulations to support HCWs during infectious disease epidemics were critical. Provision of restrooms, accommodation and good meals, online consultation with psychologists/psychiatrists, protection from financial hardships, access to social amenities, and religious activities are some essential coping strategies [34, 35, 37, 41, 44].
Shenafelt et al. observed that health care workers want unambiguous assurance that their organization/employers will support them and their families [47]. This finding includes the organization/employers listening to their concerns, doing all that is possible to protect them and prevent them from acquiring COVID-19 infection, and assuring them that if they do become infected, the employers will support them and their families on all fronts, both medically and socially [47]. Other interventions are a high level of training and professional experience; moreover, resilience and social support are necessary for healthcare workers who are required to manage public health emergencies for the first time [15, 16, 32, 46]. In addition, it is also 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 the health facilities was the most important motivational factor in encouraging the continuation of work in future outbreaks. Strict infection control guidelines, specialized equipment, recognition of their efforts by facility management and the government, and a reduction in reported cases of COVID19 provided 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 to plan proactively in anticipation of managing infectious disease epidemics, including other disasters.
Limitations
There are some limitations to this study. Most of the studies are from one country, limiting the generalizability of the results. 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. Longitudinal research on the prevalence of mental disorders in the COVID-19 pandemic is required. Studies did not adequately examine protective or coping measures. Studies did not pay strict attention to confounding variables, leading to inappropriate results and conclusions. Sample sizes were small; larger sample sizes would better identify the extent of mental health problems.
Depression, anxiety, and Stress were assessed solely through self-administered questionnaires rather than face-to-face psychiatric interviews. These studies employed a variety of instruments and used 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.
It is unknown if the studied population had pre-existing mental health illnesses that decompensated during the pandemic crisis. Most of the studies included in our analysis did not measure the baseline mental health status of surveyed participants. Investigators give little attention to stigma, burnout, resilience, and self-efficacy. Our review did not employ systematic reviews and meta-analysis; this precluded deeper insight into the quality of reviewed articles. The strict lockdown, quarantine, and isolation imposed by many countries in sub-Saharan Africa were not among the things, investigators considered in our review as possible risk factors for mental health disorders among HCWs.