A total of 1,013 studies were included (additional file 6) and 3,783 were excluded after assessment of eligibility criteria in the title and abstract: 585 studies were excluded after reading the full text: 1 was a duplicate, 4 were in a language not considered in the LSR, for 194 it was not possible to access the full text or were abstracts from conferences or posters and 235 did not meet at least one for the four eligibility criteria. A total of 345 studies, presented high risk of bias/low quality and were, thus, also excluded (Fig. 1). A table of excluded studies is provided in additional file 8.
The evidence of this LSR is derived from 1,013 studies, mainly quantitative with a cross-sectional design, addressing the impacts of COVID-19 and other PHEIC in HCW. In general, the quality of the evidence per outcome was very low, according to GRADE.
The majority of the studies were mostly concerned with the impact of PHEICs, including the COVID-19 pandemic, on the health of HCW and, more specifically, on mental health. The studies covered a variety of countries and workplaces in all continents (with a bias to the Global North and with the vast majority of studies being published from 2020 onwards and focusing on the COVID-19 pandemic) (Fig. 2), as well as HCW in general or per type of occupation (with a greater focus on nurses and physicians), thus allowing to have a comprehensive glimpse of the health and care workforce.
Much of the social rejection or other negative experiences that HCW experienced due to a disproportionate exposure to PHEIC and high risk of infection were often associated with mental health conditions (28) and these often resulted in somatization (29). The conditions under which HCW were forced to work (e.g. with PPE, during extended working periods, with changes in the organization of work), and faced with insufficient or inadequate coping strategies or resilience (30–34), impacted their physical health with reports of PPE related skin injuries and headaches or sleep disturbances. All these factors negatively impacted the performance of HCW, leading, for instance to absenteeism (35), financial problems (that backlashed on mental health) (36) and inevitably resulted in regret about choosing the profession or even intention to resign or change career (37–39) (REF of other LSR).
One of the most mentioned impacts of the PHEIC was on mental health, namely stress/distress, anxiety, depression, burnout, post-traumatic stress disorder (PTSD) and suicidal ideation (thoughts), among others.
Contrary to other mental health outcomes, such as burnout, suicide, depression or psychological well-being in general (40–47), anxiety in HCW did not seem to be a major concern reflected in the published literature before 2020 (44, 48), although its relevance became evident with the COVID-19 pandemic. Anxiety was frequently reported in the studies included in the LSR (N = 518), either as the sole outcome or measured along with depression and/or stress, among other mental health outcomes. The overall prevalence of anxiety in HCW was 39% (95CI=[37;41]) with low variation between regions 31% (95CI=[27;34]) in East Asia and Pacific and 49% (95CI=[35;62]) in Sub-Saharan Africa (Table 5 and additional file 6). This prevalence was related only with the SARS-CoV-2 pandemic.
Generally, there were higher levels of anxiety in HCW when compared to the general population (38, 49–51), in healthcare providers vs non-healthcare providers (52, 53), in frontline HCW compared to non-frontliners (54–60), in those working in high incidence areas (61–63), with infected patients (52–54) and in relation to the pre-PHEIC period (64). Anxiety was also frequently reported in female HCW (5, 51, 57, 63, 65–87).
Anxiety was frequently associated with depression and stress (88–92), sharing some of its determinants. Anxiety and depression were commonly either the result or the drivers for burnout, stress, distress and PTSD and poor well-being (31, 65, 93–97). All tended to relate to sleep quality and sleep disorders (98–102). Some resulted from or in somatization (103).
Anxiety emerged as an early consequence of the PHEIC that would: (i) either resolve by itself (improvement in symptoms of anxiety between the start the of the PHEIC and subsequent periods, even in HCW who had contracted the disease (104–112) but much dependent on overall incidence of the infection (113); (ii) or evolve to more serious presentations of mental health conditions such as depression (66), PTSD or suicidal ideation (114). Nevertheless, the levels of anxiety tended to remain high for long periods of time (105, 106) (additional file 9).
Depression was the second outcome most frequently addressed (N = 503). With a prevalence of 21% (95CI=[5;37]) before 2020 and 35% (95CI=[33;37]) after 2020 (Table 3 and additional file 6), depression, as anxiety, seemed to be more prevalent in HCW compared to the overall population (115, 116), among frontliners (5, 55, 74, 77, 117–124), those caring for patients (81, 125–127), especially for COVID-19 patients, and even on HCW that had become infected (50, 67, 77, 88, 88, 98, 109, 125, 128–130). Female gender was also mentioned to be related with depression (51, 66, 71, 74, 80, 86–88, 88, 93, 98, 122, 128, 129, 131–136).
The changes in clinical and operational practices and the level of PHEICs’ preparedness of health and care services along with adjustments in professional roles (93, 98, 137–141) were associated with depression. PHEIC seemed to exacerbate or add to existing mental conditions (67, 69, 87, 119, 131, 140, 142–145) (Table 6). High levels of anxiety and depression prevented health professionals from psychologically detaching from work (8) leading to burnout (146) and stress (147).
Health and care occupations are considered very stressful with long work hours, frequent night work, and shift duties. Hence, when compared to the with general population, HCW even in non-PHEIC situations, face high risk of stress, poor sleep patterns, fatigue and burnout (148). Not surprisingly, as a result of the PHEICs (149–152), 40% (95CI=[0;70%]) of HCW reported experiencing some level of stress before 2020 with the prevalence increasing after 2020 to 44% (95CI=[40;48%]) (Table 3 and additional file 6). Usually stress is higher in HCW than the general population (153, 154) and, despite the manifestations being more frequently psychological than physical (155, 156), few sought professional mental health support (157). Stress resulted mainly from working conditions like the complexity of patients and concerns about transmitting the disease (155, 158), disruption of familiar and social networks, exposure to disease (159) but also from workload and levels of perceived anxiety and depression (160) (additional file 9). Several studies mentioned stress to be related with female gender in HCW (67, 70, 74, 80, 87, 111, 122, 123, 131, 133, 139, 160–166).
Job stress, staff and resource adequacy, interprofessional relationships in healthcare practice, fear of infection and anxiety related to work during the PHEIC largely contributed to emotional and mental exhaustion of HCW often leading to burnout (167, 168). Burnout addressed in 235 of the included studies, had a prevalence of 46% (95CI=[42;51]) and was mainly reported after 2020 with studies conducted on East Asia and Pacific Region showing higher prevalence than in other regions (Table 3 and additional file 6). Burnout seems to be higher during PHEICs in relation to the pre-PHEIC period (169–172), evolved over time (173) and manifested through physical (chronic fatigue, extreme exhaustion, reduced energy, and sleep disturbances), emotional (frustration, irritability, anger and fear), cognitive (mental fatigue, difficulty in decisions) and behavioral (negativism, emotional outbursts, cynicism, rudeness) symptoms (169). Its negative impact is far reaching and includes not only harm to the burnt out HCW, but also to patients, co-workers, family members, close friends, and healthcare organizations (174). Similarly, burnout was frequently more reported in female HCW Female (63, 66, 77, 135, 167, 175–185).
Burnout and other mental health conditions, more frequent in women, together with feelings of dehumanization of self and/or of others can potentiate PTSD (186–188). A total of 84 studies addressed PTSD. The pooled prevalence of PTSD, after 2020, was 26% (95CI= [22;31]) (Table 5 and additional file 6). The studies point to an excess of PTSD in HCW when compared to general population (50), before the declaration of PHEIC (108) and in frontliners (66,215,326,347–349). Previous mental health conditions, especially stress, work in frontline services, high workload and access and use of PPE were the main determinants referred by the literature. PTSD seemed to be linked to suicidal thoughts (186, 189) (additional file 9).
A total of 18 studies addressed suicidal ideation in HCW. The pooled prevalence of suicidal ideation and/or attempt was 7% (95CI=[5;8]). Thoughts of suicide or self-harm were frequently related with depression and other previous mental health conditions (156,157,363). Young, male, living alone HCW were the most frequently affected (additional file 9).
In this LSR we also found sleep disorders (pooled prevalence of 36%; 95CI=[31;41]), headaches/migraines (pooled prevalence of de novo headaches 53%; 95CI=[38;67]) and skin related morbidity (pooled prevalence of 51%; 95CI=[39;64]) to be frequently reported physical health impacts of PHEIC (Table 3 and additional file 6). Other less frequent PHEICs-related morbidity studied in HCW included musculoskeletal disorders, erectile dysfunction, eye strain, weight gain, constipation and risk of infection (159, 190–194).
PHEICS often require HCW to use sophisticated PPE (e.g. gloves, respirators, eye protection, face shields masks, full body suites) more frequently and for prolonged periods of time, which seemed to be associated with dermatitis, pressure injuries, excessive heating and sweating, headaches and/or migraines, breathing difficulties, itching, cracking, burning, flaking, peeling and/or rash (195–203), although complaints varied greatly with the equipment used. Actually, the use of PPE tended to induce de novo headaches and migraines or worsen pre-existing ones, a couple of hours after the end of the shift (204, 205).
In the context of a PHEICS, workplace violence emerged also as a relevant impact, with a pooled prevalence of 48% (95CI=[32;64]) among HCW, from 2020 onwards (Table 5 and additional file 6). Known in their communities as HCW, during PHEICs these professionals cannot escape scrutiny and face stigma and violent episodes, even if they are working remotely (206). HCW continue to move freely even in curfews and lockdowns and have often to quarantine even if not infected, which places them at risk of extortion and other violent acts (207). The determinants of violence in PHEICs do not seem to differ from those identified in non-PHEIC periods and include, among others, unsupportive environment and lack of guidelines or appropriate measures to implement necessary health protocols (399,402) (additional file 9). Also in the case of PHEICs, violence (208, 209) and stigma (120, 140, 142) seem to contribute to poor mental health.
HCW and the impact that their work has on their health has been studied in the past, in particular throughout the developed world where markedly high rates of sickness absence, sickness presenteeism, burnout, and distress compared to what has been described for other sectors (210, 211).
PHEICs are inevitably linked to unplanned absenteeism. This results from HCW becoming infected, bearing the burden of working in services directly linked to the management of the PHEIC, increased physical and mental morbidity, having to assist relatives or due to non-pharmacological measures such as quarantine (212). Other recognized determinants of absenteeism in HCW include organizational aspects, inadequate working conditions, long hours, task overload, interpersonal conflicts, low autonomy and remuneration, associated with psychological, cognitive and physical professional overload (213), all aggravated during a PHEIC. Sometimes, HCW might opt to work even if not feeling well, a practice known as sickness presenteeism which as deleterious effects such as increased risk of burnout or loss of productivity (211, 214). Leaving or intention to leave the occupation emerged as a relevant impact of PHEICs (215, 216). Contrary to unplanned absenteeism, it is more definitive and represents a peril for the sustainability of provision of care during the PHEIC and afterwards. Sometimes, it is preceded by department or institution turnover (217–219). Besides, working conditions like understaffing or increased work hours (20, 37, 220), mental health issues seemed to be the most relevant determinants (37, 38, 221) (additional file 9).
Among the included studies, we only identified 9 interventions that included behavioral and organizational approaches directed at individual HCW. The timing and relative novelty and somewhat rapid resolution of most of the PHEICs might explain the lack of studies to address interventions to tackle their effects. In this LSR, all but one, which addressed workplace violence, aimed at the impacts of PHEICs on mental health. Behavioral interventions were based on therapies to increase HCW capacity to deal with stressors, building resilience and acquire and developing coping strategies (222–227). Organizational interventions were designed to strengthen the health and care service capacity to address the challenges imposed by the PHEIC (228, 229). Nevertheless, the overall evidence on this matter was very weak (additional file 10).