Mental health impact of the COVID-19 pandemic on frontline healthcare workers in Ethiopia: a scoping review of associated mental health risk and protective factors

Abstract

Objectives

The mental health impacts of COVID-19 on frontline healthcare workers have been reported globally; however, there is limited evidence from low-income countries such as Ethiopia. We reviewed the literature to understand how COVID-19 impacted the mental health of frontline healthcare workers, including the associated risk and protective factors.

Design

A scoping review of peer-reviewed research was conducted between 2020–2025 to explore the mental health and well-being of frontline healthcare workers in Ethiopia during COVID-19. The process adhered to the guidelines for data extraction outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Our search identified 35 studies, of which 29 studies were included in the final synthesis.

Data sources

Three online databases, PubMed, Web of Science and PsycInfo, were systematically searched for data.

Eligibility criteria

Studies were considered for inclusion in the review if they focused on mental health conditions and psychosocial well-being among healthcare workers during COVID-19 in Ethiopia. Studies were only included if published in English and excluded if they were conference abstracts, case studies, reviews, commentaries, contained incomplete data or lacked variables of interest.

Data extraction and synthesis

Data extraction was conducted manually by two reviewers by using a data extraction sheet created in Excel.

Results

Most frontline healthcare workers experienced symptoms of insomnia, psychological distress, stress, anxiety, post-traumatic stress disorder and depression during COVID-19. Female frontline healthcare workers, nurses, midwives and laboratory technicians reported higher rates of adverse mental health outcomes. Our results found that being married, living together with a spouse and having a high educational level were risk factors for adverse mental health outcomes.

Conclusion

The mental health and well-being of frontline healthcare workers is at risk during a global health crisis; however, there is a limited understanding of how to protect the mental health of frontline healthcare workers in low-income countries, such as Ethiopia, at such a critical time. Additional research is needed to better inform mental health preparedness interventions for frontline healthcare workers in these contexts, particularly given predictions of another pandemic occurring within the next decade.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review applied a systematic and iterative approach developed and quality-assured by the authors.

• For transparency and rigour, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews.

• A limitation to this scoping review is the absence of a consistent use of a definition of frontline healthcare workers.

• The studies included in this scoping review applied different definitions of mental health conditions and different assessment instruments and cut-off thresholds to assess the magnitude and severity of mental health conditions.

• This scoping review only included peer-reviewed published papers based on original research.

Introduction

The COVID-19 pandemic had profound consequences for both public health and particularly mental health worldwide. African countries were severely affected, reporting the highest mortality rate worldwide among critically ill COVID-19 patients.¹ Right from the onset of the pandemic, research documented the physical and mental health risks associated with providing care to patients with COVID-19.² A substantial body of knowledge—primarily generated in the North American and European contexts—has documented how frontline healthcare workers experienced elevated levels of stress, anxiety and depression during the pandemic.^{3 4} These mental health challenges are known to have adverse effects on job satisfaction, teamwork and patient care, and can lead to burnout, which carries immense economic and social costs.⁵

Globally, factors related to the contribution of COVID-19 to adverse mental health among healthcare workers have included increased workload, job strain, psychosocial stressors, moral injury, stress, exhaustion, being at risk of infection or infected and at risk of mental disorders and long covid. However, uncertainty persists about the magnitude of mental health risk experienced by healthcare workers, especially when providing care, often without adequate protection.36,8 Nursing staff who spend the most time caring for critically ill patients have been found to be at high risk of emotional distress.⁹ Healthcare workers are also at greater risk of contracting COVID-19, prompting concerns around their personal safety and the risk of transmitting the virus to family members, particularly those with pre-existing health conditions.⁹ Ethical reasoning and sensitivity—always important for healthcare workers—became even more critical for healthcare workers during the pandemic as healthcare workers navigated highly emotionally charged and complex situations.

Global systematic reviews and regional research23 5,11 suggest that healthcare workers were at higher risk of developing adverse mental health outcomes like depression and anxiety. Identified risk factors include female gender, having a comorbid health condition and worrying about family members contracting the virus who lacked access to personal protective equipment. Identified protective factors include social support, resilience, using problem-focused and emotion-focused coping, and having ‘adequate’ knowledge of COVID-19.¹² Research from other contexts such as Australia¹³ has shown that frontline healthcare professionals adopted new self-care practices and relational coping strategies. To the frontline healthcare workers, feeling socially connected and valued was critical for their adjustment to the massive disruption COVID-19 entailed.¹³

This scoping review forms part of a broader effort to understand the impact of COVID-19 on frontline healthcare workers across Africa. Ethiopia was selected as a focal country because it represents many of the structural strengths and challenges common to low-income health systems on the continent, while also being one of the African countries that has generated a substantial body of empirical research on the topic.

A scoping review was warranted because the existing evidence base on this topic remains limited and geographically narrow. The only other scoping review on the physical and mental health of healthcare workers during COVID-19, published in 2020 at a very early stage of the COVID-19 pandemic, included just 10 studies—nine from China and one from Singapore²—providing only a preliminary and highly context-specific understanding of the issue. On the African continent, psychosocial impacts of the COVID-19 pandemic have been documented in limited settings and data remains sparse.¹¹

This scoping review synthesises a substantially larger body of research conducted later in the pandemic and focuses specifically on Ethiopia. This targeted and temporally expanded approach offers a more comprehensive and contextually grounded overview of the evidence, thereby strengthening the literature and capturing developments that were not visible in earlier reviews. A cross-sectional study from Kenya shows the extent of mental health challenges among healthcare workers in Kenya.¹⁴ While several studies have been conducted on COVID-19 and healthcare workers in Ethiopia, they vary widely in their design, scope and methodological rigour.

Despite the growing number of studies, significant knowledge gaps remain regarding how COVID-19 affected the mental health of frontline healthcare workers in Ethiopia, the risk factors associated with adverse outcomes and the specific needs that emerged during the pandemic. Even less is known about protective factors, coping mechanisms and resilience among Ethiopian healthcare workers. These gaps pose significant challenges for addressing the mental health needs of frontline staff and for preparing the health system for future pandemics.

A scoping review is therefore necessary to systematically map the extent, nature and characteristics of the available literature, identify knowledge gaps and support evidence-informed policy and future research in Ethiopia. The aim of this review was to map and synthesise existing evidence on the mental health of frontline healthcare workers in Ethiopia during the COVID-19 pandemic, with the goal of informing preparedness for future public health crises.

Methods

Design

For this study, we applied a scoping review and used the framework developed by Arksey and O’Malley¹⁵ combined with the guidelines developed by the Joanna Briggs Institute.^{16 17} A scoping review can be defined as ‘exploratory projects that systematically map the literature available on a topic, identifying key concepts, theories, sources of evidence and gaps in the literature’ (Canadian Institute of Health Research). In the review process, we used the approach outlined by Peters et al, which stresses how literature searches in scoping reviews should include populations/participants, concept and context.^{17 18}

The population, concept and context of this review are defined and included in figure 1.

Figure 1. Populations/participants, concept and context.

Defining and aligning the objective/s and question/s

An initial search of the internet databases PubMed and ScienceDirect was carried out to identify relevant search terms. This search allowed us to identify 10 search terms, and the search was used for defining the following research questions for studies reporting stressor and coping mechanisms among healthcare workers during the COVID-19 pandemic in Ethiopia:

1. What is the rate of anxiety, stress and depression among healthcare workers in Ethiopia during the pandemic?

2. How extensive is the psychosocial impact of COVID-19 on healthcare workers reported in Ethiopia, including study setting and type, methods, population, approaches and perspectives represented?

3. What are the reported factors associated with stress, anxiety, depression, post-traumatic stress disorder (PTSD) and PTSD symptoms?

Developing and aligning the inclusion criteria with the objective/s and question/s

Studies were considered for inclusion in the review if they focused on mental health conditions and psychosocial well-being among healthcare workers during COVID-19 in Ethiopia. To identify as many studies as possible, no restrictions were applied as to the study design and duration, the number of participants recruited, study setting or data collection tools. However, studies were only included if published in English and excluded if they were conference abstracts, case studies, reviews, commentaries, contained incomplete data or lacked variables of interest.

Describing the planned approach to evidence searching, selection, data extraction and presentation of the evidence

For transparency and rigour, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR).¹⁹

Three online databases, that is PubMed, Web of Science and PsycInfo, were systematically searched by two researchers (TAD and LSA). The detailed search strategy used is provided in online supplemental material. A primary search was designed to identify original research, including cross-sectional studies, observational studies and qualitative studies pertinent to mental health of frontline healthcare workers during COVID-19 in Ethiopia. This involved querying databases and journals specific to the mental health of frontline healthcare workers to ensure the inclusion of all critical studies. The search was carried out from April to May 2025. Studies published until May 2025 were included. To find other relevant studies, we did hands-on searching of the included studies. This search was a targeted effort to identify other studies published and to address any gaps identified in the preceding search. The Medical Subject Headings (MeSH)/controlled vocabularies and keywords were used to build a search strategy for each database. As an example, to search the online database PubMed, we used the following MeSH terms.

‘Occupational stress’, ‘occupational epidemiology’, ‘Psychological impact’, ‘Psychosocial impact’, ‘Stress’, ‘Anxiety’, ‘Depression’ in combination with ‘Health workers’, ‘COVID-19 Pandemic’, ‘Ethiopia’, ‘East Africa’ and ‘sub-Saharan Africa’. We searched in Web of Science and PsycInfo using the keywords and the following terms: ‘coping’, ‘resilience’, ‘health workers’, ‘occupational stress’, ‘occupational epidemiology’, ‘psychological impact’, ‘stress’, ‘anxiety’, ‘depression’, ‘COVID-19 pandemic’, ‘Ethiopia’, ‘East Africa’, ‘sub-Saharan Africa’ and ‘mental health’.

Selecting the evidence

The search in databases resulted in 115 studies that were entered into the online Covidence software (Covidence.org, non-profit organisation, Melbourne, Australia). After removing 59 duplicates, TAD and LSA screened the titles and abstracts of 56 studies and excluded 21 studies, leaving 35 articles for full-text review. Another 10 articles were excluded after full-text review based on the following criteria: review articles (n=4), wrong objective/theme, that is, not focusing on mental health conditions of healthcare workers (n=3), not related to mental health conditions (n=1) and not original research article, that is case report or commentary (n=1) conducted in a setting which was not Ethiopia (n=1). Via hand searching of included studies, we identified other relevant material, which did not appear from the online database search. Thereby, another four studies were included in this review.20,22 Each included article was reviewed by TAD and LSA. Figure 2shows The process of selecting and including papers is illustrated in figure 2. Overall, 29 studies were included in the scoping review .

Figure 2. Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram outlining the process for identification and selection of studies.

Extracting the data

Data extraction was conducted manually by two reviewers (TAD and LSA) by using a data extraction sheet created in Excel. The process adhered to the guidelines for data extraction guidelines outlined in the PRISMA-ScR for scoping reviews.¹⁹ The data extraction format was refined throughout the extraction process to ensure all important data and information were appropriately captured. Data extracted related to the study and characteristics of participants, including information on first authors, country, publication year, journal, study setting (institution-based or community-based hospital-wide), sample size, study period, study design, results, conclusions and recommendations.

Analysis of data

The data was analysed using a qualitative and inductive approach, to enable an exploratory and inductive analysis of the data. Cross-cutting themes were identified as we applied a thematic content analysis approach. In line with our approach, the themes and categories emerged from the analysis. Prior to identifying themes, the data were organised into four broad categories, which reflected the main focus of each paper: (1) psychological and behavioural risk factors; (2) sociodemographic risk factors; (3) occupational risk factors (profession, work and workplace conditions); and (4) social fabric, social relation: family and social fabric and social relation to family and community. This step then led us to a closer exploration of the papers, to identify ‘story-like’ thematic units and then ordering these thematic units into cross-cutting themes/key concepts.

Presentation of the results

For the presentation of findings, we have chosen a narrative format, which is organised to meet the aim of a scoping review and to answer the research questions. Figures and tables illustrating key characteristics of the studies included are provided to support the narrative format.

Patients and Public Involvement

This scoping review did not involve patients or the study population directly. The nature of a scoping review involves synthesising existing literature to map the key concepts, types of evidence and gaps in research.

Results

Characteristics of included studies

In this scoping review, 29 studies conducted in Ethiopia were included. An overview of the studies included is provided in online supplemental table 1.

The studies included in the review were conducted between 2020 and 2022. Of the included studies, 28 used a cross-sectional design and one study used a mixed methods design, combining quantitative and qualitative methods. The studies assessed one or more than one mental health condition. Four studies assessed insomnia,23,26 and perceived stigma, perceived stress or stress was assessed in 10 surveys.2127,34 Anxiety was assessed in 14 surveys,2426 27 29 30 32 34,40 whereas 14 surveys assessed depression.2426,30 32 36 37 41 Four surveys assessed PTSD.^{20 26 40 46} Six of the included studies assessed negative emotional response and psychological distress.22,2536 47 One survey was conducted on ethical challenges and dilemmas.⁴¹ Two surveys assessed behavioural response²³ or emotional response.³¹ One survey by Tsehay et al assessed level of resilience and coping.⁴⁷ The number of participants in the studies varied between 127 and 1691. In most studies, there was an equal number of male and female respondents. The study population comprised various health professions. Two studies included the profession of public health officer.^{29 39} Three studies included midwives in the study population,^{29 30 39} and nurses were a part of the study population in seven surveys.^{25 29 32 37 39 44 45} Five of the included studies were about mental health conditions among physicians or medical doctors.^{25 29 37 39 44} Three surveys included pharmacists.^{25 29 39} Laboratory technicians were included in four studies.^{25 29 37 39} In eight studies, the study population was described as frontline healthcare workers.^{20 24 28 29 31 38 46 48} In some studies, for example, Mulatu et al, frontline healthcare workers were precisely defined, that is, ‘those participants who are directly engaged in clinical activities of diagnosing, treating, or providing nursing care to patients with confirmed COVID-19’.²⁴ In other studies, frontline health workers were either not defined or defined in general terms. Ten of the included studies defined their study population as health professions, without specifying the group, that is, healthcare providers, healthcare workers or health professionals.2122 24 33,36 40 44 47 The studies included in this scoping review were conducted in five regions of Ethiopia in various settings including: teaching or university hospital,^{21 22 25 31} general hospital,2024 28 33 38,40 43 44 hospitals specialising in the treatment of mental conditions or tuberculosis,³¹ primary hospitals,^{28 34 39 40} public referral hospitals,^{23 29 32 37 47} hospitals specialising in the treatment of patients with COVID-19,⁴⁵ urban COVID-19 treatment centres^{31 33 37 46} and health centres.^{21 33 34 37 39 44 47} In one study, the authors conducted a survey in health facilities without specifying the type of facility, that is, hospital, pharmacy, health centre or private clinic.³⁶ Other studies were conducted among all health professions^{35 48} or among a health profession, that is, midwives, but without specifying the specific setting.³⁰ All studies used probability sampling procedures. Different validated tools were used for assessing insomnia, stress, anxiety, depression, PTSD, emotional response and psychological distress. A summary of study characteristics is provided in online supplemental table 2.

1. What was the rate of mental health conditions, that is, insomnia, anxiety, stress and depression, PTSD, psychological distress, among healthcare workers in Ethiopia during the pandemic?

The mental health conditions assessed varied between studies and included: insomnia, stress or perceived stress, anxiety, depression, PTSD symptoms and psychological distress. One study examined emotional response to COVID-19. Most studies examined more than one mental health condition, that is, stress, anxiety and depression. Some studies assessed the prevalence and risk factors of one condition, that is, PTSD or anxiety^{23 46} or depression^{43 44} or ‘psychological distress’.^{23 25} The prevalence of mental health conditions varied between studies. Studies included found high prevalence rates for all mental health conditions. An overview of the psychological outcome and range of prevalence is provided in online supplemental table 3.

• 2 AHow extensive is the mental health impact of COVID-19 on healthcare workers reported in Ethiopia, including study setting and type, methods, population, approaches and perspectives represented?

We found 29 studies reporting findings from original research conducted in Ethiopia. Online supplemental table 2 provides an overview of the characteristics of studies in terms of study setting and type, methods and population.

• 3 AWhat are the reported risk factors associated with insomnia, stress, anxiety, depression, PTSD and PTSD symptoms, emotional response and psychological distress?

Among the causes of stress, anxiety, depression and psychological distress reported by study participants were fear of infecting family, negative feedback from families, presence of confirmed/suspected cases in the family and having chronic diseases, feeling rejected or stigmatisation by neighbours because of hospital work, lack of social support, visiting/treating an overwhelming number of patients per day (30–150), working in triage or in a high-risk environment, low income, not believing that COVID-19 is preventable, lack of access to preventive and protection equipment (PPE), no access to updated information on COVID-19 and not feeling confident of one’s own coping skills. A broad range of variables (32) were identified as being significantly associated with the risk of insomnia, stress, anxiety, depression, PTSD, emotional response and psychological distress. In the analysis of the included studies, we have organised the variables into four broad categories as follows: (1) psychological and behavioural; (2) sociodemographic; (3) occupational; and (4) social fabric, relations to family and community. The categories and variables associated with risk of reporting a mental health condition are provided in online supplemental table 3.

Psychological and behavioural risk factors

Psychological and behavioural risk factors for adverse mental health conditions were examined in several studies included in this scoping review. This included low self-efficacy, poor quality of sleep, insomnia, symptoms of depression, no confidence in own coping skills with COVID-19 and worrying about COVID-19, having a mental illness or a prior history of mental health conditions before the pandemic. Respondents with any or several of the above experiences or conditions were significantly more likely to report an adverse mental health condition.^{25 33 35 36 40 44 46 47}

Moral injury from ethical challenges and dilemmas as a risk factor: one of the included studies focused on ethical dilemmas, examining the moral injury following from ethical challenges and dilemmas encountered by frontline health workers amid the COVID-19 pandemic in Ethiopia.⁴⁸ For instance, already scarce resources, such as ventilators and hospital beds, were in even shorter supply than normal. Different clinical services such as family planning services, maternal and childcare, immunisation and chronic care became even more limited. Health workers were forced to ration resources and make difficult choices about which patients would get access.⁴⁸

Use of alcohol, tobacco and drugs as a risk factor: behavioural risk factors such as use of alcohol, tobacco and drugs by healthcare workers, that is, khat to cope with stress, anxiety and/or depression were both general pre-COVID-19 and specifically COVID-19 related. One study examined the behaviour of healthcare workers for coping during the first 3 months of the pandemic and found that the odds of psychological distress were higher among healthcare workers who reported coping with stress and anxiety related to COVID-19 by using alcohol, khat and tobacco.³⁶ Psychoactive drug and alcohol use during the pandemic was associated with anxiety symptoms and stress^{34 45} and depression.^{42 45} In one study, current substance users were found to be at significantly higher risk for presenting with symptoms of PTSD.⁴⁶ In a study conducted during the pandemic among midwives, Kassahun et al found that the risk of depression and stress was significantly higher for respondents who declared using substances, such as alcohol, drugs, khat and/or tobacco to cope with stress.³⁰

Limited level of preventive and protection practices against COVID-19 infection: Kassahun et al also found that health workers with a limited level of preventive and protection practices against COVID-19 infection were at significantly higher risk of anxiety and depression. Lack of preventive and protective practices was associated with risk for reporting a mental health condition. Jemal et al found that healthcare workers who did not use PPE and/or other means to adapt their behaviour to prevent and protect them from COVID-19 infection were significantly more likely to report symptoms of psychological distress, depression, anxiety and insomnia.

Beliefs about transmission of and protection against COVID-19 and attitudes in relation to COVID-19 were associated with mental health conditions in several of the studies included in this review. Kassahun et al found that participants with limited knowledge on prevention and protection measures and treatment, incorrect knowledge about prevention and protection and treatment, and having a ‘poor attitude’ were significantly more likely to report with anxiety. ‘Poor perception’ towards the COVID-19 pandemic was significantly associated with symptoms of psychological distress, depression, anxiety and insomnia.²³ Dagne et al³⁵ found an association between anxiety and participants who do not believe that COVID-19 is preventable. A low level of motivational factors for being a healthcare worker during the COVID-19 pandemic was associated with the experience of feeling anxiety, fear, sadness and anger.³¹

Perceived risk or real risk of COVID-19 infection: this was identified as a risk factor for adverse mental health among healthcare workers by several studies in this review. One study by Yadeta et al⁴⁴ found that perception or real risk of COVID-19 infection was a risk factor for adverse mental health conditions. Contact with confirmed or suspected cases was associated with high-functioning anxiety.³⁹ Presence of confirmed/suspected cases in the family was associated with anxiety^{29 38} and stress.³²

Chronic disease or medical illness as a risk factor: having a chronic disease³⁸ or a medical illness was identified as a factor for anxiety symptoms²⁸ and presenting with stress symptoms.³⁴ Participants who had families with chronic illness and had contact with confirmed COVID-19 cases were at higher risk of depression (Asnakew et al²⁸). One study by Tariku et al⁴⁵ found that presenting with symptoms of COVID-19 was a predictor of anxiety and depression in healthcare workers.

Sociodemographic risk factors

A broad range of risk factors were identified related to various sociodemographic characteristics of participants, including age, gender and socioeconomic status, their families and households, and their community and workplace.

Gender as a risk factor for mental health conditions: in nine of the included studies, being female was associated with stress, anxiety, depression and psychological distress. In a study by Dagne et al,³⁵ conducted at the early stage of the pandemic, being female was associated with anxiety. Habtamu et al,²⁶ Tariku et al⁴⁵ and GebreEyesus et al²⁹ also identified gender as a risk factor for depression. Male healthcare workers were twice as likely to experience depression compared with female healthcare workers. In contrast, Yadeta et al⁴⁴ found that female healthcare workers were more than twice as likely to have depression compared with male healthcare workers. Jemal et al²³ found that female healthcare workers were significantly more likely to have symptoms of depression, anxiety and stress. In another study, female healthcare workers were significantly more likely to report depression compared with their male colleagues. In two studies included in this review, being a female healthcare worker was shown to be associated with PTSD symptoms by Ayalew et al²⁰ and Shumye et al.⁴⁶ In two of the included studies, an association was found between being a female healthcare worker and likelihood of having anxiety.^{30 40} It was also found that being female was associated with stress, anxiety and depression.³⁰

Age as a risk factor for mental health conditions: in eight of the included studies, age was identified as significantly associated with a mental health condition. In one study, participants aged 25–31 years were found to be at a higher risk of reporting stress due to the COVID-19 virus.²¹ In a study on anxiety, Wayessa et al³⁴ found that age was a predictor of anxiety. Healthcare workers aged 20–24 years were five times more likely to present with anxiety. Age was also identified as a risk factor for anxiety in a study by Kibret et al³⁸ who found that participants aged 30–39 years and less than 40 years were significantly more likely to report anxiety. Demilew et al²² found that healthcare workers aged 35–44 years were significantly more likely to have depression.²² GebreEyesus et al²⁹ found that being over 40 years of age was significantly associated with anxiety. In three studies, the authors found that psychological distress increased with respondents being aged >40 years.^{20 25 28}

Marital status during COVID-19: in nine studies, marital status was found to be a predictor of mental health conditions. Tsehay et al⁴⁷ found that being married was associated with high psychosocial stress and GebreEyesus et al²⁹ highlighted how living with a spouse was a predictor of depression. In a study on mental health conditions, being married was associated with anxiety (Kibret et al³⁸) and Tariku et al⁴⁵ found that frontline healthcare workers who were married were at higher risk of anxiety and depression. Marital status was a significant factor for PTSD symptoms in healthcare workers during the pandemic.^{20 40} Jemal et al ²³ found that healthcare workers who had moderate to severe symptoms of psychological distress, depression, anxiety and insomnia were more likely to be married. Mulatu et al²⁴ showed that ‘being married was an independent factor associated with a high-level depression’. Habtamu et al²⁶ found that marital status was a predictor for depression. In contrast to these studies, Demilew et al²² found an association between being unmarried and presenting with stress and/or depression.

Living with family during COVID-19: this was identified by Workneh et al⁴² as increasing the likelihood of depression for frontline healthcare workers. Stressors included fear among health workers of infecting family members, the presence of confirmed cases in the family or the suspicion that cases could be at the origin of family conflicts.

Educational level: in four of the 29 included studies, the educational level of respondents was explored, showing that a higher level of education was associated with being more likely to experience a mental health condition. Chekole et al²¹ found that stress related to COVID-19 was significantly higher among healthcare workers holding a master’s degree or a diploma higher than a master’s degree. In one study on stress, anxiety and depression among healthcare providers by GebreEyesus et al,²⁹ the educational level of participants was found to be a risk factor for anxiety and being a degree holder or having a master’s level was associated with depression. Chekole et al²¹ also found that participants with a master’s level and above were at higher risk of reporting stress related to COVID-19. Demilew et al²² found that healthcare workers with higher education, such as specialty, subspecialty and PhD holders, were significantly more likely to have depression. The studies suggest that health workers with higher educational attainment had a heavier workload and were more likely to emphasise the risks of transmission or ruminate on the risks of transmission and potential outcome in terms of morbidity for health workers providing care for patients with COVID-19.

Rural/urban workplace during COVID-19: two of the included studies found a statistically significant association between geographical area of work and adverse mental conditions. In one study, carried out in the Oromiya Region, healthcare workers in the Oromiya Special Zone were significantly more likely to have symptoms of depression, anxiety and stress, compared with healthcare workers in other parts of this region where the study was conducted.³⁷ Kassahun et al³⁰ found that midwives working in a rural area were significantly more likely to have depression as compared with midwives working in an urban area. In contrast, midwives working in an urban area were significantly more likely to have stress as compared with midwives working in a rural area.

Occupational risk factors

Nine of the studies included in the scoping review examined occupational factors and found these to be associated with the risk of developing an adverse mental health condition.

Type of profession and mental health: this was a significant factor for PTSD symptoms in healthcare workers during the pandemic as shown by Ayalew et al.²⁰

Frontline healthcare workers as a risk factor: several studies identified working at the frontline as significantly associated with adverse mental health conditions. Mulatu et al²⁴ showed that ‘working in a frontline position was an independent factor associated with a high-level depression, anxiety and psychological distress’. Especially healthcare workers at the frontline were found to be at increased risk of PTSD because of stress or trauma: ‘the prevalence of PTSD among frontline healthcare providers was higher than in the general population’, (Shumye et al).⁴⁶ Ayalew et al²⁰ showed ‘high levels of PTSD symptoms as psychological challenges for healthcare workers’.

Three studies assessed mental health conditions among midwives.^{29 30 39} In one of these, the authors found a high prevalence of depression, anxiety and stress. The prevalence of depression was 41.1%, whereas the prevalence of anxiety was 29.6%, and stress was 19.0%.³⁰ Teshome et al³⁹ and GebreEyesus et al²⁹ also found a high prevalence of anxiety in the study population, but no statistically significant association with being a midwife. Medical laboratory professionals, compared with other healthcare workers, were significantly more likely to have symptoms of depression, anxiety and stress.³⁷ Several studies, including those by Kebede et al³¹ and Mekonnen et al,³² found that nurses were more at risk of an adverse emotional impact compared with other healthcare workers. In two studies, both nurses or pharmacists were found to be significantly more likely to have high psychological distress (Tsehay et al⁴⁷), or to be at higher risk of reporting stress related to COVID-19 (Chekole et al²¹). GebreEyesus et al²⁹ found that pharmacists and physicians were significantly more at risk of reporting depression compared with other health professions. Demilew et al²² found that anaesthetists were significantly more likely to have depression or stress. One study only by Asnakew et al⁴⁰ examined the association between profession and mental health and found that physicians were significantly less affected by PTSD compared with other health professions.

Type of health facility and mental health: working in a frontline position was an independent factor associated with a high level of depression, anxiety and psychological distress.²⁴ ‘Healthcare workers working in the COVID-19 treatment isolation centres were significantly more likely to have symptoms of depression, anxiety and stress compared with other frontline healthcare workers working in other facilities.²³ A study found that being a nurse and working with triage was associated with responding to COVID-19 with feelings of fear, anxiety, sadness and anger.³¹ Tsehay et al⁴⁷ found that working in an emergency or outpatient department was significantly associated with a high level of psychological distress.⁴⁷ Working in a treatment isolation centre, a case management centre/working at a high-risk site, working in general and referral hospitals, and private institutions was associated with stress, anxiety, depression and PTSD symptoms. Several studies found that working in a place with comparatively higher risk of infection was associated with stress, anxiety, depression and PTSD symptoms.⁴⁶ The same study by Shumye et al⁴⁶ found a high prevalence of 55% and 26.5% associated with the above factors. Healthcare workers working in the COVID-19 treatment isolation centres were significantly more likely to have symptoms of depression, anxiety and stress.^{37 45} GebreEyesus et al²⁹ found that health providers working in general and referral hospitals were significantly more likely to report stress. Habtamu et al²⁶ found that being assigned to work in a critical ward or an intensive care unit (ICU) was a predictor of depression, and Tariku et al⁴⁵ found that working in an ICU was a predictor of anxiety and depression. Kassahun et al³⁰ found that midwives working in the governmental health facility were at higher risk for reporting Depression, Anxiety, Stress Scales (DASS). Dagne et al³⁵ found that health workers employed at private healthcare institutions were significantly more likely to report anxiety. Jemal et al²³ found that healthcare workers working in an emergency unit were significantly more likely to report symptoms of psychological distress, depression, anxiety and insomnia. Ayalew et al²⁷ found that ‘healthcare workers who worked in units other than emergency units were less likely to develop PTSD symptoms than those who worked in emergency units’.

Conditions of work/working environment and mental health: these were significant factors for PTSD symptoms in healthcare workers during the pandemic reported Ayalew et al.²⁰ Nurses working in the night shift are more at risk of reporting stress.³² A study by Habtamu et al²⁶ found that a duration of contact with COVID-19 patients for 1–2 hours was a predictor of depression. Heavy workload/daily contact with any patients was associated with depression and stress.³⁵ Yadeta et al⁴⁴ found that healthcare workers who perceived themselves as susceptible to COVID-19 were more than four times as likely to have depression compared with other healthcare workers. Mekonen et al³² showed that respondents working in night shifts were significantly more likely to have stress.

Lack of standardised PPE supply is significantly associated with PTSD.⁴⁰ Two studies identified lack of access to PPE as a risk factor for anxiety.^{35 38} The unavailability of a guideline for providing care was significantly associated with anxiety among nurses.³² Lack of training/lack of knowledge on COVID-19 was identified as a risk factor for depression, stress and anxiety in two studies.^{30 32} PTSD was associated with lack of a daily update²⁵ in a study on mild and moderate anxiety among healthcare workers. and no updates on COVID-19 was identified as a risk factor.³⁹

Monthly income and mental health conditions: two of the included studies found monthly income to be a factor associated with stress and anxiety symptoms among healthcare workers. Wayessa et al³⁴ and GebreEyesus et al²⁹ found that participants with a low income were at significantly higher risk of reporting symptoms of stress and anxiety.

Social fabric, relations to family and community

Seven studies examined factors related to the social network and social fabric of health workers, including relations with family and community being a risk factor for adverse mental health. Factors identified in the studies as a risk for reporting an adverse mental health condition were diverse and included lack of or poor social support to be in the profession of healthcare work^{28 45} and negative feedback from family on providing healthcare during the COVID-19 pandemic.³² Other studies found that being in contact with a healthcare worker because of COVID-19 infection,³⁴ or living with a spouse or family²⁹ was associated with stress. Some studies examined the role of fear among health workers of infecting family members and found an association with adverse mental health conditions. Healthcare workers who felt or feared stigmatisation by their community²⁵ or being rejected in the neighbourhood because of hospital work³² were also found to be more likely to report a mental health condition. One study found an association between stress and having arguments and disagreements with family members or in the community.³³ All studies recommended that frontline healthcare workers be regularly screened for mental health conditions and provided with support and offered mental health services during and after the pandemic. Most studies stressed the need to identify protective factors for mental health conditions, but few studies examined psychosocial well-being among health workers, or resilience and coping mechanisms of healthcare workers during the pandemic.

Discussion

Summary of main results

The aim of this scoping review was to map and synthesise the literature available which provides evidence as to the mental health conditions and associated risk and protective factors of frontline healthcare workers in Ethiopia during COVID-19. A total of 29 studies were included in the scoping review. The studies examined insomnia, stress, anxiety, depression, PTSD, psychological distress and emotional response and the associated factors. Only one study focused on coping among healthcare workers. The prevalence of mental health conditions was found to be high compared with other countries in the region and globally. The studies included in this review identified a broad range of variables predicting mental health conditions. These variables can broadly be categorised as: (1) psychological and behavioural; (2) sociodemographic; (3) occupational; and (4) social fabric, relations to family and community. These four categories allowed us to identify the following themes: psychological, psychosocial, sociodemographic, work environment and type of facility, knowledge, attitude and perceptions, family and community social support, perceived risk or real risk of infection and transmitting infection, and, finally, access to PPE and daily updates on COVID-19. Of the included studies, 28 were of cross-sectional design and all were institution-based. One study combined a cross-sectional study and interviews with frontline healthcare workers. The study population included healthcare workers and health professionals in general, and more specific professional groups, that is, nurses, midwives, physicians, pharmacists and laboratory technicians. The included studies identified a great diversity of risk factors for mental health conditions. The results of the included studies were contradictory or inconsistent with research conducted prior to the COVID-19 pandemic on risk and protective factors for mental health conditions.

High rates of mental health conditions

In our scoping review, we found that the rates of mental health conditions were high, psychological distress was as high as 78.3% and PTSD was well higher among healthcare workers and health professionals. These rates are both higher compared with the general population¹¹ or to other professions, that is, university teachers,⁴⁹ schoolteachers⁵⁰ or bus drivers.⁵¹ Compared with healthcare workers and professionals in other countries in the region and globally, the studies included in our scoping review show a higher prevalence rate for mental health conditions. Although our study demonstrates that healthcare workers faced substantial mental health challenges during the COVID-19 pandemic, it does not definitively establish whether these challenges were directly attributable to the pandemic or were an extension of pre-existing stressors associated with the broader socioeconomic context of the country. Our findings indicate that nurses working in the night shifts were more likely to experience mental health conditions compared with other healthcare workers. However, this trend was also observed prior to the COVID-19 pandemic, thus precluding us from attributing this result solely to the impact of the pandemic.

There is little evidence on the long-term impact of COVID-19 on mental health conditions among healthcare workers in Ethiopia. However, in a study conducted among healthcare workers in early 2023, the authors found that the prevalence of occupational-related depression, anxiety and stress was 39.0%, 57.6% and 68%, respectively (Habtu et al⁵²). This finding is similar to other reviews of sub-Saharan Africa.⁵³ In a review on the prevalence and associated factors of the psychological impact of COVID-19 in Ethiopia, Bekele et al also report overall high psychological impact of COVID-19 pandemic among healthcare workers, communities and patients.⁵⁴ Especially female healthcare workers, including midwives, nurses and laboratory technicians, were at higher risk of reporting a mental health condition. Frontline healthcare workers, healthcare workers working in rural zones and healthcare workers working in emergency or outpatient departments and treatment isolation centres were at an increased risk of reporting stress, anxiety and depression. Reasons reported for high levels of stress, depression and anxiety include life and death decisions, lack of access to adequate PPE and information, risk of infection and/or transmission, and heavy workload.

Study designs, settings and populations

Almost all the studies included were quantitative and cross-sectional by design. This methodological choice provided several advantages: the studies were conducted immediately after the WHO declared COVID-19 to be a pandemic, with relatively small sample sizes; multiple exposures and outcomes could be assessed at one point in time; associations and correlations were identified and the insights from the studies could and should have served as a foundation for developing hypotheses and more in-depth research. Yet, the studies also came with more than one limitation, mainly inherent to their cross-sectional design. Some of the studies included in the review used non-random sampling methods, which may have led to selection bias and over-estimation of the prevalence of these conditions and disorders.

Variables were dichotomised and binary, and many variables were individualised, which made it difficult to establish possible causal direction. Different studies established various associations, which did not align with each other. In some studies, it was unclear how confounding factors were controlled for, which may have implied an inappropriate association of factors. Three surveys were implemented online via self-reported, self-assessed questionnaires. Online surveys come with different types of biases, such as sampling bias, response bias, non-response bias and order bias.

The included studies were all conducted between 2020 and 2022. The search did not identify any studies on the long-term effects of COVID-19 on mental health of healthcare workers. Therefore, the findings are limited to providing a quick ‘snapshot’ of prevalence rates and factors associated with mental health conditions of healthcare workers at the early stages of the pandemic. Longitudinal, prospective or retrospective cohort and case–control studies could have provided a deeper understanding of the determinants of mental health conditions. Along the same lines, qualitative studies are needed to understand the specific context in which mental health conditions occur, the nuances and variations of lived experiences of different mental health conditions, as well as the ‘how’ of some of the associations and correlations established in the included studies.

Of the 29 included studies, 26 were conducted either in the chartered city of Addis Ababa (3), or the regions of Oromia (5), Amhara (6), Central Ethiopia Regional State (1), South Ethiopia Regional State (3), North-Western Regional State (1) and Sidama National Regional State (1). Three studies were conducted online across all of Ethiopia. Regional variations in prevalence rates and factors associated with the mental health conditions of healthcare workers are not captured by our review. Other studies have found that symptoms of anxiety, depression and PTSD in the general population increased during COVID-19.⁵⁵ Within Ethiopia, studies among the general population have shown that rates of mental health conditions related to COVID-19 were high.56,60

Of the 29 included studies, all were institutions based. Studies focusing on healthcare workers in primary healthcare or community health workers in other countries have established the significant psychological repercussions of COVID-19 on mental health conditions.61,68

Psychological and behavioural characteristics as risk factors

This scoping review only identified one study with a focus on protective factors, one study assessing health workers coping with the COVID-19 pandemic and one study with a focus on factors determining a positive emotional response to COVID-19. The findings of this review are therefore limited in regard to identifying strategies adopted by frontline healthcare workers to cope with mental health conditions.

Sociodemographic characteristics as risk factors

This review found that female healthcare workers were more likely to report mental health conditions. Gender differences in mental health problems among healthcare workers during COVID-19 have been studied in other settings, that is, China, with findings similar to the studies included in this review.⁶⁹ Yet, other studies⁵³ suggest this finding overlooks the fact that female healthcare workers are often working in positions requiring closer contact with infected patients, long working hours and night shifts, more frequent contact with patients’ relatives in distress, lower wages and so on—all factors which combined can increase susceptibility to stress. Age was found to be associated with increased risk of mental health conditions. All healthcare workers, irrespective of age, experienced adverse mental health conditions. Healthcare workers of younger age, in their 20s and 30s, were more likely to experience stress and anxiety. This finding may be explained by younger and lower cadre health workers facing heavy workloads in triage and emergency units, having contact with up to 150 patients per day and being less experienced. Healthcare workers aged above 40 years were found to be more likely to experience depression and psychological distress. This finding may be explained by the fact that more experienced and older healthcare workers had more responsibilities for caring for critically ill patients and patients with severe infections.

Occupational risk factors

In the studies included in our review, frontline healthcare workers were at significantly higher risk of reporting a mental health condition than other healthcare workers. Compared with other professions or groups, the prevalence of stress, anxiety and depression was higher among healthcare workers.49,51 This scoping review found that some professional groups, such as nurses and pharmacists, were at higher risks of adverse mental health. Other research report similar findings about healthcare workers, especially those ‘working in emergency, ICUs, infectious disease wards, pharmacies and laboratories, were at higher risk of adverse mental health impacts compared with others’.⁵³ This finding may be explained by the responsibility of caring for patients who were severely ill with COVID-19.

The studies included in our review show that laboratory technicians and nurses were at higher risk of stress, anxiety and depression. Beyond workload, the nature of the work, particularly frequent and direct patient contact, may have contributed to mental health problems. Laboratory technicians may have experienced more adverse mental health conditions due to their increased workload and responsibility while they were working in a context of resource scarcity. Rose et al found that nurses were more likely to report feelings of stress, emotional exhaustion and fatigue compared with physicians and other health professionals. This study also found that ‘nurses were at higher risk for inadequate coping mechanisms and perceived the workplace as more traumatic compared with other groups’.⁹ This finding may be explained by the scarcity of PPE. Healthcare workers in daily and direct contact with patients, while working without PPE, were more at risk of contracting the infection.

Family, supervisor and community support

Two studies (Asnakew et al⁴⁰; Asnakew et al²⁸) examined the role of lack of social support as a risk factor for mental health conditions and three studies assessed the association between perceived community stigmatisation and/or negative family feedback and mental health conditions (Mekonen et al³² ; Asnakew et al⁴⁰ ; Yitayih et al²⁵). These findings from the studies included in our review are confirmed by other research on family, supervisor and community support as a factor for mental health conditions during COVID-19.70,73

Limited focus on healthcare system support

The studies included in our review predominantly focus on psychological, behavioural and sociodemographic characteristics of participants. Some studies examine occupational risk factors associated with mental health conditions. Few of the included studies examined the role of health systems or considered the support needed for healthcare workers, that is, providing PPE and daily updates on COVID-19, especially in times of a crisis of the amplitude of COVID-19. In a study on preventive measures for the COVID-19 pandemic among health professionals in public health facilities, Mersha et al have identified a gap in the healthcare system in regard to preventive measure practices for COVID-19⁷⁴. The authors found that COVID-19 preventive practices are hampered by community influences, healthcare provider-related barriers, institutional barriers and lack of communication and support. Sidamo et al⁷⁵ have shown the impact on frontline healthcare workers of ineffective implementation of public health measures for the COVID-19 pandemic. These two studies point to the institutional, health systems and societal level mechanisms to equip frontline healthcare workers with PPE and knowledge to minimise the risk of adverse mental health conditions and infection during the COVID-19 pandemic.⁷⁵

Strengths and limitations

This scoping review applied a systematic and iterative approach developed and quality-assured by the authors. For transparency and rigour, we used the PRISMA-ScR. The review also entails several limitations. One concern is the operational definitions used in the included studies, which differ substantially between defining frontline healthcare workers as doctors, nurses, pharmacists and laboratory technicians, or nurses or midwives. The absence of a consistent use of a definition of frontline healthcare workers may come with several limitations. One limitation is the exact extent and impact of COVID-19 on the mental health conditions of frontline healthcare workers compared with other healthcare workers who did not work at the frontline. Another limitation is that it remains unclear if some professional groups were at higher risk of adverse mental health conditions compared with other professional groups. Along similar lines, the studies included in this scoping review applied different definitions of mental health conditions and different assessment instruments and cut-off thresholds to assess the magnitude and severity of mental health conditions. These differences in definitions of perceived stress, stress, anxiety and depression, psychological distress, PTSD or symptoms of PTSD, and measuring instruments applied may impact the outcomes of the mental health conditions measured. This scoping review only included peer-reviewed published papers based on original research, though recognising that the inclusion of policy papers or reports could have enriched the analysis.

Future research directions

Our findings point towards a need for research on specific mental health needs that emerged from the COVID-19 pandemic in Ethiopia among healthcare workers and how they should be addressed. This research could, for instance, explore the lived experience of healthcare workers during the COVID-19 pandemic with a focus on mental health and moral injury, and mental health of healthcare workers. Few of the studies included in the scoping review examined protective factors in relation to mental health conditions, which could be relevant for future studies. Likewise, there is a need for qualitative studies exploring the strategies adopted by frontline healthcare workers to cope with mental health conditions. Finally, longitudinal studies assessing the protective factors in relation to mental health of frontline healthcare workers are necessary to inform approaches that address mental conditions among healthcare workers.

Conclusion and recommendations

This scoping review showed the profound effect of the COVID-19 pandemic on the mental health of frontline healthcare workers in Ethiopia. Levels of insomnia, stress, anxiety, depression and PTSD were very high and with potentially prolonged impact. Female and frontline healthcare workers, nurses, pharmacists, midwives and laboratory technicians were at higher risk of reporting adverse mental health conditions. Being married, living together with a spouse and having a higher level of education were also risk factors for reporting a mental condition. Our results demonstrate the impact of COVID-19 on frontline healthcare workers as well as the importance of identifying changes in the risk and protective factors for mental health conditions during a global health crisis, such as COVID-19. Based on the findings of this scoping review, we recommend that support for mental health should be provided to healthcare workers during and after pandemics such as COVID-19.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.