Night Shift Work and Self-Reported Health Problems Among Hospital Workers in Mogadishu, Somalia: A Descriptive Cross-Sectional Study

Abstract

Background

Night shift work disrupts circadian rhythms and sleep and has been linked to physical, psychological and occupational health problems. Evidence from Somalia, where hospitals operate with severe staff shortages and limited occupational health support, is scarce.

Purpose

To describe night shift work characteristics and the prevalence of self-reported physical, psychological and occupational health problems among hospital workers who work night shifts in Mogadishu, Somalia.

Methods

A descriptive cross-sectional study was conducted between January and June 2026 among 300 hospital workers recruited by purposive sampling from randomly selected public and private hospitals in Mogadishu. Nurses, doctors, laboratory staff, midwives, pharmacists and other hospital staff who had worked night shifts for at least six months completed a structured, self-administered questionnaire developed by the research team, in which each health problem was recorded as a single yes/no item. Prevalence is reported with 95% confidence intervals (CI).

Results

Most participants worked rotating shifts (60.7%), 68.7% worked night shifts of 12 hours or longer, and 68.0% were dissatisfied with their shift schedule. The most frequently reported problems were stress (78.7%; 95% CI 73.7–82.9), frequent fatigue (76.0%; 70.9–80.5), sleep problems (71.3%; 66.0–76.2), reduced concentration (68.7%; 63.2–73.7), headaches (64.0%; 58.4–69.2), anxiety (62.7%; 57.1–67.9) and burnout symptoms (58.0%; 52.3–63.4), followed by gastrointestinal problems (39.3%; 34.0–45.0), hypertension symptoms (34.0%; 28.9–39.5) and work-related errors during night shifts (30.7%; 25.7–36.1).

Conclusion

Self-reported sleep-related, physical, psychological and occupational problems were highly prevalent among night shift hospital workers in Mogadishu. Because the study was descriptive and cross-sectional, with no day-shift comparison group, the findings show the burden of these problems but do not establish that night shift work caused them. Hospital leaders should review shift scheduling and strengthen occupational and mental health support, and longitudinal studies using validated instruments are needed.

Introduction

Hospitals provide care around the clock, and a large share of their staff therefore work at night, either permanently or on rotating schedules. Nurses and midwives, the largest group in the hospital workforce, carry most of this night work, together with doctors, laboratory staff and pharmacists.^1–3 Night work keeps services running, but a substantial body of evidence indicates that it comes at a cost to the health, safety and performance of the people who do it.^1,4,5

The main explanation is biological. Human physiology is organized by an internal circadian clock that is synchronized chiefly by the light–dark cycle and that promotes wakefulness by day and sleep by night. Sleep is regulated by the interaction of this circadian process with a homeostatic process in which the pressure to sleep builds with time awake.⁶ Night work requires staff to be alert when the circadian clock promotes sleep and to sleep when it promotes wakefulness. Because light exposure at night suppresses melatonin and the clock adapts only partially to a night schedule, even after several consecutive shifts, the daily rhythms of melatonin, cortisol, body temperature and metabolism become misaligned with the sleep–wake and meal schedule.^1,7 Daytime sleep after a night shift is consequently shorter and lighter, sleepiness peaks during the shift, and repeated exposure leads to chronic sleep loss.^1,8 Night work has also been associated with changes in inflammatory markers,⁹ and experimental work indicates that prolonged stress itself impairs homeostatic sleep regulation,¹⁰ so that sleep loss and occupational stress may reinforce each other.

These mechanisms are consistent with the health outcomes reported in epidemiological studies. About one in four shift workers meets the criteria for shift work disorder (pooled prevalence 26.5%).¹¹ Shift work has been associated with a 17% higher risk of cardiovascular events,¹² with hypertension among rotating shift workers,¹³ with abdominal obesity¹⁴ and, in combination with an unhealthy lifestyle, with type 2 diabetes.¹⁵ Gastrointestinal complaints are more common among shift workers,¹⁶ whereas the evidence for headache and migraine is inconsistent.¹⁷ For mental health, a meta-analysis of longitudinal studies found a higher risk of adverse mental health outcomes, particularly depressive symptoms, among shift workers,¹⁸ and shifts of 12 hours or longer have been associated with burnout and job dissatisfaction among nurses.¹⁹ Night shifts and extended shifts also reduce alertness and performance^8,20 and are associated with a higher risk of accidents and errors.^21,22

Most of this evidence comes from high-income countries. Studies from settings closer to Somalia point in the same direction. Among healthcare professionals in Saudi Arabia, night shifts were reported to affect sleep, psychosocial and physical well-being.²³ In Ethiopia, about one quarter to one third of nurses met the criteria for shift work sleep disorder, which was related to the number of night shifts worked per month,^24,25 and nurses in another Ethiopian study reported loss of sleep, persistent tiredness and reduced concentration related to night duty.²⁶ Burnout is also common among health providers in sub-Saharan Africa.²⁷

Somalia has one of the lowest health workforce densities in the world, with fewer than 4 doctors, nurses and midwives per 10,000 population against a recommended minimum of 23, and its staff are concentrated in urban and private facilities.²⁸ Under these conditions, the staff who are available may work frequent and long night shifts with limited occupational health support. Recent hospital-based studies in Mogadishu reported burnout in 24% of healthcare workers, with higher odds among those working seven or more night shifts per month,²⁹ and poor sleep quality in 45.7% of nurses, with higher odds among night shift workers.³⁰ Symptoms of depression, anxiety and stress are also common among health professionals in the city.^31,32 However, each of these studies examined a single outcome, in a single hospital or a single profession, and treated night work as one of several covariates. To our knowledge, no study has described night shift workers across professions in both public and private hospitals in Mogadishu: how their night work is organized, and how frequently they report the range of sleep-related, physical, psychological and occupational problems that the international literature links to night work. Hospital leaders need this information to plan staffing, scheduling and occupational health services.

The study was guided by a conceptual framework derived from this literature (Figure 1). Night shift work characteristics (shift type, number of night shifts per week, hours per shift and satisfaction with the schedule) are the exposure. They are expected to act first through circadian misalignment and sleep loss, expressed as sleep problems and fatigue. These in turn are expected to contribute to physical problems (headaches, gastrointestinal problems and hypertension symptoms) and psychological problems (stress, anxiety and burnout symptoms), and ultimately to occupational consequences (reduced concentration and work-related errors). Sociodemographic factors and the work context, such as staffing and workload, may modify each step. The framework was used to select the study variables; the present study describes each component and does not test the pathways between them.

Figure 1.

Conceptual framework of the study. Night shift work characteristics are expected to act through circadian misalignment and sleep loss on physical and psychological health problems and, in turn, on occupational consequences. Dashed lines indicate sociodemographic and contextual factors that may modify these relationships. The study describes each component and does not test the pathways between them.

The study therefore aimed to describe, among hospital workers who work night shifts in Mogadishu, Somalia, (1) the characteristics of their night shift work and (2) the prevalence of self-reported physical, psychological and occupational health problems. The corresponding research questions were: how is night shift work organized for these workers, and how common are the health problems they report? As the study was descriptive, no hypothesis was tested.

Materials and Methods

Study Design

A descriptive, hospital-based cross-sectional study was conducted. It is reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.³³

Setting

The study took place in [N hospitals] public and private hospitals in Mogadishu, the capital of Somalia, that provide 24-hour inpatient services. The hospitals were selected at random from the public and private hospitals in Mogadishu. An official approval letter from Salaam University was presented to the administration of each selected hospital to obtain permission for data collection. Data were collected over a six-month period, from January to June 2026.

Participants and Sampling

Eligible participants were hospital workers aged 18 years or older, of any profession (nurses, doctors, laboratory staff, midwives, pharmacists, radiology staff and other hospital employees), who had worked night shifts, either permanently or on a rotating schedule, for at least six months and who gave written informed consent. Staff who worked only day shifts, or who had worked night shifts for less than six months, were not eligible.

Hospitals were selected at random, but participants within each hospital were recruited by purposive (non-probability) sampling. After permission was obtained from each hospital administration, staff who met the eligibility criteria were approached at their workplace, the study was explained to them, and those who agreed completed the questionnaire. [D] questionnaires were distributed and [R] were returned (response rate [X]%). A total of 300 completed questionnaires were included in the analysis.

Study Size

The sample comprised 300 participants. With this sample size, any prevalence can be estimated with a margin of error of no more than ±5.7 percentage points at the 95% confidence level, which is adequate for the descriptive objectives of the study. The study was not designed or powered to test differences between subgroups.

Data Collection Instrument and Variables

Data were collected with a structured, self-administered questionnaire developed by the research team on the basis of the published literature on shift work and health.^1,2,23,26 The questionnaire had four parts: (1) sociodemographic characteristics (sex, age group, profession and marital status); (2) night shift work characteristics (type of shift, number of night shifts per week, working hours per night shift and satisfaction with the shift schedule); (3) physical health problems (five items: sleep problems, frequent fatigue, headaches, gastrointestinal problems and hypertension symptoms); and (4) psychological and occupational problems (five items: stress, anxiety, burnout symptoms, reduced concentration and work-related errors during night shifts).

Each health problem was recorded as a single item with a yes/no response. The items were analysed individually and no composite score was calculated. Standardized scales such as the Pittsburgh Sleep Quality Index or the Maslach Burnout Inventory were not used, so the outcomes represent problems as perceived and reported by participants and not clinical diagnoses or scale-defined cases. The questionnaire was written and administered in English. The questionnaire is provided as Supplementary File 1.

Bias

The questionnaire was self-administered and no personal identifiers were included in the analysis, in order to reduce social desirability bias. A minimum of six months of night work was required so that all participants had sustained exposure. Because sampling was non-probabilistic and all participants were night shift workers, the findings describe this group and cannot be compared with those of day workers.

Statistical Analysis

Data were entered and analysed in IBM SPSS Statistics version 26. Categorical variables are summarized as frequencies and percentages. The prevalence of each health problem is presented with its 95% confidence interval (CI), calculated with the Wilson score method.³⁴ All percentages use the 300 participants as the denominator, and there were no missing data for the variables reported. The analysis is descriptive: no comparison group of day workers was included and no bivariate or multivariable tests of association are reported, so no adjustment for multiple comparisons was required.

Ethical Considerations

The study was approved by the Research Ethics Committee of Salaam University (reference 2026/SU-REC/AMSHS/P0401), and written informed consent was obtained from all participants. Full details are given in the section Ethics approval and consent to participate.

Results

Participant Characteristics

A total of 300 hospital workers took part (Table 1). Just over half were male (56.0%). Two thirds were aged 20–29 years (66.7%) and 16.7% were aged 30–39 years. Nurses were the largest professional group (42.0%), followed by doctors (16.0%), laboratory staff (14.0%) and midwives (12.0%). More than half of the participants were single (58.0%).

Table 1.

Sociodemographic Characteristics of the Participants (N = 300)

Variable	Category	n	%
Sex	Male	168	56.0
	Female	132	44.0
Age group (years)	20–29	200	66.7
	30–39	50	16.7
	40–49	32	10.7
	≥50	18	6.0
Profession	Nurse	126	42.0
	Doctor	48	16.0
	Laboratory staff	42	14.0
	Midwife	36	12.0
	Pharmacist	24	8.0
	Other	24	8.0
Marital status	Single	174	58.0
	Married	30	10.0
	Divorced or widowed	96	32.0

Notes: There were no missing data. Percentages may not sum to exactly 100 because of rounding.

Night Shift Work Characteristics

Rotating shifts were more common than permanent night shifts (60.7% versus 39.3%; Table 2). Nearly half of the participants worked three to four night shifts per week (48.7%) and a quarter worked five or more (25.3%). Just over half worked 12-hour night shifts (52.0%) and a further 16.7% worked shifts longer than 12 hours, so that 68.7% worked night shifts of 12 hours or longer. Two thirds of the participants (68.0%) were not satisfied with their shift schedule.

Table 2.

Night Shift Work Characteristics of the Participants (N = 300)

Variable	Category	n	%
Type of shift	Permanent night shift	118	39.3
	Rotating shift	182	60.7
Night shifts per week	1–2	78	26.0
	3–4	146	48.7
	≥5	76	25.3
Working hours per night shift	8 hours	94	31.3
	12 hours	156	52.0
	More than 12 hours	50	16.7
Satisfaction with shift schedule	Satisfied	96	32.0
	Not satisfied	204	68.0

Notes: There were no missing data.

Self-Reported Physical Health Problems

Frequent fatigue was reported by 76.0% of participants (95% CI 70.9–80.5) and sleep problems by 71.3% (95% CI 66.0–76.2) (Table 3). Headaches were reported by 64.0% (95% CI 58.4–69.2), gastrointestinal problems by 39.3% (95% CI 34.0–45.0) and hypertension symptoms by 34.0% (95% CI 28.9–39.5).

Table 3.

Prevalence of Self-Reported Physical Health Problems Among Night Shift Hospital Workers (N = 300)

Health Problem	Reported, n (%)	Not Reported, n (%)	95% CI for % Reported
Frequent fatigue	228 (76.0)	72 (24.0)	70.9–80.5
Sleep problems	214 (71.3)	86 (28.7)	66.0–76.2
Headaches	192 (64.0)	108 (36.0)	58.4–69.2
Gastrointestinal problems	118 (39.3)	182 (60.7)	34.0–45.0
Hypertension symptoms	102 (34.0)	198 (66.0)	28.9–39.5

Notes: Each problem was recorded as a single self-reported yes/no item. Problems are listed from the most to the least frequently reported. Confidence intervals were calculated with the Wilson score method. There were no missing data.

Abbreviation: CI, confidence interval.

Self-Reported Psychological and Occupational Problems

Stress was the most frequently reported problem overall (78.7%; 95% CI 73.7–82.9) (Table 4). Anxiety was reported by 62.7% of participants (95% CI 57.1–67.9) and burnout symptoms by 58.0% (95% CI 52.3–63.4). Reduced concentration was reported by 68.7% (95% CI 63.2–73.7), and 30.7% (95% CI 25.7–36.1) reported work-related errors during night shifts. Taken together, seven of the ten problems assessed were each reported by more than half of the participants.

Table 4.

Prevalence of Self-Reported Psychological and Occupational Problems Among Night Shift Hospital Workers (N = 300)

Problem	Reported, n (%)	Not Reported, n (%)	95% CI for % Reported
Psychological
Stress	236 (78.7)	64 (21.3)	73.7–82.9
Anxiety	188 (62.7)	112 (37.3)	57.1–67.9
Burnout symptoms	174 (58.0)	126 (42.0)	52.3–63.4
Occupational
Reduced concentration	206 (68.7)	94 (31.3)	63.2–73.7
Work-related errors during night shifts	92 (30.7)	208 (69.3)	25.7–36.1

Notes: Each problem was recorded as a single self-reported yes/no item. Within each group, problems are listed from the most to the least frequently reported. Confidence intervals were calculated with the Wilson score method. There were no missing data.

Abbreviation: CI, confidence interval.

Discussion

This study describes hospital workers who work night shifts in Mogadishu. They were mostly young and most often nurses, and their night work was demanding: about three quarters worked three or more night shifts per week, two thirds worked night shifts of 12 hours or longer, and two thirds were dissatisfied with their schedule. Self-reported health problems were very common. Stress, fatigue, sleep problems, reduced concentration, headaches, anxiety and burnout symptoms were each reported by more than half of the participants, and almost one in three reported work-related errors during night shifts.

The high frequency of sleep problems and fatigue fits the first step of the conceptual framework and the biology of night work: working against the circadian clock shortens and fragments daytime sleep and produces sleepiness during the shift.^1,7 The proportion reporting sleep problems (71.3%) is, however, considerably higher than estimates obtained with validated instruments. The pooled prevalence of shift work disorder is 26.5%,¹¹ shift work sleep disorder was found in 25.6% and 30.4% of nurses in two Ethiopian studies,^24,25 and 45.7% of nurses in a tertiary hospital in Mogadishu had poor sleep quality.³⁰ Two explanations are likely. First, a single yes/no question captures any perceived sleep difficulty, whereas diagnostic criteria and scale cut-offs identify only more severe or persistent problems. Second, our sample was restricted to staff with at least six months of night work, most of whom worked long and frequent night shifts, whereas the comparison studies included staff with a wider range of exposure to night work. In the Ethiopian and Somali studies, the number of night shifts and night work itself were among the factors most strongly related to poor sleep,^24,25,30 so a sample made up entirely of night workers would be expected to show a higher frequency.

Headaches were reported by nearly two thirds of participants. Systematic review evidence on shift work and headache is inconsistent,¹⁷ and headache in this setting may equally reflect sleep loss and long working hours. Gastrointestinal problems, reported by 39.3%, are a recognized complaint of shift workers and have been attributed to eating at times that are out of step with the circadian rhythm of digestive function.¹⁶ One third of participants reported hypertension symptoms. This finding should be interpreted with particular caution: hypertension is frequently asymptomatic and blood pressure was not measured, so the item probably reflects perceived symptoms or a previous diagnosis and cannot be read as the prevalence of hypertension. Nevertheless, rotating shift work, the predominant pattern in our sample, has been associated with hypertension and cardiovascular disease,^12,13 and objective measurement of blood pressure among Somali night workers would be worthwhile.

Stress, anxiety and burnout symptoms were reported by 78.7%, 62.7% and 58.0% of participants. These figures are well above scale-based estimates from Mogadishu, where burnout measured with the Maslach Burnout Inventory was present in 24% of healthcare workers²⁹ and anxiety and stress symptoms measured with the 21-item Depression Anxiety Stress Scales were present in 32.5% and 15.1% of nurses.³¹ As with sleep, the difference is probably explained mainly by measurement (single self-report items versus validated scales with cut-offs) and by the restriction of our sample to night workers. The direction of the finding is nonetheless consistent with the literature: shift work is associated with poorer mental health in longitudinal studies,¹⁸ shifts of 12 hours or longer with burnout,¹⁹ and, in Mogadishu, frequent night shifts and long weekly working hours with higher odds of burnout.²⁹ Burnout is common among health providers across sub-Saharan Africa.²⁷

Two thirds of participants reported reduced concentration and almost one third reported work-related errors during night shifts. Objective studies show that alertness and performance decline during night shifts in healthcare workers,⁸ and long shifts and night work are associated with a higher risk of errors and accidents.^21,22 In our study errors were self-reported, their type and severity were not recorded, and no link with patient outcomes can be drawn. Even so, in hospitals with few staff on duty at night, the frequency with which staff themselves report lapses in concentration and errors is a patient safety signal that hospital leaders should not ignore.

The Somali context is important for interpreting these findings. The country has fewer than 4 doctors, nurses and midwives per 10,000 population, and the workforce is unevenly distributed between urban and rural areas and between public and private facilities.²⁸ With so few staff, hospitals have limited room to shorten shifts, reduce the number of night duties per person or provide cover for rest, which may explain why long and frequent night shifts were the norm in our sample. The workforce was young, and night duty may fall disproportionately on junior staff. Night duty may also be accepted for financial reasons, as reported by nurses in Ethiopia.²⁶ To our knowledge, formal occupational health services, routine health screening for staff and workplace mental health support are limited in Somali hospitals. Each of these factors may influence both how much night work a person does and how healthy that person is, independently of any direct effect of night work.

For these reasons, and because of the study design, the findings must not be interpreted causally. All participants were night workers, so there was no comparison group, and we do not report analyses relating shift characteristics to health problems. The results show how common these problems are among night shift hospital workers; they do not show that night work caused them. Reverse causality is possible: staff who are stressed or sleeping poorly may be more dissatisfied with their schedule or more likely to report errors. Confounding by workload, staffing, income, family responsibilities, lifestyle and pre-existing illness, none of which were measured, is also likely. Selection may operate in the opposite direction, because workers who tolerate night work poorly tend to leave it, so that those who remain are a more resilient group.²

Despite these limits, the findings have practical implications for healthcare leadership. A workforce in which most night staff report stress, fatigue and poor sleep, and in which two thirds are dissatisfied with their schedule, warrants attention whatever the cause. Measures supported by the literature include limiting shift length and the number of consecutive night shifts, ensuring adequate rest between shifts, involving staff in the design of rosters, providing protected breaks and rest areas at night, and giving staff access to periodic health checks and mental health support.^1,2,5 Because several of these measures depend on staffing levels, they also require investment in recruitment and retention. These are proposals for consideration and evaluation in Somali hospitals; our data do not test their effectiveness.

Strengths and Limitations

The study has strengths. It included several professions from both public and private hospitals, there were no missing data for the variables reported, and it is, to our knowledge, among the first to describe the night shift hospital workforce in Mogadishu. It also has important limitations. First, the cross-sectional design and the absence of a day-shift comparison group preclude causal inference. Second, the analysis is descriptive: associations between shift characteristics and health problems were not estimated, and no adjustment for confounding was possible. Third, participants were recruited by purposive sampling from selected hospitals in one city, so the sample may not represent all hospital workers in Mogadishu or elsewhere in Somalia, and selection bias cannot be excluded. Fourth, all outcomes were self-reported with single yes/no items and not with validated scales or clinical measurement, which is likely to overestimate prevalence relative to scale-based studies and makes the results sensitive to recall and social desirability bias. Fifth, duration of employment, total weekly working hours, lifestyle, family responsibilities and pre-existing conditions were not measured. Future studies should include day workers as a comparison group, use validated instruments and objective measures such as blood pressure and actigraphy, apply multivariable analysis and follow workers over time.

Conclusion

Among 300 hospital workers who work night shifts in Mogadishu, most worked rotating shifts (60.7%), night shifts of 12 hours or longer (68.7%) and three or more night shifts per week (74.0%), and two thirds were dissatisfied with their schedule. Self-reported stress, fatigue, sleep problems, reduced concentration, headaches, anxiety and burnout symptoms were each present in more than half of the participants, and about one in three reported work-related errors during night shifts. These findings indicate a high burden of self-reported health problems in this workforce. Given the descriptive cross-sectional design and the lack of a comparison group, they do not establish that night shift work caused these problems. Hospital leaders and policymakers should review shift scheduling and staffing and strengthen occupational and mental health support for night staff. Longitudinal and comparative studies using validated instruments are needed to determine causal relationships and to evaluate interventions.

Funding Statement

This research received no external funding.

Data Sharing Statement

All data supporting the findings of this study are available from the corresponding author upon reasonable request.

Ethics Approval and Consent to Participate

The Research Ethics Committee (REC) of Salaam University reviewed and approved this study (2026/SU-REC/AMSHS/P0401). The study was conducted in accordance with the principles of the Helsinki Declaration of 1964 and its subsequent amendments.

Written informed consent was obtained from all participants before data collection. Prior to obtaining consent, the study objectives, procedures, potential benefits, and participants’ rights were clearly explained in the local language (Somali). Participation was entirely voluntary, and all participants were informed of their right to decline participation or withdraw from the study at any time without any consequences. Confidentiality and privacy were maintained throughout the study, and no personal identifiers were included in the analysis.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that there are no financial, personal, or professional conflicts of interest that could have influenced the work reported in this study. No funding or sponsorship was received that could have affected the study design, data collection, analysis, interpretation, or publication of the results.