Burnout among healthcare workers during public health emergencies in sub-Saharan Africa: Contributing factors, effects, and prevention measures


 Countries in sub-Saharan Africa (SSA) are expected to experience more public health emergencies (PHEs) in the near future. The fragile health systems emanating from poor health governance, inadequate health infrastructure, shortage of healthcare workers (HCWs), inadequate essential medicines and technology, and limited funding will make responses to these outbreaks slow and ineffective as seen with the COVID-19 pandemic. The workload for HCWs will grow due to these PHEs, which will increase the likelihood that they may experience burnout. This narrative review loosely followed the guidelines provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement. Google Scholar, PubMed, and ScienceDirect databases were used to retrieve relevant articles. Two reviewers assessed the titles and abstracts of all identified articles and extracted the data independently and compared their results thereafter. The causes of burnout among HCWs, its impact on patients, HCWs, and healthcare institutions, as well as preventive steps that should be taken to safeguard HCWs from burnout, are all covered in this article.



Introduction
Working in an emotionally and physically taxing setting for an extended period leads to burnout. Even though burnout can impact any profession, it is becoming acknowledged as a serious issue for healthcare workers (HCWs) globally, particularly during public health emergencies (PHEs) (1). Burnout can have negative implications on patients, HCWs, healthcare organizations, and healthcare systems if it is not properly handled (2). Burnout, initially described by Herbert Freudenberger in 1974 (3), is a multifaceted illness, characterized by emotional tiredness, depersonalization, and a diminished sense of personal success (4). Freudenberger's twelve phases of burnout development were ultimately reduced to five (5). The five phases are shown in Figure 1 below. Without coping mechanisms, burnout starts during this phase. The second phase, stagnation, or stress onset is when HCWs recognize some days are harder than others. HCWs' personal, family, and social lives are disregarded. This phase causes physical and emotional stress. The third phase is the chronic stress period. Chronic stress frustrates HCWs, and they feel incomplete, helpless, and unappreciated. They feel like failures during this stage. The fourth phase, the apathy phase, involves despair and disillusionment. HCWs feel trapped and grow apathetic. The final step, habitual burnout, is marked by physical and emotional symptoms that lead to HCWs seeking help (6).
· Initial excitement · Job stress sets in pandemic, cholera, yellow fever, dengue fever, and the Ebola virus disease (EVD).
Responses during these PHEs were usually slow and ineffective due to the weak and fragile health systems resulting from poor health governance, inadequate health infrastructure, a lack of HCWs, inadequate essential medicines and technology, and limited funding (5). It is projected that the PHEs will increase the workload for the HCWs because there is a scarcity of HCWs in SSA, which subsequently will lead to rises in the incidence of burnout (7).
Considering this, we explore the causes of burnout among HCWs during PHEs, its effects, and preventative steps that can be taken to reduce its burden in this narrative review with a focus on SSA.

Study design
This narrative review loosely followed the guidelines provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement (8).

Research question and study eligibility
The problem-interest-context (PICo) framework was used to determine the eligibility criteria for the review question. In this framework, we defined the problem as burnout among HCWs, interest as public health emergencies, and context as sub-Saharan Africa (SSA). This review sought to answer the following research questions: i. What are the risk factors for burnout among HCWs during public health emergencies in sub-Saharan Africa? ii.
What are the effects of burnout among HCWs? iii.
What prevention measures can be put in place to reduce burnout among HCWs during PHEs?

Inclusion criteria
Studies were eligible if they were original qualitative and quantitative studies published in English and reported on the risk factors, the effects, and the prevention measures of burnout among HCWs, and were conducted in sub-Saharan Africa. Review articles, systematic reviews, meta-synthesis, editorials, and letters to the editor were excluded.

Literature sources and search strategy
We compared their results thereafter. Where discrepancies were identified, these were resolved by discussion or adjudication by a third reviewer.

Data extraction
The data extraction form developed by the authors captured information on the names of the authors, publication year, country, publication type, study design, key findings on risk factors, and effects of burnout, as well as prevention measures among HCWs during PHEs.
After extraction, we presented a narrative account of the main findings from the included articles.

Results
The initial search retrieved 542 articles from all the databases used. A total of 130 articles remained after removing duplicates. Following title screening, 100 were eligible for abstract screening. At the conceptual screening stage, reviewers checked whether the articles retrieved reported on burnout among HCWs in SSA. The reviewers also checked the date of publication of the articles and whether they reported on original research or not. Eighty-eight articles were excluded at the conceptual screening stage, leaving 12 for full-text screening.
Two articles were excluded at the full-text screening stage because they did not report on burnout in PHEs. A total of 10 articles were included in this review. More details are presented in Figure 2.

Characteristics of included studies
A total of ten articles were included in this review. All the articles were published journal articles. The authors used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) 22 items checklist (9) to assess the quality of the included quantitative studies while qualitative studies were assessed for credibility, dependability, confirmability, and transferability (10). The reviewers agreed that all the included articles were of good quality. Two studies were conducted in Zimbabwe (11,12), two in Nigeria (13,14), two in Sierra Leone (15,16), and one each in Kenya (7), Ghana (17), South Africa (18), and Ghana and Kenya (19). Six of the studies used a cross-sectional study design (7,13,(16)(17)(18)(19), three a qualitative design (12,14,15), and one a mixed methods design (11). Only two of the studies conducted in Sierra Leone studied burnout among HCWs during the Ebola virus disease outbreak (EVD) (15,16), while the rest were conducted during the COVID-19 outbreak. More details are presented in Table 1.

Review findings
The findings of this narrative review are presented below. More details are presented in Table   2.

Effects of burnout
Only three of the included studies reported on the effects of burnout (13,16,17). One study reported that burnout caused medication errors and physical health conditions among HCWs (17), one reported poor quality of care resulting from burnout (16), and another reported low productivity among HCWs as a result of burnout (13).

Burnout prevention measures
Only one study included in this review did not report on burnout prevention measures (13).
We categorized the prevention measures into individual, institutional, and community-level factors. Personal measures reported in the included articles for this review include building individual resilience (17), exercising (11), and turning to religion (15). Institutional measures include having a mental health response plan in place (7), training HCWs on disease outbreaks (7,13,15,18), providing toll-free mental health helplines (7), providing risk allowances (7,14,15), providing adequate equipment for the disease outbreaks (16), and ensuring that the institutions are adequately staffed (14). Community measures include developing social media platforms for HCWs where they can support each other (15), and colleagues, friends, and family support (12,15,16,18,19). This review revealed that several institutional factors also contribute to HCW burnout. One of the identified factors is increased workload. This finding concurs with findings from previous studies (22,26,27). The previous studies reported that a lot of effort was involved during the COVID-19 pandemic since a lot of people contracted the disease and needed hospital treatment. The countries distributed this increased workload to HCWs who were already understaffed, and this led to stress which could cause burnout (22,26,27). The increased workload, obligations, and pressure from superiors during PHEs on HCWs raise the likelihood of burnout (29). HCWs may be reassigned to work in the regions most impacted by the PHEs, occasionally without the required training or understanding of their responsibilities. Role ambiguity may lead to poor task coordination and ineffective teamwork (22). The cost of the redeployment may be borne by the HCWs, who may have to move their properties and find new housing. HCWs may still be underpaid despite the additional workload, which further compounds their dissatisfaction with the working environment (22). HCWs are traumatized as a result of these choices and events, which put them at risk for burnout (22).
Lack of resources, such as PPE, can hinder HCWs' ability to do their jobs during PHEs, raising their risk of contracting infectious diseases. Even when personal protective equipment (PPE) is accessible, it may still make the HCWs uncomfortable and interfere with their ability to communicate with patients and with one another (27). The added time needed to manage PPE and the associated paperwork also contributes to the workload. Furthermore, a lack of social support for HCWs due to poor organizational management may further raise their risk of suffering from burnout (26). Communities may make matters worse by stigmatizing and discriminating HCWs during PHEs because of their ignorance about the diseases (26).

The effects of burnout
This review revealed that burnout has detrimental effects on HCWs and patients. These findings concur with those of a previous review (28). HCWs may experience unhappiness, anxiety, depression, and loneliness translating to job dissatisfaction (28). Some of the consequences of burnout among HCWs are substance use leading to addiction, strained or broken relationships, divorce, and suicidal attempts (28). Also, burnout among HCWs may lead to occupational injuries like needle stick injuries, increasing the likelihood of acquiring infectious illnesses like hepatitis B and HIV (3). Burnout among HCWs may lead to lessthan-ideal patient treatment and hence low patient satisfaction. Additionally, it may cause more medical mistakes, which might endanger patients. Litigation and subsequent malpractice claims may result from this (3). Patients who receive suboptimal care from burntout HCWs are prone to lose faith in them and may stop showing up for follow-up appointments. Poor patient outcomes could arise from this, which would worsen the population's health (3). Burnout may cause healthcare organizations to experience decreased production because of presenteeism and absenteeism. In addition, they can incur higher operational costs because of litigation, a high turnover rate among HCWs, and early retirements. Early retirements could make the region's HCW shortage worse (28).

Prevention measures
This narrative review revealed that personal measures to reduce burnout include resilience building, exercising, and turning to religion (11,15,17). These findings concur with those of a previous scoping review which revealed that HCW self-care activities and spiritual support may prevent burnout (22). Even though HCWs put in longer hours during PHEs, they should still engage in some physical activity whenever they have downtime because it will lower stress (28). HCWs should also practice good sleep hygiene and a balanced diet to prevent burnout. To avoid burnout, HCWs must also be encouraged to seek professional assistance anytime they have psychological symptoms (28).
Healthcare institutions should make sure HCWs are involved in management decisions, especially during PHEs, to lessen burnout among HCWs. HCWs will feel respected and appreciated by the organizations as a result (29). Healthcare institutions should make sure HCWs are adequately resourced, like having enough PPE, because doing so will relieve their anxieties about contracting infectious diseases from patients and other staff members, which mitigates burnout (27). Institutions should provide training on the management of the specific infectious disease causing the PHE and their unique tasks to lessen HCW anxiety associated with being deployed in unfamiliar work environments (29). Institutions should also provide a risk allowance to HCWs as an incentive for the work they undertake because they have a higher risk of contracting infectious diseases than the general population (22). This can be provided in the form of a monetary bonus or in-person benefits like family medical insurance, life insurance, or other benefits that their loved ones can use if they die from diseases they contracted at work (28). Task shifting is another strategy that healthcare institutions should use to prevent overworking any one HCW group during epidemics. Some tasks usually done by registered nurses such as giving patients parenteral medications can be shifted to enrolled nurses after they have received proper training (22). To prevent any HCW from being compelled to make life-or-death decisions that may later only affect them, healthcare institutions should establish committees that deal with ethical concerns (29). Additionally, organizations ought to provide social media channels for HCWs to communicate difficulties they encounter during PHEs since this can lessen their stress at work and lower the number of people who experience burnout (28).
Communities must be informed about the diseases during PHEs to lessen the stigma associated with working in hospitals. This will give them knowledge about the diseases' modes of transmission, effective methods for preventing transmission, and the crucial function that HCWs do during PHEs. Education can be provided by organizing workshops, or by mass media (30). Another effective way of providing education to communities is through distributing information, education, and communication (IEC) material through different platforms in different languages. The IEC materials should be placed at strategic points in the communities such as schools, shopping centers, churches, and community boreholes (31).
This review had some limitations. One of the limitations is that only three databases were used to retrieve relevant articles, making it possible that some relevant literature might have been missed. Another limitation is that only articles published in English were included in this review, which might have resulted in language bias. However, the fact that two reviewers extracted and synthesized that data make the results believable. Furthermore, the review followed PRISMA-P guidelines, which makes the study reproducible. Future longitudinal studies should, however, be carried out during PHEs to determine their dynamic effects on HCW burnout.

Conclusion
More PHEs are anticipated in SSA countries in the near future. As was the case with the COVID-19 pandemic, responses to these outbreaks may be slow and ineffective due to the fragile health systems resulting from poor health governance, inadequate infrastructure, a lack of healthcare workers, inadequate essential medicines and technology, and limited funding. These PHEs will raise the burden for HCWs, which is likely to increase the likelihood that they may experience burnout. Burnout among HCWs is a result of a variety of individual, institutional, and community-level factors. The HCWs, patients, and healthcare institutions may all be affected by burnout. Countries in SSA should implement plans to stop and handle HCW burnout if they want to be better equipped to handle future PHEs. These tactics fall into three categories: HCW-level, institutional-level, and community-level.

Conflict of interest
None declared.

Funding
This study was not funded.