Introduction

Employment is a beneficial determinant of health,1 including mental health, and plays a vital role in achieving sustainable development goals2 of mental well-being. However, the increased risk of common mental disorders associated with work-related psychosocial stressors has become an increasingly pressing concern for researchers and policymakers.3 Therefore, addressing how health workers perceive those mental health issues and their work-related stressors contributes to supporting sustainable development goals 3 (good health and well-being) and 8 (decent work and economic growth) of health workers.2 The prevalence of CMSs, such as occupational stress, anxiety4 5 and depression,6 is notably higher among health professionals due to their exposure to various work-related psychosocial factors. During the COVID-19 pandemic, approximately 37%, 40% and 37% of health workers globally reported experiencing mental distress, anxiety and depressive symptoms, respectively.3 In Ethiopia, the prevalence of psychological distress, anxiety and depression during the COVID-19 era ranged from 12.4% to 61.9%,7–10 21.9% to 78%7–10 and 20.2% to 60.3%,7–10 respectively. Moreover, the prevalence of these CMSs among health workers continued to rise even after the pandemic had ended.11 However, such a high prevalence rate may not accurately reflect reality and be overestimated or underestimated due to misconceptions about these CMSs among health workers.

Given the subjective nature of symptoms and the complex perceived causal links to these symptoms, exposure to work stressors may be interpreted differently among health workers. Therefore, exploring how health workers understand or conceptualise these CMSs from an aetiological perspective (ie, work-ascribed manner) and their persistent experiences of exposure to work-related stressors may provide insights into the rising prevalence of these symptoms and associated work-related psychosocial factors. This understanding contributes to essential components of selective prevention and the promotion of mental health in the workplace12 by generating evidence for effective interventions. To better understand the rising prevalence of CMSs among health workers, it is essential to examine how health workers conceptualise CMSs, such as how they perceive, interpret and conceptualise these symptoms. This focus on the subjective interpretation of CMSs lays the groundwork for exploring how health workers assign meaning to their symptoms and connect them to specific work-related stressors as well as their ability or inability to recognise, address and seek support for these issues. Similarly, the perceived or actual experience of exposure to work-related psychosocial stressors, coping strategies employed and barriers to seeking support would also add more information to targeted interventions to enhance the workplace mental well-being and professional quality of life (PQoL) of health workers.

The conceptualisation of CMSs including stress, anxiety and depression, in this study, pertains to how health workers assign meaning to or recognise symptoms experienced resulting from work-stressor responses. It encompasses their understanding of vulnerability, perceived and actual experiences; and practice of linking a specific work stressor to the symptoms of CMS symptoms, perceived controllability and prevention strategies. Health workers are expected to possess an adequate understanding of these issues, but many may lack the skills for early self-identification of CMSs within the work-ascribed or aetiological contexts which can impede their ability to seek care due to low mental health literacy.13 This is a gateway for seeking care or support from mental health professionals or any other workplace mental health therapists (eg, organisational psychologists and/or clinical psychologists). A failure to accurately define CMSs, connect these symptoms to a specific work-related stressor(s), recognise confounding factors (such as life stressors) and misunderstand the biopsychosocial context can lead to challenges in symptom recognition. This can increase both the duration of stressor exposure and the risk of developing mental illnesses.14 A study indicates that health workers often fear stigmatisation, perceive themselves as invulnerable to mental health issues, may overlook symptoms due to time constraints and heavy workloads and perceive symptom identification as futile in the absence of access to support for persistent specific symptoms.15 Furthermore, an underestimation of symptoms16 and inadequate mental health literacy17 hinder health professionals from actively seeking support. Similarly, the perceived and actual experiences of work-related stressors, along with an inability to cope with them, can also lead to either overestimation or underestimation of the risk of common mental health symptoms.

Despite the high prevalence of CMSs among health professionals, including those in Ethiopia, there is limited comprehensive evidence on how these individuals conceptualise stress, anxiety and depression from an aetiological perspective, particularly the perception of work-related stressors as causative agents. Additionally, the subjective experiences of work-related stressors and their link with those CMSs, coping strategies employed, barriers to mitigating these stressors and barriers to actively seeking support from mental health practitioners (eg, mental health specialists, organisational and clinical psychologists) or relying on collegial and supervisory support remain largely underexplored. Therefore, this study aimed to investigate how health professionals conceptualise CMSs, explore their exposure to work-related stressors, explore perceived causal pathways and the impact of these stressors on their PQoL, identify coping practices and barriers to reducing stressors and support-seeking behaviours among health workers in Central and Southern Ethiopia.

Theoretical frameworks for the study

To guide our research question and streamline the complexities inherent in pure constructivism and interpretivism, we used combinations of theoretical frameworks to conceptualise and explore exposure experiences to work-related psychosocial stressors. Specifically, we used seven theoretical frameworks to guide our research questions, develop our interview guide, develop code frames and the moderation or interview processes: self-identification as having common mental health symptoms (SICMS),13 the occupational depression inventory (ODI),18 perceived occupational stress,17 the job demand-resources model (JD-R),19 effort-reward imbalance (ERI) model,20 PQoL21 and the transactional model of stress (TMS).22 The philosophical frameworks of constructivism and interpretivism intersect with phenomena related to perceived mental health symptoms, such as the perception of symptoms and corresponding work-related stressors, perceived vulnerability to these symptoms, the subjective experience of such symptoms and their impact on perceived PQoL. However, an exploration of coping practices and barriers to seeking support and mitigating stressors may require the coding of descriptive realities.

The SICMS is based on the health belief model,23 which seeks to explore how individuals perceive and recognise symptoms, particularly in the context of diseases, including mental conditions. Our investigation was guided by the constructs of SICMS, focusing on health workers’ awareness of symptoms, perceived vulnerability, experiential perceptions of those symptoms and their perceived causal links between workplace stressors and CMSs. We also explored their perceptions of the controllability and preventability of occupational stress, anxiety and depression. Within the SICMS framework, the perceived meaning or awareness of symptoms (stress, depression and anxiety) was evaluated against the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria24 for anxiety and depression.18 24 The perceptions of health workers about the causal links between specific work-related stressors identified by themselves and CMSs of our interest were explored on immediate mention of stressors. This helped determine whether they denote terms like ‘occupational stress’, ‘occupational depression’ or ‘occupational anxiety’ to describe the conditions. We examined the relationships between occupational stress and various somatic and mental symptoms over an extended duration (6 months or more) as well as the frequency of occurrence of work stressors and their duration based on occupational aspect measures of distress.17

We selected the JD-R model19 to guide the exploration of health workers’ perceptions of high demands (such as high workloads and emotional stressors that may cause negative mental or physical symptoms when they exceed health workers’ coping resources) and low job resources (limited support, autonomy, opportunities, emotional readiness and resiliencies) due to better accommodation of multiple work-related stressors. The JD-R model can be seen as an extension of the Job Demand-Control (JDC) model.25 While the JDC model focuses primarily on the balance between job demands and employees’ control over their work, the JD-R model broadens this perspective by incorporating not only job demands and control but also the importance of job resources in influencing employee well-being and performance. Hence, we selected the JD-R theoretical model to guide our study to incorporate broader work-related stressors identified by the health workers. The ERI20 model is also another stress-health model that suggests stress arises when the effort employees invest in their work is not matched by adequate rewards, including financial compensation, esteem and career opportunities. This imbalance can lead to negative health outcomes, including mental health outcomes and lower job satisfaction, as individuals perceive their contributions as undervalued in relation to the demands placed on them. Similarly, we selected the ERI model to incorporate the high effort and low reward,20 whether perceived or experienced by health workers, as identified during our interviews and focus group discussions (FGDs). Furthermore, we explored the perceived impact of exposure to high job demand, low job control or decision latitude, low job resources, high effort–low rewards and the subjective experience of CMSs on three components of PQoL21: burnout, compassion satisfaction and compassion fatigue (CF). Finally, we applied the transactional theory of stress22 to investigate, code and thematise coping strategies employed to manage the abovementioned work-related stressors.

MethodsStudy settings

We conducted this study in eight public health facilities (HFs) located in the Central and Southern Ethiopian regions of Ethiopia, the central area of the former Southern Nations, Nationalities and Peoples’ Regional Government from 15 January to 28 February 2023 among health workers. This qualitative study was conducted in randomly selected healthcare facilities stratified into primary hospitals, general hospitals and tertiary hospitals. Public health hospitals were selected using stratified random sampling for the quantitative component of a larger PhD project. The project incorporates both quantitative and qualitative approaches to address distinct research questions from different perspectives and ultimately integrate the findings for a comprehensive understanding of the problems under study in the same target population. Therefore, this qualitative exploration aimed to complement the quantitative objectives which focus on assessing the prevalence of occupational CMSs and their associations with work-related psychosocial factors.

The healthcare facilities serve a diverse, multiethnic, multilingual population residing in five administrative zones. These include four zones within the current Central Ethiopian Region (Hadiya, Halaba, Kembata and Silitie Zones) and one zone within the current South Ethiopian Region (Wolaita Zones). These zones are located approximately 203–328 kilometres from the capital city, Addis Ababa. The total population residing in these five zones, along with an additional eligible zone (the Guragie Zone), is approximately 9 201 127. The study areas where the selected public hospitals are located are shown in figure 1.

Figure 1

Map of the study areas in the Central and South regions of Ethiopia, February 2023. SNNPR, Southern Nations, Nationalities and Peoples' Regional Government.

Study design

This study employed a descriptive–interpretive phenomenological qualitative design, guided by a combination of theoretical frameworks, to explore participants’ lived experiences and interpretations. Participants were encouraged to describe their experiences through probing, focusing on both their perceived and actual exposure to specific work-related stressors. We applied a descriptive approach to document participants’ experiences and an interpretative analysis to uncover deeper meanings. This included exploring participants’ perceptions of CMSs, their interpretations of vulnerability and the links they perceived between specific work stressors and CMSs. The analysis also considered participants’ thoughts on the controllability and prevention of these symptoms. Although variations are expected in health workers’ lived experience of CMSs, the meanings they attach to these symptoms, their exposure to work-related stressors, the perceived and actual impacts on their PQoL, coping strategies and perceived and actual barriers hindering coping with the stressors or seeking support can be assumed as constructive realities of health workers. We also considered the design phenomenological if a health worker shared their colleagues’ experiences on the above issues during an interview or FGD, despite some distinctions to consider.26 27 To analyse these experiences, we applied either descriptive coding (eg, capturing clear perceptions or actual experiences) or interpretive coding (eg, deriving deeper meanings from a segment), depending on the context.

Study participants and sampling strategy

We purposefully selected study participants from various units within the selected hospitals. We conducted in-depth interviews (IDIs) for a deeper exploration of individual experiences, emotions and perceptions related to CMSs and work-related stressors. We also conducted FGDs to facilitate interaction among participants, allowing for the sharing of diverse viewpoints and experiences regarding CMSs and exposure to various work-related stressors. The sampling process began with identifying departments or pinpoints or unit heads in the HFs included in the PhD study that analysed the same target population with different initial research questions or objectives28 guided by the hospital’s matrons and medical directors.

Participants for IDIs were purposely chosen based on having at least 2 years of work experience, engagement in clinical or paramedic activities and holding managerial roles such as directors, unit heads, outpatient and inpatient ward coordinators or other key positions within HFs. Participants for IDIs were deliberately chosen based on having at least 2 years of work experience, involvement in clinical or paramedic activities and holding managerial roles such as directors, unit heads, managers, coordinators, ward heads or other key positions within HFs. 10 healthcare workers were selected for IDIs based on the assumption that they possessed rich information about CMSs, their prolonged exposure to work-related stressors, their understanding of colleagues’ experiences and their knowledge of the subjective and actual impacts of these stressors on PQoL in the workplace. Additionally, they were supposed to provide rich information on coping strategies and the perceived and actual barriers to mitigating work-related stressors or seeking support.

Similarly, participants for the FGDs were purposely selected to ensure representation across various healthcare cadres, including physicians, nurses, midwives, laboratory technologists, pharmacists and other paramedical health workers. This approach aimed to gather insights into how health workers conceptualise CMSs (occupational stress, occupational depression and occupational anxiety) as well as their subjective and actual experiences with work-related stressors within each cadre. We conducted three FGDs, each involving eight participants. We assumed that all health workers possess a shared understanding of CMSs, work-related stressors, their perceived impact on PQoL, coping strategies, barriers to mitigating work-related stressors and seeking any support in the workplace, despite belonging to different specialty groups and experiencing varying magnitudes and severities of stressors and mental health symptoms. We continued these discussions until we identified recurring information.

Data collection procedures

Guides for conducting IDIs and FGDs were developed and translated into Amharic. The guidelines were developed to capture information on how health workers conceptualise CMSs in work-ascribed perspectives (ie, linking each CMS to the work-related stressors to comply with the terms ‘occupational stress’, ‘occupational-related depression’ and ‘job anxiety’), subjective exposure to work-related stressors based on the theoretical work-related psychosocial stressors, the perceived impact of stressors and/or CMSs on PQoL, the experience of coping strategies and barriers to reducing stressors and feelings about CMSs.

We trained two research assistants, both experienced in supporting qualitative research and with professional expertise in health to assist the FGDs, one holding a Master of Science (MSc) in community psychiatry and the other a Master of Public Health (MPH) degree in epidemiology. Additionally, two research assistants were recruited to take detailed notes and record audio during the FGDs. During the training process, key topics were addressed, including CMS definitions, diagnostic approaches, work-related perspectives, the study’s approach, interview guidelines and theoretical frameworks relevant to the study. Based on the interview guidelines, skills on how to initiate and probe a descriptive approach to capture participants’ experiences, such as perceived and actual exposure to specific work-related stressors and applying interpretative analysis to derive deeper meanings were discussed during the training session. For example, how to explore participants’ perceptions of CMSs, their interpretations of vulnerability and perceived connections between specific work stressors and CMSs, along with considerations of controllability and prevention.

We started by conducting IDIs to gather rich individual insights first and then conducting FGDs to explore broader group dynamics or consensus as a methodological triangulation to integrate data from FGDs and IDIs, enhancing the validity of the findings. Accordingly, interviews investigated deeper specific issues, while focus groups provided broad insights, allowing for iterative refinement of findings. The principal investigator and one of the research assistants moderated FGDs. Similarly, the IDIs were carried out by other research assistants and the principal investigators of the study.

Under the support of hospital matrons and medical directors, moderators recruited FGD and IDI participants based on the selection criteria. The moderator or interviewer of each session informed the purpose of the study, selection process and norms to be followed during the interview or discussion, assured confidentiality, agreed on the pseudonyms for each study participant, obtained written consent from each participant and checked the audio record before starting each interview or group discussion. FGDs were conducted in relatively quiet halls within the respective HFs, with a duration ranging from 90 min to a maximum of 190 min. The discussions were highly engaging and interactive, reflecting the participants’ awareness of current and pressing challenges. The minimum IDI took 45 min and the maximum took 90 min. The individual interviews were held in private rooms or offices at the participants’ workplace, with the doors secured to ensure confidentiality until the conclusion of the discussions. Except for two IDIs, all the interviews were interactive and engaging. Field notes and summaries, expanded scribbles of IDIs and FGDs, audio records and other important details such as participant backgrounds were daily submitted to the principal investigator.

During the interviews and discussions, participants were invited to define or reflect on symptoms of CMSs (stress, depression and anxiety) based on their own perceived or actual definitions of each symptom and asked when they considered themselves or their colleagues under stress, depression and anxiety because of their work stressor(s). The subjective and actual experiences of each CMS were assessed based on the SICMS’s theoretical components, such as vulnerability, subjective experience, perceived controllability and prevention. After discussing the identified CMSs, participants were invited to list potential work-related stressors based on the theoretical frameworks chosen for the study. When specific work-related stressor(s) were mentioned, we proceeded to explore healthcare workers’ perceptions of how these stressor(s) might contribute to at least one symptom of common mental health symptoms, either in themselves or their colleagues, to assess perceived causality. Additionally, participants were asked to link the identified stressors to aspects of PQoL. To facilitate this, the components of PQoL; burnout, CF and compassion satisfaction, were explained and discussed during the discussions and interviews.

For health workers who could not provide specific symptoms for any of the CMSs mentioned above, their causal perceptions were identified while mentioning their actual or perceptual stressors, either in our ‘workplace stressor section’ or elsewhere during our interviews and discussions. The remaining theoretical components of SICMSs (ie, vulnerability, subjective experience, perceived controllability and prevention) as well as the perceived impact on PQoL, coping strategies and barriers were explored using the same approach.

Operational definitions of terms

CMSs for this study refer to health workers’ actual experiences of feelings, subjective feelings or reflections on their colleagues’ experience of developing mental and somatic symptoms related to three prevalent mental health issues in the workplace:

Occupational stress for this study refers to the presence of persistent somatic and mental symptoms lasting for 6 months or more, combined with a perceived inability to manage work-related stressors, such as the feeling of high workload or high job demand and low control over resources, based on the perceived occupational stress symptoms scale.17 In this study, participants’ perceptions were also considered, particularly because of the difficulties they faced in accurately recalling the duration of symptoms during our interviews and discussions. Health workers who demonstrated an understanding of the specified symptoms outlined in the perceived occupational stress symptoms scale and could link these symptoms to work stressors, including their duration and frequency, were categorised as having ‘a better comprehension of the meaning of occupational stress’. Whereas health workers who mentioned only ‘high job demand vs low resources or low control or low social support (in their account or understanding’, irrespective of other symptoms, were coded as having a ‘low understanding of symptoms’ of occupational stress.

Occupational depression is also referred to as work-related depression for this study which applies to the recognition of key depressive symptoms based on the DSM-5 criteria24 (online supplemental material 1) over two or more weeks. If health workers were unable to recall specific symptoms with their duration, their general perceptions of symptoms were also considered. To identify occupationally linked depressive symptoms, participants needed to associate at least one symptom with work-related stressors, as defined by the new occupational depression definitions.18

Accordingly, participants were categorised into four based on their awareness and belief about occupational depression. Those who were able to identify five or more of the nine DSM-5 depressive symptoms and link them to work-related stressors were classified as having ‘high awareness of symptoms of occupational depression’. In contrast, those who identified fewer than five symptoms but still linked them to work-related stressors were coded as having ‘low awareness of occupational depression’. Third, participants who were able to identify five or more symptoms of depression, but did not believe these symptoms were related to work-related stressors were coded as ‘did not believe depression is linked to work-related stressors’.

Lastly, those who could not identify at least one cardinal symptom of depression were classified as having ‘no awareness of occupational depression’.

Job or occupational anxiety refers to health workers recognising symptoms of generalised anxiety based on the DSM-5 criteria24 (online supplemental material 2) due to work-related stressors. A participant was classified as ‘aware of job or occupational anxiety’ if they could identify the link between these symptoms and perceived or hypothesised views or actual. The summarisation is the same as that for occupational depression.

SICMSs for this study refer to perceptual opinions of health workers, such as vulnerability to, subjective experiences of and perceived causal links with work stressors, perceived controllability and perceived preventability of previously specified CMSs.13

Work-related stressors or work-related psychosocial stressors for this study refer to all broad work-related stressors as defined by theoretical frameworks, the JD-R framework19 and the ERI model. Additional definitions of these stressors are provided in the codebook for selected stressors (online supplemental material 2).

Data processing and analysis

The primary investigator transcribed all audio recordings from the interviews which were conducted in Amharic and then translated these transcripts into English. Expanded scribbles and field notes provided by the moderators and notetakers were cross-validated and incorporated into the corresponding transcript. Throughout the transcription process, the primary investigator sought clarification by contacting participants via phone and documented during fieldwork when significant or confusing information arose. The English versions of the transcripts were imported into MAXQDA 2020 software to support the coding, categorisation process, generating code book and generating code frequencies.

We identified and developed a coding frame using constructs derived from the combined theoretical frameworks used in the study. The theoretical frameworks help interpret or categorise the data, without aiming to directly test the theories from the emerging data. We allowed themes and patterns to emerge from the data itself, even if they were informed by constructs of the theoretical frameworks. For each segment of the interviews and FGDs imported into MAXQDA 2020, we used either descriptive coding (to capture clear perceptions or actual experiences) or interpretive coding (to derive meaning from the data), depending on the content of the segment. A consistent coding scheme was established to systematically analyse the data, and insights were cross-referenced to maintain clarity and coherence. Themes emerged from the categorisation of code frames developed based on the theoretical frameworks used in the study to highlight significant data. To triangulate data from FGDs and individual interviews, the study cross-checked findings for consistency and employed participant validation to confirm accuracy. We integrated the two data sources as part of a single, cohesive data set, contributing collectively to the understanding of each theme as guided by the theoretical frameworks used for the study.

Two community mental health experts, each holding an MSc in community psychiatry in community psychiatry, were briefed on the theoretical frameworks used in the study. They were invited to review a sample of codes related to emerging themes to validate the primary investigator’s categorisation and theming process. Member checking was by inviting selected participants to review summaries of merged findings of FGDs and IDIs to ensure that data accurately reflected the realities faced by health workers to enhance the trustworthiness of the findings. We described the sociodemographic characteristics of our participants using absolute numbers and illustrated the relationships among themes with causal diagrams. Finally, we presented our findings under each theme and supported these with direct quotes from participants relevant. We reported our findings according to the standards for reporting qualitative research (SRQR)29 (online supplemental material 3).

Public and patient involvement statement

Study participants were involved in the conducting (ie, filed work and findings validation) stage of the research process. As described in the analysis subsection, they were invited to review the preliminary findings from the interviews and FGDs. Matrons from the selected hospitals participated in the selection of study participants to ensure that those with richer information and greater exposure to work-related psychosocial factors were included. However, the study did not include a formal planning process that involved close collaboration with study participants or direct assessments of research needs before conducting the study.

Ethical statements

The participants were informed of voluntary participation and were given the option to withdraw at any stage of our discussion and interview and the right not to respond to any questions they did not want to respond to. Pseudonyms were assigned to both the FGD and IDI participants to ensure their confidentiality. Accordingly, the FGD participants were given pseudonyms as ‘P1, P2, P3…’ and in-depth interviewees were given ‘IDI1, IDI2, IDI3…’. We used these pseudo-names for each in-depth interviewee and discussant for use in the transcripts throughout the coding and analysis process in MAXQDA 2020. Any identifying information such as the participant’s working unit, managerial positions and name of the specific hospital background associated with the reported findings was not reported to maintain confidentiality. Written informed consent was obtained from the participants. To maintain data confidentiality, audio files and transcripts were stored on a password-protected computer only accessible to the researchers.

We used age ranges rather than exact ages for quotes in the results section that contained direct participant quotes to ensure sufficient anonymity. We used age ranges from ‘25 to 30’, ‘31 to 35’, ‘36 to 40’, ‘41 to 45’, ‘46 to 50’ and ‘51 to 55’ when referring to ages based on the age ranges of our participants. We also used a maximum of two indirect identifiers, age range and sex in our questions to keep anonymity. Following the Ethical Review Board’s recommendations, participants were reimbursed for expenses like communication and transportation after the discussions or interviews.

ResultsParticipants’ sociodemographic characteristics

A total of 34 health workers participated in the study which included three FGDs and 10 IDIs. The FGD involved 24 health workers from different healthcare cadres, while 10 health workers participated in the IDIs. The age of the focus group participants ranged from 28 to 55 years, with a mean age of 32 years, while the interviewees ranged in age from 30 to 41 years, with an average age of 35. Most participants were male. Of the professional categories, nurses of all categories, midwives, pharmacy, community psychiatry, public health officers, medical laboratory, emergency surgery and radiology participated in the interview and FGD. Among these, nurses of all categories followed by midwives composed the study participants. Table 1 presents the sociodemographic characteristics of study participants (table 1).

Table 1

Sociodemographic characteristics of the study participants, Central and Southern Ethiopia, February 2023 (n=34)

Emerged themes

Four theoretical framework-informed themes emerged from the coding and categorising segments of the data: ‘conceptualization of CMSs’, ‘experience of work-related stressors’, ‘perceived impact of work-related stressors on PQoL’, ‘experience of coping strategies’ and ‘barriers to seeking care and lack of interventions’. The relationships of the themes and subthemes with the number of segments coded for perceived and actual reflection by health workers are displayed in figure 2.

Figure 2

Theme relationship and causal perceptions between work-related stressors and common occupational mental symptoms in Central and South Ethiopian region, February 2023.

Figure 3

Frequency of mentions of work-related stressors and outside work stressors by segments with code of the study participants, Central and South Ethiopian Region, February 2023. WS, Work stressor.

Figure 3 also presents the frequency of mention of all work-related stressors. Limited managerial and social support, shortages of medical supplies and equipment, inadequate WASH (water, sanitation and hygiene) in the care areas, higher perceived effort-reward imbalance and work-family conflict were the top five most frequently mentioned stressors by health workers.

Theme 1: conceptualisation of CMSs

This theme explores how health workers conceptualise occupational stress, occupational anxiety and occupational depression. Before exploring the meanings of their CMSs in work-stressor or occupational linkage, we started exploring health workers’ awareness of symptoms CMSs to the generic diagnostic criteria and proceeded to the occupational or work-ascribed perspectives. Accordingly, participants reflected their interpretations or meanings they attached to, perceived vulnerability to, subjective lived experiences of, causal beliefs of work stressors with CMSs, perceived controllability and preventability of CMSs.

Subtheme 1: conceptualisation of occupational stress

This subtheme explores how health workers define or interpret (aware of), perceived vulnerability to, subjective lived experiences of, causal beliefs of work stressors with occupational stress, perceived controllability of and prevention of occupational stress.

Awareness about symptoms of occupational stress

Following the exploration of health workers’ awareness of stress in general, participants were asked about ‘occupational stress’ symptoms based on perceived occupational stress measures described in the subheading of ‘definition of terms’ in the methods section. Accordingly, health workers exhibited varying levels of awareness regarding occupational stress symptoms.

While participants (notably those with mental health backgrounds) with a mental health background had a better understanding of occupational stress based on a theoretical framework (ie, perceived occupational stress), the majority struggled to define occupational stress or its symptoms. Of those who had a better understanding, one participant linked stress to excessive workload and described associated physical and emotional symptoms such as headaches, body aches, anger and emotional instability:

[…] I recognised that I was stressed due to my extreme workload. If judged myself too harshly for it, I found I couldn’t control the situation. In such situations, I experience physical and mental symptoms, such as headaches, body aches, emotional instability, anger, conflicts, and a decline in performance. If I cannot recover quickly and the stress persists for six months or more, I might suspect that I am suffering from chronic work-related stress. (Female, 36–40 years old)

Of those participants who were unable to mention all the symptoms with the recommended duration of occupational stress, one participant said:

I think stress, anxiety, and depression are related illnesses. To be honest, my understanding of them is based on common sense, but I don’t how to define them precisely. As a midwife, I am not very familiar with the concept of ‘occupational stress’ […]. However, I think, like any disease, it could be linked to our work environment. (Female, 25–30 years old)

Most participants normalised stress as part of their daily lives, attributing the difficulty of defining symptoms to their overlap with other mental health conditions. They also perceived that it stems from multiple unavoidable causes, including work-related causes, making it a futile exercise to dwell on it. For example, one participant reflected on a perspective commonly shared among many health workers:

I do not believe stress should be considered a disease. After all, is there a health professional who doesn’t experience ‘stress’ during the day? It is a normal part of life, especially for those of us working in healthcare. It should not be considered a disease. We shouldn’t waste our time defining it. (Male, 25–30 years old)

The latter was a view that stress has many causes and could not be prevented; thus, trying to invest time and resources would not give public health importance. For example, a participant explained the multiple-cause scenario as follows:

You know, we [health workers] cannot have complete pictures of the symptoms of these [stress, depression, and anxiety] diseases even if we study the health profession. […] I mean […] owing to the web of causes they may have. Therefore, I usually fail to think about symptoms, particularly stress, in the context of work. […](Male, 13–35 years old)

Vulnerability to occupational stress

Most participants perceived themselves as vulnerable to occupational stress, citing their subjective and actual work-related stressors and the potential impact of these stressors on their physical and mental health. One participant described his perceived vulnerability to occupational stress as follows:

Yes, despite having inadequate information to identify symptoms, I strongly believe that I may have experienced stress at various points in my life due to work. […]Because of my workload, I suffer from persistent back pain. I am also worried about how my health will be affected. Along with the stress, additional health issues may develop in the future. (Male, 36–40 years old)

The subjective experience of occupational stress

Most health workers believed they had experienced occupational stress at least once in their professional lives, though they found it difficult to consciously recognise its severity or link it directly to work-related stressors. One participant stated his experiences as follows:

I realized I was stressed, but I wasn’t fully aware of how severe it was, how long it had lasted or the exact moments that had caused it. […] I did not consult any mental health professionals. I had experienced symptoms like physical, mental, and emotional. […] However, how did I know if it was chronic stress or not? How could I identify whether my symptoms were linked to specific work-related stressors? (Male, 25–30 years old)

Causal beliefs of work stressors with occupational stress

Participants widely acknowledged that work-related stressors contribute to occupational stress, but found it challenging to define specific causal pathways due to the multifactorial nature of work stressors. One participant shared his perspective:

[…] You [referring to the interviewer] can’t fully understand the causes of stress, even with expertise in health professions like clinical psychiatry. It’s difficult to pinpoint which specific work stressors lead to particular stress symptoms. Instead, the focus should be on assessing how removing or adjusting specific types of work stressors might impact individual stress levels. (Female, 36–40 years old)

Perceived controllability and prevention of occupational stress

Most participants believed that they had little individual control over occupational stress. The majority of the participants thought that only employers had the power to avoid/reduce stressors, not at the individual level, and accepted stress as part of normal life. They attributed this to systemic factors like workload and institutional failure to implement prevention strategies. One participant, for example, reflected on his doubts about his ability to control or prevent occupational stress:

As previously discussed, the workload was the main reason for high-level stress. However, how can it be controlled or prevented? If I seek to be counselled for this issue, what steps can I take to improve the situation? Without institutional prevention strategies, the situation is unlikely to improve. […] Counselling or any behavioural change interventions could help, but changing the situations will require broader systemic change. I do not know how we could change. (Female, 41–45 years old)

Subtheme 2: conceptualisation of occupational depression

This subtheme explores how health workers define or interpret (aware of), perceived vulnerability to, subjective lived experiences of, causal beliefs of work stressors with occupational depression, perceived controllability of and prevention of occupational depression. Similar to our exploration of occupational stress, we began by examining health workers’ definitions of depression based on the cardinal symptoms outlined in the DSM-5 (online supplemental material 1). We then explore their reflections on how they connect these symptoms to work-related stressors, using the approaches of ODI.18

Awareness about symptoms of occupational depression

Many health workers had limited awareness of occupational depression symptoms. They found it difficult to identify the cardinal symptoms outlined in the DSM-5 (see online supplemental material 1) or link them to specific work-related stressors. However, most believe that work-related stressors increase the risk of depressive symptoms. In the end, few participants mentioned at least a single cardinal symptom nor believed in the link between work-related stressors and depressive symptoms. The participants also frequently mentioned low awareness of occupational depressive symptoms among their colleagues. One participant described the challenges he and his colleagues faced in defining depression as follows:

I use the term ‘depression’ like my colleagues, but I can’t mention its symptoms. I also don’t believe depression is linked to my job-related stressors. […] Instead, I think behavioural and physiological changes may cause the disease. […] I have not ever paid attention to defining such mental health diseases. When I feel something bad at work or other places, I usually go to church and pray for relief. […] (Male, 36–40 years old)

Another participant shared that he found it challenging to define depressive symptoms from a neutral perspective, without attributing them to specific work-related stressors or job-related causes.

Let alone the work-ascribed one, I can’t understand how I feel when I get depressed. […] I feel like I have always been this way. (Male, 25–30 years old)

Vulnerability to occupational depression

Most health workers frequently fear experiencing occupational depression during their careers, as the overwhelming nature of work stressors contributes significantly to their vulnerability. One participant, for example, shared worries about the risk of experiencing depressive symptoms:

[…] When I fail to meet expectations despite my extra effort at work, I start asking myself questions repeatedly. I feel as if I’ve made a mistake in choosing this career.[…] When such events keep occurring, they can lead to sadness, hopelessness, emotional exhaustion, and even physical symptoms like loss of appetite and trouble concentrating. I believe all of these are symptoms of depression […]. (Male, 51–55 years old)

Another participant added about her vulnerability, including her colleagues:

I served as a coordinator. In the past three days, I have experienced the symptoms, I mentioned earlier, especially when faced with challenges. I feel particularly vulnerable in these situations. However, I am not completely familiar with the specific criteria for diagnosing mental health issues including depression. I believe that healthcare professionals are at a higher risk than the general population. (Female, 36–40 years old)

The subjective experience of occupational depression

Most participants did not perceive themselves as experiencing depression due to work-related stressors, although many acknowledged that such stressors increase the risk of depressive symptoms. However, during interviews, participants often referred to their colleagues’ experiences rather than their own, suggesting a tendency to downplay or conceal their struggles for various reasons. For instance, one participant shared:

I haven’t been sick with this disease. But, my colleagues told me they had experienced it. […] It is seen as caused by bad spirits affecting individuals. However, our [referring to himself and his colleagues’] spiritual outlook is strong. […] The disease doesn’t affect us. (Male, 41–45 years old)

However, a few participants disclosed that they had experienced it at least once after entering their professional lives. One participant shared their experience as follows:

Yes, […] I was taking care of a mother who safely gave birth. […] When I came back the next morning, they [referring his colleagues in shift] told me that she had passed away. I became sad and depressed. My sleep has been disturbed for days. […] I was not happy to talk to my family, including my husband. I was blaming myself. […] I hated every activity I enjoyed before. I lost my appetite. These feelings last for a week. […] (Female, 31–35 years old)

Causal beliefs of work stressors with occupational depression

Many health workers perceived that work stressors contribute to causing depressive symptoms. However, a significant number of them highlighted the challenges in identifying the specific symptoms associated with distinct types of work stressors, citing the complexity and multifaceted nature of these stressors. Conversely, only a few health workers believed that workplace stressors do not play a role in causing depressive symptoms. The following quote illustrates how one participant acknowledged that work-related stressors elevate the risk of depressive symptoms, while also emphasising the importance of distinguishing between the terms ‘cause’ and ‘risk factors’.

There may be several causes and factors that contribute to depressive symptoms. However, we do not call them causes of depression, but they can be a risk factor. (Female, 36–40 years old)

Another participant also shared his beliefs as follows:

I believe there’s a strong connection between workload and mental health. I know that some nurses and doctors are under psychiatric care, although I’m not sure what the specific risk factors are in those cases. Work-related stressors can worsen mental health conditions, including depression.[…] Honestly, I find it challenging to clearly explain the pathophysiological mechanisms that link work stressors to specific symptoms of depression.(Male, 36–40 years old)

Perceived controllability and prevention of occupational depression

Many health workers were afraid of the inability to control or prevent work factors for depression. One of the participants from the psychiatry profession mentioned her fear as follows:

[…] I don’t think that because they [her colleagues or other health workers] hadn’t these [mental illness] issues. They may be afraid of coming to this room [psychiatry room]. […] They often do not consider […] depression and […] as illnesses. […] If you explore closely, intellectuals, including health professionals, perceive mental illnesses as evil spirits. (Female, 36–40 years old)

Subtheme 3: conceptualisation of occupational or job anxietyAwareness of job anxiety symptoms

Most health workers, apart from mentioning ‘excessive worrying’, were unable to list the cardinal symptoms of general anxiety as per our operational definition.24 Additionally, they were not able to link any specific symptoms with the work-related stressors discussed during the interviews. Participants cited various reasons for this challenge, such as the broad range of symptoms, overlapping symptoms with symptoms of other mental health illnesses and the lack of specific guidelines to identify job anxiety within their hospital. One participant described how he was struggling to identify the symptoms of anxiety:

I couldn’t recall the specific symptoms of anxiety. To me, it seems more complicated than depression. Also, I’m a bit confused about the symptoms compared to stress. They feel similar, but maybe stress is a bit less severe than anxiety. I think anxiety is like ‘worrying about nothing and over a fear of something. (Male, 36–40 years old)

Many participants believed their work-related stressors could increase the risk of developing anxiety, even though many of them were unable to mention its cardinal symptoms. One participant shared his live experience:

I think. I’m thinking about my work. I feel like I have always been this way. […] I mean, the feeling of […] anxiety […] symptoms. […] I am restless even right now. […] It happens when my workload is always beyond my control. […] And yeah, I am not always happy with my performance; I feel tense about it. […] (Male, 25–30 years old)

Vulnerability to occupational anxiety

Although most participants struggled to identify the specific symptoms of anxiety, they generally believed they could experience anxiety and perceived that the disease could affect them similarly to other mental health issues. One participant shared his fear as follows:

Yes, we are at risk of experiencing anxiety symptoms because of our[referring to his colleagues, too] jobs. […] I always worry about what will happen if medical errors occur. Right now, I feel insecure, and it’s becoming a risky profession. […] We don’t have enough protection. […] Just recently, my friend was attacked by a patient’s relatives while working in the emergency ward. (Male, 31–35 years old)

However, few participants were able to either mention any symptoms of anxiety or believed that anxiety was linked to their job. One participant shared his thoughts as follows:

[…] I don’t also believe that anxiety, and […] are linked to my job.[…] Why would I go [to the mental health professionals] instead of going to church to pray? I am very happy with Jesus. So, I don’t believe I will be affected by any mental health disorders (Male, 36–40 years old)

The subjective experience of job anxiety

Although the majority of health workers had a high vulnerability perception to job anxiety, only a few participants believed they could experience it. One participant, for instance, reflected on his experience as follows: