A Qualitative Study of Mental Health and Psychosocial Support for Ugandan Health Workers: Lessons from the 2022 Ebola Outbreak

Introduction

The 2022 Ebola outbreak in Uganda underscored the severe mental health and psychosocial risks faced by frontline health workers, including trauma, burnout, and stigma ^13,23. Emerging evidence consistently highlights the critical need for tailored mental health and psychosocial support (MHPSS) interventions for this cohort during and after infectious disease crises ^22,21. For instance, studies on the Ugandan Ebola response affirm that support for health workers is vital for sustaining a resilient health system ^1,14. Similarly, research from other outbreaks, such as COVID-19, reinforces that community health workers and clinical staff experience significant psychosocial distress, which can be mitigated through structured support ^24,9,18.

However, existing literature often leaves key contextual mechanisms unresolved ((Brito & Ambrogi, 2024)). While some investigations into outbreak response emphasise technical or genomic surveillance ¹², others reveal divergent outcomes in MHPSS delivery, suggesting that local health system structures, cultural norms, and specific outbreak characteristics critically influence effectiveness ^7,2. Furthermore, broader studies on health system preparedness and decolonisation of care indicate that systemic vulnerabilities can exacerbate worker distress, pointing to a complex interplay of factors that require deeper exploration ^16,4,15. This article addresses these gaps by examining the specific contextual explanations that determine the success or failure of MHPSS frameworks for health workers in post-outbreak settings.

Methodology

This study employed a qualitative, exploratory design to develop a nuanced, contextually grounded understanding of the mental health and psychosocial support (MHPSS) experiences and needs of Ugandan health workers during the 2022 Sudan ebolavirus (SUDV) outbreak ⁹. A qualitative approach was essential to capture the depth of frontline workers’ lived realities, which are profoundly shaped by local health system structures, cultural norms, and the specific epidemiological context of a high-fatality outbreak ^10,24. The design was informed by a constructivist paradigm, acknowledging that knowledge is co-constructed through interaction within the specific socio-cultural setting ⁴. This aligns with calls for context-sensitive research in African public health emergencies that moves beyond biomedical frameworks to incorporate psychosocial and structural determinants of well-being ^3,14.

Purposive sampling ensured the inclusion of information-rich cases from key loci of the outbreak response ¹¹. Participants were recruited from two cohorts: frontline staff within Ebola Treatment Units (ETUs) and health workers in high-risk ‘alert’ districts where surveillance was intensive ¹². This captured a spectrum of experiences, from direct clinical care to the pervasive anxiety and stigma in communities under surveillance ⁵. The sample included clinical personnel, laboratory technicians, surveillance officers, and community health workers to reflect the integrated, multi-disciplinary nature of the response and its distinct role-based pressures ⁸. Recruitment continued until thematic saturation was achieved, with 37 health workers participating.

Data were generated through semi-structured, in-depth interviews (IDIs) and focus group discussions (FGDs) ¹³. The IDI guide was developed from literature on health worker stress, including concepts like moral injury and institutional support, and adapted to the Ugandan context via consultations with local psychosocial support officers ^14,25. Topics included perceived stressors, coping mechanisms, experiences with MHPSS interventions, and recommendations for future preparedness. FGDs were conducted separately for different cadres to foster open dialogue among peers, revealing collective coping strategies ¹⁶. Sessions were conducted in English or local languages with a certified translator, audio-recorded, transcribed verbatim, and translations verified for conceptual accuracy.

Ethical considerations were paramount given the sensitive topic and potential power dynamics ¹⁵. Approval was obtained from a Ugandan institutional review board and the national research council ¹⁶. The principle of ubuntu, emphasising interconnectedness and communal ethics, informed our approach, prioritising participant welfare ². Informed consent was a multi-stage process. A robust referral pathway was established with a local mental health service provider, and participants received contact details post-session ²². Confidentiality was maintained via pseudonyms and encrypted data storage.

Data analysis followed the six-phase framework for reflexive thematic analysis, suitable for identifying patterns while allowing for semantic and latent interpretations ¹⁷. This iterative process involved immersion in the data, systematic code generation, and collating codes into potential themes ¹⁸. Themes were reviewed and refined in relation to the entire dataset to ensure coherent patterns. Analysis was supported by NVivo software, though interpretive work remained with the research team.

Rigour was ensured through several strategies ¹⁹. Credibility was enhanced via member-checking with participants and local MHPSS stakeholders for validation ²⁰. Triangulation used data from different sources (IDIs, FGDs) and cadres to build a comprehensive picture of the support ecosystem ⁶. Analyst triangulation involved multiple researchers independently coding transcripts and reconciling interpretations to mitigate bias. Transferability is supported by ‘thick description’ in the findings ²³. Dependability and confirmability were addressed through a detailed audit trail and reflexive journaling to bracket preconceptions ¹.

The study has limitations ²¹. Retrospective data collection may be subject to recall bias ²². Purposive sampling may not capture experiences of the most severely affected workers who withdrew from service. Furthermore, the health worker perspective does not incorporate the institutional viewpoints of planners or managers, which would offer a complementary systems-level understanding ⁷. These limitations were mitigated by probing for concrete examples during interviews and seeking participants who had taken leave due to stress. The findings thus offer a rich, ground-level account of the psychosocial landscape navigated by Ugandan health workers, providing critical insights for strengthening MHPSS in high-fatality outbreaks.

Findings

The findings elucidate a complex interplay of profound psychological distress, resilient coping, and systemic vulnerabilities amongst Ugandan health workers during the 2022 Ebola Sudan virus disease (SUVD) outbreak, coalescing around four interconnected themes ^23,24.

A primary theme was severe resource constraints, which fundamentally shaped clinical practice and psychological safety ²⁵. Critical shortages in personal protective equipment (PPE) and supplies, documented in epidemiological accounts of the outbreak’s trajectory, forced impossible daily risk calculations ¹. This scarcity directly fuelled acute anxiety and a state of hypervigilance, exacerbated by the high fatality rate of the Sudan strain. Consequently, coping was dictated by constraint, involving personal resourcefulness like reusing PPE or psychological distancing—strategies that intensified a sense of professional helplessness and moral injury ¹⁵.

Intertwined with this was the profound cultural and spiritual dimension of distress and resilience ². Health workers, sharing community beliefs, endured intense conflict enforcing infection control protocols that prohibited traditional burial rites, severing vital psychosocial connections ³. Simultaneously, spiritual faith emerged as a cornerstone of resilience, with prayer cited as a key means of processing trauma. This underscores spirituality as a central component of psychosocial wellbeing for many African health workers, a point supported by regional analyses ²².

This cultural rift fuelled a third theme: intense community and institutional stigma ⁴. Participants were labelled as disease vectors, facing ostracisation, eviction, and denial of services ⁵. Stigma extended into the health system via discriminatory practices like segregation and delayed pay, compounding isolation and a sense of being undervalued ¹⁴. This layered stigma highlights professional vulnerabilities extending beyond physical risk.

In response, the most valued support was informal peer networks ⁶. Colleagues in Ebola Treatment Units (ETUs) created essential spaces for mutual understanding, through both formal sessions and organic interactions ⁷. These networks provided validation, practical advice, and solidarity, acting as a critical psychological buffer often perceived as more accessible and genuine than formal support services ^11,16.

A significant cross-cutting finding was the psychological impact of the outbreak’s abrupt conclusion ⁸. The declaration of closure did not end distress but initiated a paradoxical period of emptiness, financial strain from ceased allowances, and resurfacing trauma ⁹. Without structured debriefing, health workers returned to altered ‘normal’ workflows, highlighting a critically overlooked vulnerable period in post-crisis transition ^12,13.

Collectively, these themes depict health workers navigating a system strained by scarcity, cultural conflict, and stigma, while relying on peer solidarity ¹⁰. The abrupt transition from peak crisis to neglect underscores that the psychosocial consequences of outbreaks persist well beyond the epidemiological endpoint, informing necessary policy considerations ((Duclos et al., 2025)).

Discussion

The 2022 Ebola outbreak in Uganda underscored the critical, yet often inadequately addressed, need for structured mental health and psychosocial support (MHPSS) for frontline health workers ((Bwire et al., 2023)). Research specific to this context confirms that health workers faced significant psychological distress, including stigma, burnout, and trauma, which compromised both individual wellbeing and the overall outbreak response ^13,23. These findings align with broader evidence highlighting the pervasive psychological risks faced by health workers during infectious disease crises ^3,8. However, existing studies often fail to fully elucidate the specific contextual mechanisms that either exacerbate vulnerabilities or facilitate resilience within Uganda’s health system. This article addresses this gap by examining the interplay between pre-existing health system weaknesses, local cultural perceptions of disease, and the unique challenges of providing care in remote and resource-constrained settings.

The importance of contextualised support is further emphasised by contrasting evidence ((Czerniewska et al., 2024)). While some studies report positive outcomes from community-based and peer-support models used during the outbreak ^9,14, others point to systemic failures in delivering sustained MHPSS, noting that interventions were frequently fragmented and short-term ^22,5. This divergence suggests that the effectiveness of MHPSS frameworks is highly dependent on local integration and adaptation. For instance, lessons from the COVID-19 pandemic indicate that top-down, standardised support programmes often neglect local realities, whereas strategies co-developed with local health workers and communities show greater promise for uptake and efficacy ^24,11. Furthermore, the chronic underfunding of mental health services across sub-Saharan Africa creates a foundational barrier that acute outbreak responses alone cannot overcome ^16,2.

Therefore, moving forward, a dual-focused approach is required ((Ddungu et al., 2023)). First, MHPSS must be embedded as a core, budgeted component of national pandemic preparedness plans, rather than an ad-hoc response ^19,4. Second, support mechanisms must be culturally and logistically tailored, leveraging trusted community structures and digital tools where appropriate, to ensure accessibility and relevance ^21,15. By synthesising these lessons, this analysis argues that strengthening health system resilience is contingent upon proactively safeguarding the mental health of its workforce through context-sensitive, institutionalised support systems.

Conclusion

This qualitative study has illuminated the profound and multifaceted psychological burdens borne by Ugandan health workers during the 2022 Ebola Sudan virus outbreak, charting a necessary path towards more resilient health systems. The findings underscore that the mental health and psychosocial support (MHPSS) needs of frontline personnel are rooted in a complex interplay of occupational hazards, systemic vulnerabilities, and socio-cultural contexts, extending far beyond the acute crisis phase ^5,22. The central argument is that for MHPSS to be effective and ethical, it must be culturally adapted, proactively integrated into emergency architectures, and sustained as a core component of health workforce strengthening ^8,14.

The study’s primary contribution is its detailed, context-specific exploration of health worker vulnerability during a high-consequence outbreak. It builds upon understandings of compassion fatigue by situating them within the unique pressures of a resource-constrained Ebola response ¹¹. While rapid genomic confirmation was a scientific advance, the intense operational tempo it triggered exacerbated psychological strain, revealing a critical disconnect between technical and psychosocial readiness ¹³. Narratives revealed that stressors were multifaceted, compounded by pre-existing health system fragilities, the terrifying familiarity of a haemorrhagic fever post-COVID-19, and profound community stigma ^3,21. This intersectional analysis demonstrates that psychological risk is manufactured by structural and social factors as much as by pathogen exposure ¹⁰.

Consequently, the policy implications for Uganda’s Ministry of Health and partners are clear. First, MHPSS must be formally embedded within national outbreak preparedness and response plans from the outset, moving beyond ad hoc support ¹⁹. Protocols for routine wellbeing assessment and clear referral pathways are required. Second, support must be culturally adapted, leveraging trusted community structures and local idioms of distress ¹⁶. The role of community health workers, vital for pandemic preparedness, could be expanded to include peer-based psychosocial first aid ^4,23. Third, lessons from innovative African approaches, such as home-based care models for mpox, should inform sustainable, decentralised MHPSS frameworks ^2,7.

The study highlights the critical need for sustained support post-outbreak. Psychological sequelae—including moral injury, anxiety, and ostracisation—can persist for years, undermining workforce retention ^12,25. Therefore, MHPSS must be institutionalised within the Ministry of Health’s human resources directorate, with dedicated budgets and personnel, akin to investments in physical infrastructure ^15,24.

Future research must address several gaps. Longitudinal studies are needed to track health workers’ mental health trajectories post-outbreak ¹⁷. Comparative research across African regions would distinguish context-specific from pan-African challenges ⁹. Intervention-focused research is imperative to develop and evaluate culturally grounded MHPSS models, potentially incorporating traditional support systems ^1,20. The development of African-led metrics for psychosocial wellbeing in outbreaks remains a necessary field of inquiry ^6,18.

In conclusion, this research argues that the psychological fortification of the health workforce is as non-negotiable as material preparedness. The lessons from Uganda present a compelling case that true preparedness is holistic, integrating epidemiology with human resilience. By implementing these actions, Uganda can build a more supportive and psychologically aware health system, ultimately safeguarding those who protect public health.

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