Despite the growing recognition of mental health challenges among healthcare workers globally, there remains a significant gap in data from low-income countries, including Mozambique. This lack of local evidence limits the ability to understand the extent and factors behind psychological distress among healthcare workers, particularly those working in high-risk settings such as communicable disease services.

This study addresses this gap by focusing on the mental health of healthcare workers in Mozambique who provide services related to communicable diseases, a group frequently exposed to psychological stress due to their work environment. By understanding the prevalence and factors associated with mental disorders in this population, the study will contribute to evidence-based strategies aimed at improving working conditions and mental healthcare for healthcare professionals in the country. Furthermore, the findings of this study have the potential to inform policies and interventions that support the mental well-being of health professionals, ensuring a healthier and more effective workforce.

This study aims to assess the levels of Stress, Anxiety and Depression among health professionals providing services related to communicable diseases in Maputo City. It also seeks to identify personal and professional factors associated with mental health disorders in this population.

Thus, we aim to answer the following research questions:

The conceptual model of this research is based on the dynamic interaction between personal and professional factors that influence the mental health of health professionals (figure 1), considering the professional factors. This model was developed by the research team based on an integration of existing theories and empirical studies on occupational mental health. It synthesises key elements from prior research, adapting them to the specific context of healthcare professionals, particularly those exposed to high emotional and biological risks. The model will serve as the foundation for constructing the questionnaire and guiding the data analysis, helping to identify and interpret the relationships between personal and professional factors and the mental health outcomes of interest.

The mental health of health professionals is influenced by a combination of inter-related factors, which can act synergistically to increase or decrease the risk of mental disorders.22 23 Among the main factors are emotional demand, exposure to biological and chemical risks and job satisfaction.7 16

Constant exposure to life-or-death situations, the need to make quick and accurate decisions and frequent contact with critically ill patients impose a significant emotional burden.4 Emotional demand refers to the psychological impact of dealing with stressful situations, such as the need to manage patients in serious or terminal conditions. This type of demand can generate emotional exhaustion, leading to increased stress levels and contributing to the occurrence of disorders such as anxiety and depression.16 23 The situation can be further aggravated by the perception contagion risk, especially in contexts of communicable diseases, where the fear of contracting diseases is constant.11 When emotional demands are not accompanied by adequate support, such as psychological support or supervision, professionals can feel overwhelmed, exacerbating the negative impact on their mental well-being.4

Exposure to biological and chemical hazards is another significant source of stress. Working in environments with a high risk of contamination, such as in epidemic situations or when treating patients with communicable diseases, increases the perception of constant danger. This perception, when prolonged, can lead to a chronic state of alertness and fear, negatively affecting psychological well-being.4 11 The interaction between emotional demands and exposure to risks can create a cycle of mental exhaustion, where the fear of contamination intensifies the emotional load and vice versa.

Job satisfaction also plays a crucial role in mental health. Feelings of professional recognition, institutional support and a safe and collaborative work environment can mitigate the negative impact of stressors, promoting a state of well-being.7 23 However, when job satisfaction is low, due to factors such as work overload, lack of resources or inadequate support, the risk of mental disorders increases significantly. Dissatisfaction may amplify perceptions of emotional demand and make exposure to risks even more burdensome, creating an environment conducive to the development of mental health deterioration.24

Thus, the interaction between these factors does not occur in isolation, but in an interdependent way, where the aggravation of one factor can enhance the effects of the others. Understanding this dynamic is essential for developing integrated interventions aimed at improving the mental health of healthcare workers by addressing the multifaceted nature of their occupational environment.16 25

None.

A quantitative observational cross-sectional design was chosen for this study as it allows for the assessment of the prevalence of mental health conditions at a specific point in time, as well as the identification of associated factors.26 Moreover, this type of study is recognised for its cost-effectiveness in addressing the research objectives and is well suited for explaining associations among the variables being analysed.

The study will be conducted in the PHUs located within Maputo City, the capital of Mozambique. Maputo City is the economic centre of the country, with a total population of 1 127 565 inhabitants, served by 7866 health professionals spread over 38 HUs, 31 of which are primary-level.27 These PHUs serve as the primary point of care for the city’s population and play a crucial role in the delivery of essential health services.28

In Mozambique, PHUs are classified as Urban and Rural. Urban Health Centres (UHC) are located in urban areas and, in principle, Rural Health Centres (RHC) are located in rural areas.28 In turn, RHC are of two types (I and II) according to the degree of technical complexity of their physical infrastructure and their organisation and equipment according to their staffing and the population to be served in their Area of direct influence.28 The UHCs are of three types (A, B and C), depending on the population to be served within a radius of 1–4 km.28

The choice of the PHUs in Maputo City as the study site is justified by their strategic importance in the National Health System (NHS). Maputo, as the capital and economic centre of Mozambique, concentrates a high population diversity and has a coexistence of communicable and non-communicable diseases, characteristics similar to those of other regions of the country. PHUs play an essential role as a gateway to the NHS, offering promotion, prevention and curative care services to the population. In addition, the concentration of health professionals and the existing infrastructure ensure the logistical and operational feasibility of the research, contributing to the efficient collection of data relevant to the objective of the study.

The study is expected to take place in 7 months, starting in October 2024. Of this period, 3 months (October to December) will be dedicated to the submission and approval of the Protocol by the Bioethics Committee, 2 months to data collection (January and February), including preparation for fieldwork, and the remaining 2 months (March and April) will be dedicated to data analysis, preparation of the study report and dissemination of results.

The study population of this research is the health professionals providing services related to communicable diseases in the primary-level HUs in Maputo City.

The sample size was manually calculated using a sample size formula for proportions of infinite population29 as described in figure 2, considering a 5% margin of error (e), a 95% confidence level, and an estimated prevalence of mental health disorders (p) of 54% (based on a similar study by Kakemam et al). This calculation resulted in a required sample size of 382 participants.

A stratified sampling approach will be employed, stratifying the PHUs by type (UHC A, B, C and RH C 1 and 2). Within each stratum, a convenience sampling technique will be used to recruit participants who meet the inclusion criteria and are available for inquiring (see table 1).

Data will be collected through a structured questionnaire written in Portuguese. All target group members are fluent in Portuguese, the official language of the country, and therefore no translation of the instruments is expected. The questionnaire is structured into two main sections, as detailed in table 2: sociodemographic and occupational information, and the mental health assessment using the Portuguese version of the Depression, Anxiety and Stress Scale (DASS-21):

1. The second section will be related to the screening of signs and symptoms of mental disorders: it will focus on the assessment of self-reported symptoms of mental disorders, using the Portuguese-validated version of the DASS-21.30 This scale consists of 21 statements in which the participant must indicate the degree to which each statement applies to him/her, considering the last week before the assessment. The sum of the score attributed by the participant to each statement will be used to calculate the final score for each domain (Depression, Anxiety and Stress), which will allow classification into different severity levels of psychological distress, but does not constitute a clinical diagnosis.

Participants will be approached by the data collectors during the operation of the HU. Before starting data collection, each participant will be informed about the objectives of the study, the nature of their participation, the potential risks and benefits, and the confidentiality of the data.

Data collectors will be hired for data collection. These professionals must have previous experience in the health area, understood as practical experience in HUs or participation in similar studies. The data collectors will be responsible for recruiting participants and applying the data collection tools, which are estimated to last a maximum of 30 min. They will administer the questionnaire in person through face-to-face interaction, reading each question aloud to the participant and directly entering their responses onto a tablet using the Research Electronic Data Capture (REDCap), checking for completeness of responses before saving the questionnaire. This technique was chosen due to its potential to increase the response rate, clarify any doubts participants might have in real-time and guarantee the accurate completion of the instrument, especially considering the variability in familiarity with self-administered digital questionnaires. The training of the data collectors will be conducted by members of the research team with experience in data collection methodologies and mental health. The training will last 8 hours, divided into 2 days, to ensure adequate preparation. During the training, data collectors will be introduced to the research project, including details about the sample and sampling, the objectives of the study and the variables to be investigated. Detailed guidance on data collection tools and instructions on how to complete the questionnaire will be provided. In addition, there will be a hands-on session to simulate data collection, allowing the data collectors to familiarise themselves with the process.

The Principal Investigator will review all completed questionnaires to assess the quality and completeness of the data. If there are gaps or errors, the data collectors will be asked to correct or complete the questionnaires, where possible. The data will then be exported to MS Excel for cleaning and then to IBM SPSS V.25.0 data analysis software for further analysis.

The database will be inspected to identify and correct input errors. Duplicate data will be removed, and inconsistencies will be checked and corrected. Missing data will be treated according to the nature and extent of the missing data, choosing to remove the records containing the missing values or replace the missing values with a fixed value, such as zero or the mean of the variable in question.

Descriptive analysis will include calculating measures of central tendency and dispersion to describe the participants’ sociodemographic and occupational characteristics. Proportions and frequencies will be used to describe the prevalence of symptoms of mental disorders among health professionals.

The analytical component of the quantitative data will be based on simple and multiple logistic regression analysis, to estimate the effect of different factors on the occurrence of symptoms of mental disorders.

Comparisons of groups of patients with different diagnoses based on quantitative variables (eg, age) will be made based on Student’s t-tests or analysis of variance, depending on the number of subgroups to be compared.

By convention, a margin of error of 5% will be considered and 95% s will be calculated to estimate the significance of all measures and tests used in this study.

This study is a research protocol and does not use any secondary or publicly available data sets. All data to be analysed will be collected prospectively by the research team during the implementation phase of the study. No external data sources were used in the development of this protocol.

The study acknowledges the potential for biases that could influence the results. First, the use of convenience sampling introduces a risk of selection bias, as the participants included in the sample may not be representative of the broader target population. However, the study’s primary aim is not to make generalisable inferences but rather to explore specific associations and patterns within the sampled group.

Second, data on mental health status will be collected through self-reported questionnaires. This method is prone to response bias, as participants may overestimate or underestimate their symptoms due to factors such as social stigma or fear of professional repercussions. To mitigate this, the study will employ validated measurement scales and guarantee participant anonymity to reduce the influence of stigma on reporting.

Third, recall bias may occur if participants are required to report on past experiences or symptoms, as memory inaccuracies could affect the reliability of their responses. To address this, the questionnaire will focus on current or recent experiences to minimise recall errors.

While every effort will be made to minimise these biases, it is important to acknowledge their potential influence on the study findings and interpret results accordingly. Furthermore, to ensure research rigour, we will employ a validated instrument (the Portuguese version of the DASS-21), standardised data collection procedures and training of data collectors to maintain consistency. Validity will be supported through the use of a previously validated scale, and reliability will be enhanced by preprogramming logic checks into REDCap to minimise data entry errors and ensure uniform administration across participants

The protocol of this study has been approved by the Institutional Committee on Bioethics in Health of the Faculty of Medicine/Maputo Central Hospital (CIBS FM&HCM), following the reference number CIBSFM&HCM/117/2024. Administrative authorisation will also be obtained from the Ministry of Health (MoH) to ensure compliance with institutional and governmental regulations. The research team will present the administrative approval document, the Ethics Committee approval letter and the participant information sheet to each HU, and specific authorisation will be requested from the administrative body (HU Director/Clinical Director) of each facility prior to data collection.

All participants will be informed about the voluntary nature of participation in this study, emphasising their right to withdraw their participation or request the removal of their data at any stage without any repercussions to their work or employment status. Written informed consent will be obtained from participants immediately before administering the questionnaire.

Given the nature of the study, no substantial risks are anticipated. However, participants may experience some discomfort while discussing sensitive topics such as mental health. To minimise this risk, the study will prioritise confidentiality through strict data protection measures. Participants who experience significant discomfort or crises, such as anxiety episodes, will be promptly referred to mental health services within the health network for appropriate support and follow-up. Additionally, participants will be asked if they would like to know the results of their mental health screening. Those expressing interest will be informed after completing section 2 of the questionnaire. Participants with normal or mild conditions will receive educational handouts with mental health care tips, while those diagnosed with moderate to extremely severe conditions will also be provided with a referral guide to the health referral system alongside mental healthcare tips.

To ensure anonymity and protect participant privacy, no identifying personal information will be collected and each questionnaire will be assigned a unique numeric code. Anonymisation of data, use of secure mobile devices and computers protected by individual passwords and administration of questionnaires in private settings will ensure participant privacy and data security. All data collectors and investigators will sign confidentiality agreements, ensuring that the data collected are exclusively used for the study’s scientific objectives and advocacy efforts to strengthen health sector protections.

Participants will not receive direct monetary or material benefits from their participation in this study. However, indirect benefits are expected through the study’s contributions to raising awareness and improving mental health care and support for healthcare workers in the country.

Dissemination of the study findings will begin with the presentation of a Master’s thesis. Subsequent dissemination will occur through submission to peer-reviewed journals, presentations at national conferences and journal clubs targeting stakeholders in health policy and practice, and via reports shared with the MoH to inform strategies for protecting the mental health of healthcare workers.

Not applicable.