Study settings and period

We conducted this study among health workers at eight public health facilities in the Central Ethiopia Region and One Southern Ethiopia Region from 15^th January to 28th February 2023. The first in-depth interviewees were recruited on Sunday 15th January 2023, and the first FGD discussants were recruited on 17 January 2023. The last in-depth interviewee was recruited on 27 Monday, and the last FGD discussant was recruited on Tuesday 28 February 2023.

This qualitative study was conducted in randomly selected healthcare facilities (primary hospitals, general hospitals, and tertiary hospitals) for the quantitative study of a larger PhD project having both quantitative and qualitative objectives to address research questions, from different perspectives, and ultimately integrate the findings. Therefore, this study is one of the five PhD project studies on the same target population of the study setting. Among the other work-related stressors explored, WASH-related stressors and their link with common mental symptoms among healthcare workers are addressed within this study. The healthcare facilities selected for the study, the total estimated population, the population characteristics, and other study settings are described elsewhere [24].

Despite no information for the study area regarding related stressors, it is believed that the challenge would not differ from what we could observe in the context of low-income countries [6]. For example, the studies from the capital city of the country found that 100% had limited sanitation access, 88.4% had limited and 3.5% had no access to hand hygiene services, 97.7% lacked environmental cleaning services, and 29% lacked waste management services [7].

Study design

We used interpretative phenomenological and descriptive qualitative design guided by theoretical frameworks. As explained in the introduction section of this work, the theoretical frameworks to guide explanations for the link between WASH components as stressors and common mental health symptoms, and professional quality of life were the TMS [4] and the JDR models [5]. To discuss the work-ascribed forms of common mental symptoms, we first explored how participants conceptualize common mental symptoms (stress, anxiety, or depressive symptoms using another theoretical framework, self-identification as having common mental health symptoms (SICMS) [12] before trying to explore their link with WASH related stressors. This was believed to help the participants interpret the symptoms, and how those symptoms may be linked to the current stressors of interest (WASH as work stressors). Although they are health professionals, this step was considered because participants may not have had adequate information about how those symptoms of mental health disorders were conceptualized and our discussion smoothly addressed the main objective of the study. Secondly, participants’ or colleagues’ experiences of stressors including inadequate WASH were also discussed during our interview and discussions. Thirdly, participants’ understanding of how each component of WASH (as stressors or risks or perceived causes) and common mental symptoms (outcomes) are linked was explored with their interpretation or meanings assigned to the stressor and perceived symptoms.

Study participants and sampling strategy

Participants were selected from various units of the selected hospitals using a purposive sampling procedure. The initial stage involved the identification of departments or pinpoints in the health facilities (HFs) selected for PhD study with peer guides from the hospital’s matrons and medical directors.

We purposely selected healthcare workers who were working in three strata(primary hospitals, general hospitals, and specialized or teaching hospitals) of healthcare facilities—from different professional categories. Participants of in-depth interviews were purposely selected if they had 2 or more years of work experience, engaged in clinical or paramedic activities, held managerial positions such as directors or unit heads or managers or coordinators, or held ward heads or pinpoints from health workers at different health facilities. These in-depth interview participants were selected assuming that they have more understanding and experience with workplace mental well-being approaches and policy and readiness to provide occupational mental well-being services and resilience strategies at work. Ten healthcare workers for the in-depth interview to obtain rich information about the inadequacy of WASH-related stressors and their perceived link with common mental health symptoms.

Similarly, focus group discussants were purposely selected based on the representativeness of healthcare cadres such as physicians, nurses, midwives, laboratory technologists, pharmacists, and other paramedical health workers, to collect information on how health workers conceptualize occupational stress, occupational depression, occupational anxiety, and subjective exposure to WASH related stressors, and other work-related stressors in each cadre. We conducted 3 focus group discussions with eight study participants involved in each focus group discussion assuming that all health workers share a common understanding of stressors and related mental feelings despite having different speciality groups and different magnitudes and severities of stressors until we found repeated information.

Data collection procedures

Interviewer guides for in-depth interviews (IDIs) and focus group discussions (FGDs) were developed and translated into the Amharic language. We trained two research assistants who had experience in assisting qualitative research with expertise in the health profession: one with an MSc degree in community psychiatry and another with an MPH in epidemiology to moderate focus group discussions. Two research assistants for taking notes and recording audio of the focus group discussion were recruited. Research assistants and one of the investigators of the study conducted in-depth interviews.

Moderators, under the guidance of the matrons and medical directors of the selected hospitals, recruited FGD and IDI participants based on the selection criteria. Moderators explained the purpose of the study, the selection process of respondents, the norms followed during the discussion, assured confidentiality, agreed, assigned participants, obtained written informed consent, and checked the audio recorder. Field notes, summary notes, and expanded scribbles of IDIs and FGDs were prepared and submitted daily by moderators and audio recorders, respectively. The recorded audio and background of the participants were submitted to the researcher at the end of each interview.

During the in-depth interviews and focus group discussions, all participants were invited to reflect on the symptoms of stress, depression, and anxiety. After exploring the perceived and actual definitions and symptoms of these common mental health symptoms, participants were also invited to explain how each symptom was associated with “occupational factors or stressors” to label them as “occupational stress”, “occupational depression”, and “job anxiety”. Once participants discussed those symptoms, they were invited to list possible work-related stressors including WASH-related stressors, and requested to perceptually link with at least one symptom of each common mental health symptom. Upon immediately mentioning specific work-related stressor(s) including the extent of inadequate WASH at the points of care, we proceeded to explore the perceptions of healthcare workers on how WASH-related components as a stressor(s) possibly cause at least one symptom of specific common mental health symptoms to themselves or their colleagues. Similarly, study participants were also invited to link WASH-related components as a stressors with components of professional quality of life (PQoL) by explaining to them the components of PQoL as burnout, compassion fatigue, and compassion satisfaction throughout the discussions and interviews.

Operational definitions

‘Inadequate WASH’ for this study applies if participants listed limitations or inaccessibility or unavailability of at least one basic WASH services at the points of care areas according to the WHO’s and UNICEF’s standards for [6]. These include water for cleaning and keeping hygiene; functional hand hygiene facilities (water, soap, alcohol-based hand rub, sanitizers, etc.) within 5 meters of toilets at points of care areas; environmental cleaning services (availability of cleaning protocols with trained staff and required supplies); and waste management services (waste segregation into at least 3 bins, safe disposal of sharps and infectious wastes) at the points of care areas (a place where health workers, patients, diagnosis and treatment, and visitors are located). The study participants’ accounts of their subjective experiences with WASH and related stressors at work were also considered in our study despite having difficulties in a clear understanding of the basic WASH standards at points of care.

Common mental symptoms (CMSs) are health workers’ subjective feelings or reflections of colleagues’ experience of mental and somatic symptoms related to the 3 common mental health issues hereafter termed ‘occupational stress’, ‘occupational depression’, and ‘occupational anxiety or job anxiety’ at work:

1. Occupational stress was defined as the ability of health workers to mention various somatic and mental symptoms for chronic or an extended duration (6 months or more participants’ perceived chronicity of the symptoms if difficulty in the duration of recall faced during our discussion or interview), and perceived inability to control work-related stressors (feeling of high workload or high job demand and low control (low resources)) according to the perceived occupational stress symptoms [16]. Accordingly, those health workers reflecting the perceived symptoms of all the new perceived occupational stress symptoms and able to provide the link between work stressors [16] with the duration and frequency of occurrence were coded as having “better comprehension of the meaning of occupational stress”. Whereas health workers who mentioned “high job demand versus low resources or low control or low social support (in their own wordings understanding)” irrespective of other symptoms were coded as having “low understanding of symptoms” of occupational stress.
2. Occupational depression or work-ascribed depression refers to health workers’ ability to mention cardinal symptoms of depression based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (S1 File) for 2 or more weeks. Participants’ perceptions of the symptoms were also considered if they couldn’t recall specific symptoms with duration. The ability to perceptually link at least one symptom of depression with any WASH-related stressors they mentioned was considered to assume occupationally linked depressive symptoms as defined in the new occupational depression definitions [15].
   Accordingly, those health workers who were able to mention five or more symptoms out of nine cardinal symptoms of depression and were able to link them with any work-related stressors were coded as having “awareness about symptoms of occupational depression”. Those health workers who had mentioned fewer than five symptoms but were able to link them with any work-related stressors were coded as having “low awareness about symptoms of occupational depression”. Those health workers who were able to list five or more cardinal symptoms of depression but who perceived that symptoms could not be completely linked to work-related stressors were coded as “did not believe depression is not linked with work-related stressors”. Health workers who were not able to mention at least one cardinal symptom were coded as “has no awareness about occupational depression”.
3. Job anxiety or occupational anxiety for this study refers to health workers’ ability to mention cardinal symptoms of generalized anxiety based on DSM-5 (S1 File) as a result of exposure to any work-related stressors including WASH-related stressors. Then, health workers were classified as “aware of occupational anxiety or job anxiety” if they could perceive the link between each symptom with work-related stressors they perceived or hypothetical views. The summarization is the same as that for occupational depression.

The remaining important perceptual opinions of health workers, such as vulnerability to, subjective experiences of, and perceived causal links between work stressors, including inadequate WASH, and perceived controllability of common mental symptoms, were assessed based on theoretical constructs used to understand health workers’ self-identification as having common mental health symptoms [12].

The perceived link between inadequate WASH as stressors and CMSs for this study was explored after participants’ subjective definition of CMSs and how they reflected the link based on either how they appraise inadequate WASH as threatening and inability to cope with and continue to be afraid of infection to themselves and their patients, fear of the poor medical outcome of patients they care for and fear of reduced performance [4] based on TMS theoretical framework [4] and/or [2] exposure to inadequate WASH and perceived inability to control the demand due to resource constraints based on the JDR framework [5].

Data processing and analysis

The primary investigator transcribed, coded, and categorized all the audio recordings in the Amharic language and translated them into English. Moderators and/or note-takers and one of the investigators submitted the expanded scribbles, observations about WASH and related stressors at the points of care areas, and summary notes. Observations, scribbles, and field memos were cross-validated and merged into the corresponding transcripts. For significant information that seemed to be confusing, phone clarification was sought from the participants through contacts previously documented with the researcher during fieldwork. Then, translated transcripts were imported to MaxQDA 2020 software for coding and categorizing codes or creating themes.

Codes were developed as a coding frame from lists of constructs of the theoretical frameworks used for significant information. Both descriptive and interpretive coding were used for a single segment when necessary. Once significant information was obtained from the transcripts, themes emerged from categorizing codes containing the significant data. Two community mental health experts (MSc in community psychiatry) were briefed about the theoretical frameworks used in the study and invited to check a sample of codes to identify themes to validate the primary investigator’s categorization. After a discussion with the coder, corrections were made to some of the coding processes. We invited one member from each focus group discussion and four in-depth interviewees to check whether summaries reflected what had been discussed with participants and the realities among health workers to increase the trustworthiness of the information. Finally, we narrated findings under each theme and supported them with participants’ quotes when necessary. The findings are reported according to standards for reporting qualitative research (SRQR) [26] (S2 File).

Ethical considerations

This study was approved by the Addis Ababa University College of Health Sciences-Institutional Review Board (CHS-IRB) as a PhD study under protocol number 080/22/SPH. Participants were made aware that their participation in the conversation and interview was entirely voluntary, and they were given the freedom to leave at any moment and to choose not to reflect any ideas they felt uncomfortable with. To maintain confidentiality, the FGD participants were given pseudonyms as “P1, P2, P3…”, and in-depth interviewees were given “IDI1, IDI2, IDI3…”. We used such pseudo-naming for each in-depth interviewee and discussant on the transcript and during the MaxQDA2020 software’s coding and analysis process. The data file (audio and transcripts) was also saved on a password-protected personal computer, and only the researchers had access to them. Based on the recommendation from the Ethical Review Board, reimbursement costs for expenses such as communication and transport were covered for each participant at the end of the discussion or the interviews.

Sociodemographic characteristics of the study participants

Ten in-depth interviews and three focus groups involving thirty-four health workers were conducted. Ten and twenty-four health workers from various professional categories participated in the in-depth interviews and focus group discussions, respectively. The age of focus group discussants ranged from 28 to 55 years, with an average age of 32 years. Similarly, the age range of participants in the in-depth interview was between 30 and 41 with an average age of 35 years. Many of them were males (24 participants). The majority of participants were married (26 participants) had a Bachelor of Sciences (BSc) degree (26 participants), and had less than 10 years of working experience (23 participants), and were followers of protestant religion (20 participants) (Table 1).

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Table 1. Sociodemographic characteristics of study participants in Central Ethiopia Region, February 2023.

https://doi.org/10.1371/journal.pone.0314170.t001

Participants’ conceptualization of common occupational mental health symptoms

Before, exploring participants’ perceived causal link between inadequate WASH and common mental symptoms, we first explored participants’ awareness of, vulnerability to, subjective experiences of, and perceived causal link between inadequate WASH as work stressors and perceived controllability of common mental symptoms. The participants’ conceptualisation of common mental health symptoms was assessed using self-identification as having common mental health symptoms (SICMS) [12] frameworks.

Accordingly, many participants had low symptom recognition, high perceived vulnerability to, high subjective experience of, and high perceived causal link between inadequate WASH as work-related stressors at the points of care areas. Participants also had a low perceived ability to control and prevent occupational stress believing it as if it was a normal part of work life. Similarly, participants had low cardinal symptom identification status and high perceived vulnerability to common mental symptoms. Many healthcare workers also had a high perceived link between inadequate WASH-related stressors and depressive and anxiety symptoms, but low perceived ability to identify causal pathways, and perceived difficulty in preventing and controlling both symptoms. Furthermore, the majority of participants had low subjective experience with both occupational depression and anxiety. Key findings and sample quotes for each common mental symptom discussed are summarised in Table 2.

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Table 2. Health workers’ awareness about, vulnerability to, subjective experiences of, belief in the causal link between work stressors and CMSs, and perceived controllability of common mental symptoms.

https://doi.org/10.1371/journal.pone.0314170.t002

Despite there being some paradoxical findings between low symptom identification skills and high perceived vulnerability to common mental symptoms, health workers perceived or appraised that their work-related stressors, including inadequate WASH, went beyond their control capacities, leading to the belief that work-related stressors, including WAHS, caused them to experience increased symptoms of common mental illnesses.

Emerged themes

Four themes emerged from coding segmented data and categorising them based on the constructs of two theoretical models relevant to the study questions: ‘Exposure to inadequate WASH and perceived link with common mental symptoms’, ‘Perceived impact of inadequate WASH on professional quality of life’, ‘Experience of coping with inadequate WASH’, and ‘Barriers to reducing inadequate WASH as stressors to mitigate mental health impact’.

Fig 1 illustrates the relationships between the themes that emerged from the data. The causal pathway is drawn from the health workers’ perceptions or beliefs expressed during the interviews and the discussion based on the guiding theoretical model of psychological stress: TMS [4] and JDR [5]. As observed from the perceptual causal directions in Fig 1, one can understand that health workers’ exposure to inadequate WASH and other important factors mentioned in each theme may have at least the following interrelationships: (1) inadequate WASH is perceived to increase the risk of CMSs through negatively affecting coping strategies(personal psychological and physical resources), professional quality of life (burnout, compassion fatigue, compassion satisfaction), and by exacerbating the negative impact of barriers; (2) inadequate WASH is also perceived to negatively influence coping strategies (e.g., participants felt that WASH issues were being individually unaddressed), and barriers at all levels can also cause inadequate WASH to be a persistent stressor; (3) poor coping strategies for healthcare workers, barriers at all levels and professional quality of life (e.g., burnout and compassion fatigue) together with inadequate WASH increase the risk of CMSs.

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Fig 1. Perceptual link between inadequate WASH with common mental symptoms, and professional quality of life in health workers, February 2023.

https://doi.org/10.1371/journal.pone.0314170.g001

Theme 1: Exposure to inadequate WASH and perceived links with common mental symptoms

We explored how health workers comprehend symptoms of stress, anxiety, and depression. We then explored how they associate inadequate WASH as a workplace stressor with each symptom after asking participants about the cardinal symptoms of each mental illness. Although not all health workers listed each symptom precisely, their subjective reflections were considered perceptual causes through the interpretive coding strategy of segmented data. According to the participants, inadequate WASH was ranked as the fifth most mentioned work-related stressor in the points of care areas, as illustrated in Fig 2, which summarises the code frequency of the segmented data.

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Fig 2. Frequency of mentions of common mental symptoms as perceived stressors among health workers in the Central Ethiopia Region, February 2023.

https://doi.org/10.1371/journal.pone.0314170.g002

Most participants perceived shortages of functional hand hygiene facilities, a shortage of continuous clean water supplies for sinks and nonfunctional sinks, a lack of soap, nonfunctional or unavailable washing facilities at 5-meter toilets, and alcohol-based hand rub at points of care areas. Additionally, many participants reported experiencing a shortage of water for cleaning floors, medical equipment, and other sanitation and hygiene-related tasks in the hospital. One participant mentioned:

“[…] Most sinks lack water due to interruptions in supply. […] Soapis often unavailable. […] The only sinks with water are in the surgery and intensive care units. I always fear the risk of infection. I’m also concerned about how patients and visitors perceive us. How can I address this problem? I believe that this persistent worrying contributes to a depressed mood.” (Female, 37 years old, MSc in Community Psychiatry)

Most participants perceived inadequate basic waste management services, including the unavailability of at least three bins for segregation, unsafe segregation practices, and improper disposal of medical waste. These issues caused health workers to fear for their safety as well as that of their patients, and visitors at points of care. Many believed that these factors were among the most persistent stressors in these settings, potentially increasing the development of symptoms related to stress, anxiety, and depression. One of the participants reflected on these problems:

“Sometimes, waste bins are relocated to another ward, leaving our ward without one. […] Additionally, staff and patients toilets are not separated. […] It is always difficult to keep my hygiene as I desire.[…] I believe fear of infection due to such limitations contributes to persistent stress, a depressed mood, and excessive worry”. (Male, 35 years old, BSc in Nursing)

The majority of health workers reported substandard implementation of infection prevention control (IPC) for both cleaners and healthcare staff. Almost all participants indicated that they had received IPC training; however, practice-related gaps persisted. One participant stated the issues and the perceived link between environmental cleaning at points of care, and mental health symptoms.

“Cleaners often lack awareness of infection prevention and control (IPC) protocols. They [cleaners] believe that cleaning once a day is adequate, which increases our workload and raises concerns about infections and negative care outcomes. I worry about infections affecting myself, my patients, and my family. Yea, such persistent worry can cause mental strain, tension, depression, and demotivation.” (Male, 41 years old, MSc in Adult Nursing)

Many health workers expressed concerns that inadequate WASH challenged their ability to manage job demands in various ways and decreased their hope of using their personal coping and resilience strategies as if the problems could not be resolved at the individual level. One participant stated that the interaction between inadequate WASH and other stressors, particularly challenges related to infection prevention and control activities, exacerbated their psychological difficulties.

“[…] Hygiene and sanitation are persistent challenges here [at the hospital]. […] Compliance with infection prevention and control practices is difficult. We have no separate water source for the hospital. We get water from the town. Only a few hospital units, such as the surgery wards, intensive care units, and delivery wards receive water from reservoirs.[…] Imagine how this can hinder us from meeting our goals, creating discomfort, and negatively impacting the community’s perception of us [healthcare workers], causing distress for patients and visitors. I think this could also make us fail to control and cope with other stressors.” (Male, 34 years old, BSc in Community Psychiatry)

Theme 2: Perceived impact of inadequate WASH on professional quality of life

Under this theme, we explored the perceived impact of exposure to inadequate WASH on professional quality of life (PQoL) using two key components of PQoL [27]: compassion fatigue, and burnout feelings, as well as compassion satisfaction. The components of PQoL, particularly burnout and compassion fatigue, may also contribute to increased distress, anxiety, and depressive symptoms, as shown in Fig 2, which describes the relationships among the themes. Similar to the challenges in identifying symptoms of common mental illnesses, many health workers struggled to identify the independent contributions of inadequate WASH This included difficulties in recalling each episode of symptoms concerning duration and intensity, as well as establishing independent links with any components of WASH. Nevertheless, many health workers believe that inadequate WASH, in conjunction with other work stressors increases the risk of decreased compassion satisfaction and increased burnout. A participant summarized the impact of insufficient WASH and the imbalance between high effort and low reward (another stressor) as follows:

"[…] I switched from laboratory to the nursing department 2 years ago, but the challenges are almost the same. Forget about better pay, I do not even have a clean workplace. No matter how much I scrub the floor never feels clean. Sometimes, the disinfectants, and cleaners we need are not available. I am always afraid of being infected due to spill overs of urine, blood, and bodily fluids. As you can sense at this moment, it smells unbearable. I worry every day about contamination. […] Most shifts, I’m the one cleaning, even though I’m supposed to be a nurse. I can’t even list all the problems. I can’t list all the problems. […] I’m exhausted, frustrated, and bored. I need to get out—before I lose myself to this job." (Male, 32 years old, BSc Nurse)

Many participants also worried about the medical outcomes of their patients, but there were many persistent challenges in WASH near the points of care. A participant, for example, stated that he was emotionally drained and physically exhausted due to prolonged exposure to persistent inadequate WASH and other stressors at the points of care.

“As a doctor, I can’t imagine the pressure of working or performing a surgical procedure in an environment lacking proper hygiene and cleanliness. The use of stored water for cleaning, occasional lack of disinfectants, inadequate handwashing facilities, and improper waste management greatly concern me. What terrifies me even more is thinking about what it would feel like as a patient. Would I feel safe, or would I be gripped by fear knowing the risks?” (Male, 33 years old, MD)

Theme 3: Coping experience with inadequate WASH

This theme explored the strategies health workers employed to cope with the inadequate WASH component they raised during the interviews and discussion. We categorized coping strategies into two groups according to the TMS theoretical framework [4]: adaptive (problem-solving and/or positive emotion coping strategies), and maladaptive (negative action and/or negative emotion thought) strategies. Another classification for summarizing the findings was for those who either did not recall any coping strategies or had no planned coping strategies. Accordingly, many health workers felt that addressing WASH issues necessarily requires intervention from higher-level bodies or authorities such as sectorial officials as individual efforts had a limited impact. Additionally, nearly equivalent numbers of participants either did not recall or did not have planned coping strategies with inadequate WASH. One participant shared insight into how his attempts to solve inadequate WASH problems at the individual level had been unsuccessful, illustrating the challenges faced by many health workers in this regard.

“[…] We remind hospital officials to keep water tankers filled as a reserve. I usually rely on alcohol-based hand rubs for hand hygiene. But, sometimes they aren’t available. What should I do, for example, in case of a shortage of water? In the past, I did not take any steps to prepare for it. Can I or my colleagues do anything about it?” (Male, 28 years old, BSc Midwife)

Study participants believed that they could reduce the negative consequences of inadequate WASH on common mental symptoms, mainly by avoiding the problem. However, only a few participants felt that they could have an impact through emotional preparation, such as seeking psychological support or other emotional copping strategies. One participant, a general practitioner, advised health workers should emotionally prepare themselves to accept these problems and seek support from others.

“I think we can think of emotional self-management by considering acceptance as a solution alongside personal coping efforts and support from hospital officials. However, most of us tend to see problems like inadequate WASH and other stressors as overwhelming threats that we feel powerless to address.” (Male, 33 years old, MD)

Theme 4: Barriers to reducing inadequate WASH as a stressor

In this theme, we explored health workers’ experiences with the barriers they faced to improving coping with inadequate WASH. Many healthcare workers frequently encounter barriers to improving at the individual level, such as inconsistent waste segregation practices (improper use of labelled bins, relocation of waste bins, shortage of labelled waste bins), and a tendency to only rely on higher authorities to solve these issues. Additionally, there is often a lack of organizational commitment to maintaining proper WASH infrastructure, and other system-level gaps.

Although healthcare workers acknowledge the impact of inadequate WASH on mental health outcomes, many of them primarily look to external bodies for solutions. One of the participants expressed concern about implementing IPC measures mentioning one of the most important components, segregation practices.

“We face enormous challenges with waste segregation in the care areas. […] Even with IPC training, implementation is still lacking. If we worry about infection, we must ensure strict adherence to proper protocols.” (Male, 41-year-old, MSc Adult Nurse)

Similarly, participants raised organizational-level barriers. These included a lack of commitment to hospital WASH initiatives and insufficient mental health-related training for coping with such problems. One participant described the commitment challenge for the hospital management.

“During the COVID-19 pandemic, there were adequate portable alcohol hand sanitisers in the hospital. However, in the aftermath, we faced a troubling scarcity of these essential items, highlighting significant shortcomings in the administration’s ability to maintain critical supplies.” (Female, 37 years old, MPH&Nurse)

Participants raised many system-level barriers that require collaborative efforts between the health system, water supply, sewerage, and municipal waste management bureaus to alleviate inadequate WASH.

“We have no separate source of water for the hospital. The city’s water supply and sewerage services must work together with the health system to ensure a continuous supply. […] Currently, less than 10% of the points of care points receive continuous water, as it is delivered in rotation, just like in the surrounding community. However, this kind of limited access is unacceptable for healthcare facilities.” (Male, 55 years old, BSc Nurse)

Trustworthiness and limitations of the study

Exploration of common mental symptoms such as stress, anxiety, or depressive symptoms along with their effects followed by how participants link each component of WASH to these symptoms as causes or risks, would enhance our understanding of perceptual causation. Identifying symptoms (stress, anxiety, or depression), and assessing the duration and specific nature of these symptoms associated with each component of inadequate WASH can help reduce recall bias. Utilizing a theoretical framework may support a causation explanation of how inadequate WASH contribute to common mental symptoms. We ensured the trustworthiness of our study through various strategies. Member checking was used to validate our interpretations by summarizing narratives for participants’ confirmation, thereby enhancing credibility. We documented every step of the research process including data collection, analysis, and interpretation to ensure dependability, employing explicit, and systematic coding based on theoretical frameworks to maintain transparency and allow for replication by future researchers. The inability of professionals to review coding samples and the discussions with researchers contribute to confirmability. We provided a detailed description of the study context, participants, and research methods, with findings for each theme supported by participants’ quotes to enhance transferability.

However, despite the conceptualization and expectations surrounding mental health symptoms, health workers found it challenging to recall specific mental symptoms (stress, anxiety, or depression) and specific stressors (s). This may complicate the verifications of whether changes in feelings were influenced by specific stressors and hinder the assessment of the variability of exposure to those stressors [28]. Difficulties in recalling specific stressors, the duration of exposure, and their interaction with a specific mental health symptom or multiple symptoms whether singly or in combination with other stressors would limit the ability to provide a sufficient counterfactual, regularity, necessity, and invariability of causation [28]. This suggests a need for additional mixed study designs [28] and longitudinal qualitative [10] research, because, the causal relationship between psychosocial determinants such as inadequate WASH and mental health symptoms is complex. Similarly, determining which coping strategies corresponded with a specific stressor(s) and/or symptoms of common mental disorders was difficult due to health workers’ recall bias, despite efforts to elicit coping strategies during our interviews and discussions.

Policy implications and recommendations

With limitations specified before, our findings still highlighted the need to integrate WASH and mental health services for healthcare workers, which could involve ranging from establishing individual-level interventions and promoting collaborative efforts among hospital administration, health systems, water and sewerage services, and various national and international organizations. The healthcare policies should also invest in better water supply, sanitation, environmental cleaning, and waste management at the points of care and healthcare facilities in general. Mental health support systems and strategies for with coping WASH-related stressors including counselling and stress management as workplace wellness packages, should be tailored for healthcare workers. Additionally, ongoing education on WASH protocols and workplace well-being monitoring approaches will enhance both WASH standards and mental health outcomes, ultimately improving healthcare workers’ professional quality of life.