The World Health Organization (WHO) declared the Sars-CoV-2 virus outbreak in early 2020 as a global public health emergency [1]. Although the outbreak was initially located in China, it quickly spread throughout Asia and the rest of the world. According to the WHO, as of the end of July 2021, there have been 190,770,507 confirmed cases of COVID-19 worldwide, of which 4,095,924 have died [2]. In April 2021, Mautong et al. published that in Ecuador, the first case of coronavirus was identified in February 2020, and after a few weeks, in the city of Guayaquil alone, the largest in the country, approximately 2,200 cases were reported, which corresponded to 70% of the cases in the country [3]. The number of confirmed cases is 476,065 and 21,953 deaths according to the WHO [2]. However, as Cevallos-Valdiviezo et al. pointed out, the actual figure could be much higher due to underestimation derived from delays in death records, the lack of enough test kits across the country, false-negative test results, or the incorrect attribution of COVID-19 deaths [4].

The spread of the pandemic is accelerating thanks to the fluidity of the international mobility of the population and the ease of transmission of the virus [5]. COVID-19 is transmitted through close contact with an infected person, through droplets or aerosols emitted by the infected person during respiratory activities such as talking, coughing, laughing, sneezing. The receptor can be contaminated by direct inspiration from an infected aerosol in the vicinity of a sick person or by touching a contaminated surface [6]. Many of the patients remain asymptomatic and are unaware of their spreading potential, which is the same as that of a patient with symptoms, something that aggravates and favours transmission [7].

Before the availability of the vaccine and in the absence of specific treatment, the most effective way to address the pandemic was preventive containment measures, hand hygiene, face mask, social distance, and isolation [8]. Despite these measures, the virus spread rapidly, collapsing health systems. The Sars-CoV-2 virus triggers a respiratory inflammatory crisis that, together with certain previous risk factors such as advanced age (≥65 years), male sex, hypertension, cardiovascular diseases, diabetes, COPD, and malignant neoplasms, causes the person to require hospitalisation, complex respiratory support, admission to the ICU and, in many cases, leads to death [9]. Patients with COVID-19 remain hospitalised between 5 and 29 days, and those admitted to the ICU have a mean stay between 1 and 3 weeks [10]. All this translates into a care overload that healthcare workers, especially those on the front line, have to face, working directly with COVID-19 patients. In addition to work overload and long hours, healthcare professionals have had to perform their work in very difficult physical and psychological conditions [11]. The complex situation of the pandemic forces them to work under the feeling of constant threat due to direct exposure to the pathogen itself, with a shortage, at times, of protective material, and also due to fear of transmitting the virus to family or friends that can lead to social isolation, or professional frustration at the loneliness and death of the coronavirus patients they care for [11–13].

These exceptional circumstances have an unavoidable impact on the mental health of healthcare workers. High levels of anxiety, depression, post-traumatic stress, insomnia, obsessive-compulsive symptoms, emotional disorders, and somatization among healthcare workers have been described during the COVID-19 pandemic [14–17]. These consequences are especially accentuated in nurses, women, involved in the diagnosis, treatment or care of patients with coronavirus [16]. During the pandemic, high levels of compassion fatigue and burnout have been reported among healthcare professionals and a significant decrease in compassion satisfaction [18, 19]. This burnout is not only conditioned by the overload of work and the psychological demands of the pandemic situation, but also by the feeling of threat the workers experience and the lack of social support [20]. The psychological and emotional load of healthcare workers has repercussions in the performance of their functions, by conditioning their capacity for attention, understanding, and decision-making [17]. It is therefore imperative to address the psychological needs of healthcare workers in order to effectively deal with the pandemic.

Although the health crisis caused by COVID-19 has been a challenge for all health systems in the world, for low and middle-income countries, which are currently in a situation of inadequate resources, the challenge of COVID-19 has led to a worsening of the health gap, especially in terms of mental health [21]. Ecuador has been one of the countries hardest hit by the pandemic with a mortality rate among the highest in Latin America [22], which reached 8.5%, although it was probably much higher as many people died from the virus but undiagnosed [23]. In March 2020, of the four geographical regions of Ecuador, the coast and the city of Guayaquil were the most seriously affected areas since they accounted for 82.57% of the confirmed cases of COVID-19 and coincided with an area that had already been seriously affected by dengue cases (84%) [24].

To cope with the advance of the pandemic, the Ecuadorian government established containment measures such as confinement, traffic and movement restrictions, and curfew [25]. However, these measures were implemented unevenly throughout the country due to the fact that there is no universal health coverage because of difficulties in communications and geographical. Some groups such as indigenous populations or refugees may find it more difficult to take preventive measures [26]. The response of the Ecuadorian public health system has been slow and insufficient. The high number of cases and deaths collapsed the system and evidenced its operational shortcomings and the absence of a strategic plan to contain the spread of the infection [23]. Given this scenario and with the country’s scarce health resources, the threat is particularly serious for Ecuadorian healthcare workers, who have to fight the pandemic in one of the countries with the highest number of cases and deaths per capita worldwide [24]. It is necessary to know the psychological impact of the pandemic on health staff due to the negative consequences it can trigger for the group itself, for the people affected, and for society in general given its leading role in addressing and containing the pandemic.

The objective of this study is to analyse the levels of psychological distress during the COVID-19 pandemic among healthcare workers in Ecuador.

The results of the study revealed a moderate-high level of psychological distress (66.0%) among healthcare professionals during the COVID-19 pandemic. These results coincide with those obtained by other international studies on anxiety, depression, and stress among healthcare professionals working on the front lines of the COVID-19 crisis [14, 28, 29]. Previous studies that included Ecuadorian healthcare professionals in their sample also obtained similar results in relation to the manifestations of stress (59.5%), anxiety (45.7%), depression (55.4%), and post-traumatic stress (70.2%) [5, 30]. However, our results were higher than those found by Mautong et al. in their study on the mental health of the Ecuadorian population during confinement, obtaining 17.7% of depression, 30.7% of anxiety, and 14.2% of stress [3]. This difference is consistent with previous studies that identified significantly higher levels of PD among healthcare professionals, as compared to the general population [31, 32]. In particular, distress has been described as especially high in front-line healthcare professionals versus those who do not work with COVID-19 patients [16, 19].

Some authors have suggested the lack of resources and protective equipment as a factor associated with healthcare workers’ anxiety in the face of the pandemic [33, 34]. In Ecuador, the health system’s response to the coronavirus outbreak was insufficient, especially regarding healthcare human resources and the provision of personal protective equipment [23]. The results found by Martín-Delgado et al. described a shortage of personal protective material manifested by 70% of healthcare workers in Brazil, Colombia, and Ecuador, especially of suits, masks, and face shields, even in areas where aerosol-generating procedures were performed [35]. To address the lack of material and technical resources, Ecuador requested international assistance and eventually had to accept donations from the Pan-American Health Organization (PAHO) of protective equipment for front-line workers [23]. The deficiencies not only affected the supply of equipment, but also the training on its correct use, since 51.5% of Ecuadorian healthcare professionals admit not having received training on the use of personal protective equipment [35]. However, Zhang et al. study on organisational support for healthcare workers in Peru, Ecuador, and Bolivia did not identify risk control and protection as a predictor of professionals’ anxiety [36].

On the other hand, it has been pointed out that being informed about the health crisis through official sources with verified data is associated with fewer PD [37] and that a greater number of daily hours obtaining information from different sources increases PD in non-healthcare workers [38]. Ecuadorian healthcare professionals have said they are unaware of the protocols for the care of COVID-19 patients [35]. This lack of knowledge could explain the high levels of PD found in our study. Chen et al. conducted a study on the COVID-19 beliefs of healthcare workers in Ecuador and identified conspiracy theories regarding the origin of the virus. Professionals who believed the virus was intentionally developed in a laboratory were more likely to have an anxiety disorder [39]. The study by Bates et al. on the Ecuadorian general population, despite identifying good knowledge about COVID-19, concluded that this was not enough to motivate a change of attitude towards the pandemic and confidence in overcoming it [40].

According to our results, women have greater psychological distress than men, which resembles previous similar studies [30, 31, 41]. Similarly, in the present study, the presence of COVID-19 symptoms and the history of contacts with infected people was associated with higher levels of PD and taking preventive measures against COVID-19 implied a lower decline of the mental health of healthcare workers. Similar results were obtained by Wang et al. in their study on psychological responses during the first stage of the pandemic in China. According to these authors, participants with symptoms such as chills, myalgia, cough, dizziness, rhinitis, sore throat, and shortness of breath had higher levels of anxiety, depression, and post-traumatic stress [42]. In addition, according to the results found by Alkhamees et al. from a similar study, not experiencing any of the symptoms listed above was significantly associated with lower PD scores [43]. It is striking that, as in previous studies, the least frequent symptoms were fever and respiratory difficulties, given that COVID-19 is an inflammatory respiratory disease.

As our results show, contact with infected people or material has previously been identified as an influential factor for the psychological impact on healthcare professionals [44]. Healthcare professionals working in the front line, at greater risk of infection by close contact with COVID-19 patients, have reported greater psychological deterioration than others [16, 19]. It has been identified that these professionals are more likely to suffer from anxiety, depression, and insomnia [16, 45] and have more secondary traumatization [31]. Exposure to risk and threat perception leads professionals to feel more vulnerable and, as a result, suffer more PD [46, 47]. The lack of protective measures has been associated with higher levels of anxiety and depression among healthcare professionals [48].

In Ecuador, in the sociocultural context in which this study was developed, the population has suffered a greater psychological exhaustion than other countries, which confirms our results [5]. The Ecuadorian coast was considered the region most affected by COVID-19, with the highest number of cases [24] and significantly higher levels of anxiety and depression [22]. An international study conducted in Ecuador, Chile, Colombia and Spain, revealed that Ecuadorians, although they perceived the health crisis with severity, showed less adherence to health recommendations and reported lower levels of awareness of their health status, as compared to other countries [30]. The psychological impact has had consequences for the health of the population in relation to their eating habits, with changes in meal times or increased intake and a worsening of sleep quality [49]. However, according to Bermerjo-Martins et al. [30] in relation to self-care, the elderly and women are generally more involved in self-care activities and adopt healthier daily routines. The crisis has been particularly severe for healthcare professionals, who, in addition to the exposure to risk and fear of contagion of their relatives, have endured an overload of work in difficult conditions, under psychological and emotional pressure. Despite working in this harsh scenario, healthcare professionals in Ecuador have manifested high levels of work engagement and compassion satisfaction, which describes them as a positively involved and committed group despite the difficulties [50]. Initiatives have been proposed that promote coping strategies and self-care to maintain the psycho-emotional balance of these workers and enable them to play their role in the fight against the pandemic [41]. In the Ecuadorian healthcare environment, it has been identified that exercising, maintaining daily routines, and staying informed about COVID-19, but limiting it to 1 h a day, is associated with better mental health [22].