Mar 26, 2026
Protocol for a qualitative systematic review of the experience of burnout in sub-Saharan African healthcare workers.
- Imre Papp1,
- Zubia Mumtaz1
- 1School of Public Health, University of Alberta
Protocol Citation: Imre Papp, Zubia Mumtaz 2026. Protocol for a qualitative systematic review of the experience of burnout in sub-Saharan African healthcare workers.. protocols.io https://dx.doi.org/10.17504/protocols.io.yxmvm8br5g3p/v1
License: This is an open access protocol distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Protocol status: Working
We use this protocol and it's working.
Created: March 24, 2026
Last Modified: March 26, 2026
Protocol Integer ID: 313860
Keywords: burnout, sub-saharan africa, healthcare, healthcare workers, health systems, job satisfaction, qualitative, experience of burnout, examining burnout, job satisfaction among healthcare worker, job satisfaction, qualitative systematic review, health system conditions across diverse setting, health system condition, healthcare worker, global health database, implications for workforce retention, workforce retention, sensitive health system intervention, quality of care,
Abstract
This protocol outlines a qualitative systematic review examining burnout and job satisfaction among healthcare workers in sub-Saharan Africa. The review will systematically search five databases (MEDLINE, Global Health Database, PsycINFO, Web of Science, and CINAHL), apply predefined inclusion and exclusion criteria, and use Thomas and Harden’s thematic synthesis approach alongside GRADE-CERQual to assess confidence in findings.
The review is expected to generate in-depth, contextually grounded insights into how burnout is experienced, understood, and shaped by health system conditions across diverse settings. Findings will likely identify recurring structural and organizational drivers, as well as their implications for workforce retention and quality of care, offering evidence to inform more context-sensitive health system interventions.
Troubleshooting
Safety warnings
Several limitations of this review should be acknowledged. First, the restriction to English-language publications may result in the exclusion of relevant studies published in other languages, potentially introducing language bias. Second, the exclusion of grey literature may limit the inclusion of context-specific or practice-based insights that are not captured in peer-reviewed publications. Third, variability in how burnout is defined and conceptualized across studies may introduce challenges in synthesis and interpretation. Finally, the exclusion of certain healthcare worker groups, such as mental health professionals, may limit the breadth of perspectives captured, although this decision was made to reduce conceptual heterogeneity.
Ethics statement
No ethical approval required as this study uses published data. This review is conducted by a research team based at the University of Alberta with training and experience in global health and qualitative research. The team brings perspectives shaped by academic training in high-income settings, which may influence how burnout and health system challenges in sub-Saharan Africa are interpreted. We acknowledge that our positionality as researchers external to many of the study contexts may shape the interpretation of participants’ experiences, particularly in relation to health system constraints, workforce dynamics, and sociocultural understandings of burnout.
To address these potential biases, reflexive practices will be integrated throughout the review process. Coding and theme development will be conducted iteratively, with regular discussions among team members to challenge assumptions and ensure that interpretations remain grounded in the primary data. Where possible, we will prioritize participants’ own words and meanings, including the use of illustrative quotes to preserve contextual nuance. Discrepancies in interpretation will be resolved through discussion, with attention to alternative explanations.
In addition, we will remain attentive to the diversity of contexts across sub-Saharan Africa and avoid overgeneralization of findings. Analytical decisions will be documented to enhance transparency, and the synthesis will aim to reflect the range and complexity of experiences reported in the included studies.
Before start
This systematic qualitative review addresses this gap by synthesising sub-Saharan African healthcare workers’ perspectives on burnout, including how they define and experience it, and how burnout affects their wellbeing and work performance. Research question: How do healthcare workers in sub-Saharan Africa experience, understand, and describe burnout, and what are the perceived impacts of burnout on their wellbeing and work performance?
Systematic Review Protocol
Search five databases: MEDLINE, Global Health Database, PsycINFO, Web of Science, and CINAHL.
Use search terms related to burnout concepts (e.g., burnout, compassion fatigue, occupational stress, desire to leave, attrition, job satisfaction), health worker populations (e.g., healthcare workers, nurses, community health workers, physicians, midwives), and geographic locations (e.g., sub-Saharan African countries or capital cities). Full search strings may vary slightly between databases.
Example for Web of Science: (burnout or burn-out or occupational stress or compassionate fatigue or indifference) (Topic) and (health providers or health professionals or clinicians or nurses or clinical officers or healthcare workers or healthcare providers) (Topic) and "sub-saharan africa" or "sub saharan africa" or angola* or botswana* or lesotho* or malawi* or mozambiq* or namibia* or swampland or zambia* or zimbabwe or zulu or tanga or xhosa or swamp or ndecane or tswana or soothe or shrna people or balansa or mundo or ovimbundu or Chaga or saruma OR pretreat or Cape Town or Johannesburg or durian or Port Elizabeth or Bloemfontein or windhoek or masers or Pietermaritz or nelspruit or somato or Polokwane or limpopo or rustenburg or mafeking or oudtshoon or Stellenbosch or pearl or gabosines or luanda or cabins or huambo or lubing or knit or melange or lobata or lelong or Blantyre or mizuku or maputo or matobo or beidu or nampula or chimoio or nucula or Quelimane or lusaka or kitwe or nmole or kcable or copperfeld or hardware or Bulawayo or Chitungwiza or mutate or markings or mashonaland or medicalband
Limitations: English-language, published between January 1, 2000, and December 2, 2025.
If satisfied with search results, save search string and record date of search. Download RIS file of publications.
If not satisfied, refine search and reassess before recording search string.
Upload RIS files containing search results to Covidence software [1] for review.
Covidence automatically removes most duplicates. If some remain, remove manually.
Assess eligibility based on title relevance according to inclusion and exclusion criteria. Two independent reviewers complete the screening process (steps 6-8) and must reach consensus. If there is disagreement regarding the eligibility of a study at any point in the screening process (steps 6-8), the reviewers should discuss together and reach an agreement.
Inclusion criteria: English language, qualitative or mixed methodology, set in sub-Saharan Africa, focus on healthcare workers (including community health workers, physicians, midwives, clinical officers, nurses, and other workers directly engaging in patient care), examine burnout or job satisfaction, peer-reviewed publications.
Exclusion criteria: non-English language, exclusively quantitative methodology, not set in sub-Saharan Africa. Exclude articles focusing on burnout due to the COVID-19 pandemic due its exigent nature. Exclude studies focusing on mental health workers to reduce conceptual heterogeneity, as the sources and manifestations of burnout in these populations may differ due to the unique emotional demands of therapeutic work.
Repeat step 7, this time assessing abstract relevance to determine potential eligibility.
Finally, conduct a full-text review of remaining studies to determine eligibility.
Import included studies into qualitative data analysis software (e.g., Quirkos) to facilitate systematic coding and organization of data.
Analyze data using Thomas and Harden's thematic synthesis approach [2]. First, conduct line-by-line coding on the findings sections of each included study, generating codes inductively from the data. Coding is to be conducted iteratively, with initial codes refined and expanded as new studies are incorporated. To enhance rigour, a subset of studies should be independently coded by at least two reviewers, discrepancies should be discussed and resolved through consensus.
Codes should then be grouped into descriptive themes that capture recurring patterns across studies. A constant comparative approach should be used to examine similarities and differences within and across studies, ensuring that themes remain grounded in the primary data.
Analytical themes can then be developed through interpretive analysis, moving beyond the original study findings to generate higher-order insights related to the research question. The development of analytical themes involves ongoing discussion among the research team to challenge assumptions and ensure coherence. To enhance the credibility of the synthesis, illustrative participant quotes will be used to support key themes, and an audit trail of analytical decisions will be maintained throughout the process.
Extract descriptive data from each included study in a spreadsheet. The spreadsheet should contain the following fields: 1) title, 2) author, 3) year of publication, 4) country and setting of study, 5) aim of study, 6) study design, 7) start/end date, 8) population, 9) inclusion criteria, 10) # of participants, 11) identified themes/subthemes, 12) important quotes, 13) synthesis of results, 14) limitations, 15) notes.
Assess methodological quality and confidence in the findings using the GRADE-CERQual approach [3]. The methodological quality of included studies will be assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist. Each study will be evaluated across domains including study design, data collection, reflexivity, ethical considerations, and rigor of analysis. Quality appraisal will be conducted independently by at least two reviewers, with disagreements resolved through discussion.
Confidence in the review findings will be assessed using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach.
Each review finding will be evaluated across four domains:
- Methodological limitations: the extent to which there are concerns about the design or conduct of the primary studies contributing to a finding
- Coherence: the degree to which the finding is well grounded in and supported by the data across studies
- Adequacy of data: the richness and quantity of data supporting the finding
- Relevance: the applicability of the data to the review question and context
Each finding will be assigned an overall level of confidence (high, moderate, low, or very low), and a summary of qualitative findings table will be produced.
Protocol references
[1] Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org.
[2] Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8: 45. doi:10.1186/1471-2288-8-45
[3] Lewin S, Booth A, Glenton C, Munthe-Kaas H, Rashidian A, Wainwright M, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. Implementation Science. 2018;13: 2. doi:10.1186/s13012-017-0688-3