COVID-19, which originated in Wuhan, China as an atypical pneumonia [1], brought about an overload in health systems in all countries, especially in Intensive Care Units in Europe [2] and in less economically developed countries, such as Ecuador, with a lack of supplies, personnel, and installed capacity [3]. This situation did not only lead to biological pathologies, but also the psychological distress (PD) of healthcare professionals increased [4].

A multicentre study found that the COVID-19 pandemic was associated with a higher incidence of mental health symptoms than that identified in previous stressful situations such as post-traumatic stress disorder, anxiety, depression, insomnia, and dissociation, being higher in Latin America and lower in North America [5].

Healthcare workers are being the most studied group internationally in relation to the COVID-19 pandemic, although there is still a gap in the literature regarding organisational support aimed at the mental health of healthcare workers [6], especially concerning professionals in charge of treating infected patients [7]. PD has been proven to be linked with patient safety and care, family and work environment, media and public perceptions, and government response to the pandemic, with exacerbations of uncertainty, hypervigilance, and moral distress found to increase the level of PD [8].

Ecuador is a country of about 17 million people with an uneven distribution of the health system to deal with severe cases of the disease, especially in the coastal areas, where COVID-19 cases have overlapped with a high number of dengue cases. In addition, it is considered that there is no universal health coverage because of transport difficulties and geographical issues. Therefore, some groups of indigenous population or refugees found it more difficult to receive appropriate health attention [ [9]]. This situation is similar to that of many other Latin American countries and differs from the lower number of difficulties faced by European countries and the USA in diagnosing and controlling the pandemic [10]. Ecuador is a country where one of the largest COVID-19 pandemic health scares in Latin America occurred, especially in more populated and industrialised areas such as Guayaquil [11], which accounted at certain times for 70% of all reported cases in the country [12]. This revealed that the response of the Ecuadorian health system in the early stages of the pandemic was not as rapid and effective as might have been expected [13].

Compared to studies in Asia, the USA, or Europe, there are few articles assessing the PD of healthcare workers in Latin American countries [14–16]. In these cases, stress, anxiety, depression, and post-traumatic stress reached significantly high levels of incidence [17]. In particular, distress has been described as especially high in front-line healthcare professionals who worked with COVID-19 patients [18].

Work engagement (WE), measured through the Utrecht Work Engagement Scale (UWES) is a positive and satisfying work-related attitude defined by the vigour, dedication, and absorption dimensions [19]. It is a multi-axial concept that brings together multiple factors that influence WE, including organisational climate; work, professional, and personal resources; job demands; and demographic variables [20]. Sense of coherence (SOC) is described as an ability to understand a situation, perceive it as manageable, and mobilise resources to develop an effective response, and is composed of the comprehensibility, manageability, and meaningfulness dimensions [21].

It is known from previous studies that sense of coherence and work engagement are key influencing factors for healthcare workers [22] and that lower SOC may be a protective factor in later stages of the pandemic [2]. Work engagement and sense of coherence positively correlated with each other and both negatively with PD. Thus, healthcare professionals, though experiencing PD, perceive their work positively and satisfactorily despite the severity of the situation and the harsh working conditions [23]. Looking specifically at women, both healthcare and non-healthcare workers, the presence of work overload and concerns about their health status or economic situation were observed, and these variables were predictors of stress among these workers in the second wave of the pandemic [24].

The importance of maintaining an optimal work environment has been shown not only to increase workers’ motivation, satisfaction, or performance [25], but also to reduce the negative effects of the pandemic on workers’ mental health [26]. It was found that, among nurses, the increased workload of the pandemic was positively associated with work engagement [27].

Sense of coherence, according to the salutogenic model [28, 29], is known to be an important predictor and modulator of mental health and psychopathological symptoms during the pandemic, and these changes are sustained over a long period of time [30]. Prior to the COVID-19 pandemic, it had been proven that a high SOC in nurses was associated with better health and work engagement [31]. In non-healthcare workers who performed essential activities during the confinement period of the first phase of the pandemic, it was observed that low levels of WE and SOC were associated with higher levels of PD [32].

The purpose of this research was to test the association between the sense of coherence, work engagement, work environment, and psychological distress in healthcare workers in Ecuador during confinement in the first phase of the COVID-19 pandemic.

This study has allowed to assess the SOC of healthcare professionals in Ecuador during the first phase of the COVID-19 pandemic, which could have been influenced by the WE, work environment, and PD variables.

The results obtained confirm previous findings in which a high SOC was positively associated with work environment, and both were negatively associated with PD [2, 24]. Work environment is influenced by the level of job satisfaction, where SOC acts as a modulating factor and where both job satisfaction and SOC are better predictors of work environment than resilience [40]. Similarly, the association found between a positive work environment and a high SOC confirms previous studies, which have found that an improvement in the working environment of nurses, with an increase in SOC, leads to improvements in their own health [41].

In line with the present results, it is known from previous studies that SOC and WE are key influencing factors for workers. In this sense, European healthcare workers with higher levels of work-related SOC may have been protected from changes in psychological symptomatology for about 3 months, decreasing this level of protection over the course of the pandemic and leading to the deterioration of mental health [22]. In contrast, healthcare professionals with lower SOC may be protected in later stages of the pandemic [2].

The present study shows that people who have a partner and those who have children have a greater SOC, which confirms previous studies performed in Japanese hospitals where higher levels of PD were found in those living alone [42], thus finding an inverse association between the SOC and PD. On the other hand, this differs when analysing women and younger people [42], or when relating women with the level of studies [31], variables for which no differences have been found regarding the SOC. Having studies on healthcare workers during the COVID-19 pandemic, affecting all workers regardless of their different socio-demographic characteristics [43], should be necessary.

What has not been possible to assess has been whether infected healthcare workers showed differences with non-infected workers, as studies have found differences in their mental health [44]. This has been due to the fact that, although participants were asked about it in the questionnaire, in the early phases of the pandemic diagnostic tests were carried out on a low percentage of professionals, which is consistent with the worsening of occupational health conditions perceived in the present study in that phase of the pandemic and whose effects had been maintained 6 months after the end of confinement [45].

A not so small percentage, 23.4% of the healthcare workers who responded, worked from home. This is the group that in the first phase of the COVID-19 pandemic was involved in administrative activities or did not require contact with the infected, physicians who attended medical or nursing consultations by videoconference or telephone or who managed suspected cases of the disease, among others. No differences were observed between those who teleworked and those who continued working in health centres, probably because there were health risks associated with exposure to the sick and also associated with teleworking and depending on the working conditions or those of their own homes [46–49].

Predictably, healthcare professionals consider that the quality of healthcare, working conditions, and occupational health have worsened significantly during the health crisis, as compared to the previous situation. Previous studies have proposed strategies to enhance positive factors at work that compensate for increased workload and associated stress [50]. Stressors may be associated with the threat of contracting the disease, infecting others, or with work itself, but may also be due to measures taken to limit the transmission of the virus [5]. Socio-economic and political reasons have been offered for why certain countries had a worse response to the pandemic [51], among others the low percentage of healthcare professionals who had been vaccinated in some countries and which may have been influencing their behaviour within the population as a whole [52]. In Ecuador, the public health system’s response seemed insufficient specially regarding human resources and equipment, which increased the exposure to risk and fear of contagion of relatives [53].

The results found in the present study, in which healthcare workers have perceived a clear worsening of their working conditions during the pandemic, are consistent with what has already been published in Ecuador [11, 12] and explainable by the slow response of the Ecuadorian health system [13]. Being able to maintain and not worsen the working conditions in health centres during a pandemic will depend, to a large extent, on the strength of the public health system to take on this unforeseen increase in workload, especially in Primary Health Care [54]. However, as detailed in previous studies, public employees showed higher PD compared to employees of private or independent companies in this country [55]. The need to redefine the public mental health system after the COVID-19 pandemic in developed countries has been raised [56, 57], but this is more difficult for developing countries, such as most Latin American ones.

It should be noted that the data were collected in the first phase of the COVID-19 pandemic, where the peak incidence occurred. This can be compared to the study conducted in four countries (Argentina, Chile, Colombia, and Ecuador) where, as expected, the worst mental health outcomes for healthcare workers were found during the peaks of the highest incidence of cases, in those working in Intensive Care Units, and those who were infected or had doubts about being infected [15].

The COVID-19 pandemic has highlighted the role of public health and the importance of acting in all areas of life: family, community, education, leisure, and work; this would be facilitated by incorporating the “occupational health perspective” into the public health system [58].

Among the limitations of the study, it is worth mentioning that most of the analysed population had university level of studies, as it was focused on medical and nursing staff. Thus, the results are less applicable to less qualified healthcare workers, who should also be studied. Another limitation is not having analysed the results in terms of the job function or whether the participant was working for a public or private institution. Another limitation could have been the need to have devices with internet access, but the group studied did not encounter any problem in this regard, and the questionnaire could be answered from any device: computer, tablet, or mobile phone. Regarding the statistical analysis, the non-probabilistic snowball sampling design, disseminated through institutions and social networks, was chosen to achieve a rapid response in the first phase of the pandemic, being this the method that has subsequently been used in the European [59]. Furthermore, it should also be noted that the internal consistency of the SOC scale in its published version adapted to Spanish obtained low values. On the other hand, the validation of the SOC-13 published in Spanish does not provide values for the minimum clinically important differences (MCID) either [60]. This issue could affect the assessment of the sense of coherence in the present study. Therefore, future studies should update the psychometric properties of the scale in its Spanish adaptation.

The greatest limitation of this research is related to the work requirements of health personnel during the first phase of the pandemic, when the information was collected, conditioning the number of responses but, at the same time, giving greater value to the people who responded. Some variables have not been considered in this study, but it would be necessary to include them in future research, such as the specific area of work, work experience and work status.

In conclusion, during the first phase of the pandemic, the variables that determine the level of sense of coherence among healthcare workers in Ecuador are PD, WE, work environment, age, feeling appreciated by society as a healthcare professional, and having observed an increase in labour conflict in their work during the pandemic.

The healthcare workers assessed felt that the quality of care, working conditions, occupational health, and patient safety had significantly worsened, as compared to the situation prior to the health emergency caused by the COVID-19 pandemic. As a whole, these workers have a high SOC and are associated with WE in its three dimensions: Vigour, Absorption, and Dedication, as well as with PD, but inversely. Work environment is significantly correlated with the level of safety and effectiveness provided by the companies to protect themselves from infection by COVID-19 or the distance maintained by colleagues to avoid infection. The degree of job satisfaction during the pandemic or the perception of being appreciated as a healthcare professional by society are variables that condition the SOC, while the level of conflict in the workplace or the level of stress are inversely associated. Finally, it is worth noting the great importance given to the need for psychological support for those affected by the disease, the healthcare professionals involved in the treatment, and even the general population.