Psychological impact of COVID-19 on health-care workers: A multicenter cross-sectional study
Mohammad Mousavi1, Najmeh Ahmadi2, Hooria Seyedhosseini Ghaheh3, Atefeh Vaezi1, Shaghayegh Haghjooy Javanmard4
1 Applied Physiology Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
2 Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Pharmaceutical Biotechnology and Pharmaceutical Sciences Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Physiology, Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||04-Oct-2020|
|Date of Decision||15-Dec-2020|
|Date of Acceptance||18-Jan-2021|
|Date of Web Publication||30-Sep-2021|
Dr. Atefeh Vaezi
Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Health-care workers (HCWs) as frontline soldiers are involved in the war against COVID-19. Not only their protection from COVID-19 is important but also their mental health is a concern. This study aimed to measure the psychological distress among HCWs in the time of COVID-19 in Isfahan, Iran. Materials and Methods: A cross-sectional study was conducted in the 2nd month of the spread of COVID-19 in Isfahan, Iran (March 16 to April 3). A total of 321 HCWs participated in an online survey and answered the General Health Questionnaire, the Insomnia Severity Index, and the Medical Outcomes Study Social Support Survey. t-test and ANOVA were used for comparing variables between groups. Multiple linear regression was used to evaluate the predictive factors of psychological distress. Results: About 34% of our HCWs suffer from some levels of psychological distress. The result of multiple linear regression (R2: 0.41) shows that the predictive variables with the highest value were insomnia, working as a medical resident, and lack of social support (standardized coefficient of beta: 0.51, 0.25, and 0.16, respectively; P < 0.05). Conclusion: The result of our study shows that about one-third of HCWs in COVID-19 special hospitals have some psychological problems. Being a medical resident, suffering from insomnia, and lack of social support are predictive variables.
Keywords: COVID-19, health personnel, mental health, public health
|How to cite this article:|
Mousavi M, Ahmadi N, Seyedhosseini Ghaheh H, Vaezi A, Javanmard SH. Psychological impact of COVID-19 on health-care workers: A multicenter cross-sectional study. J Res Med Sci 2021;26:77
|How to cite this URL:|
Mousavi M, Ahmadi N, Seyedhosseini Ghaheh H, Vaezi A, Javanmard SH. Psychological impact of COVID-19 on health-care workers: A multicenter cross-sectional study. J Res Med Sci [serial online] 2021 [cited 2021 Dec 1];26:77. Available from: https://www.jmsjournal.net/text.asp?2021/26/1/77/327205
| Introduction|| |
More than a year have passed since the announcement of the first cases of COVID-19 in China. In the era of COVID-19, one of the main responsibilities of public health is to protect health-care workers (HCWs). First from the main disease as HCWs are the frontline of the fight against this pandemic, but afterward, they must be protected from the psychological impacts. Working as a frontline HCW in times of health crisis can increase the risk of mental problems in the short and long term., Previous studies in outbreaks of SARS and MERS revealed that HCWs in comparison to the normal population may suffer more frequently from psychological symptoms such as insomnia, depression, anxiety, and stigmatization.,, Furthermore, it has been reported that HCWs involved in the SARS outbreak experienced significant levels of chronic psychological distress for more than 1 year after the outbreak, showing that the reaction is not merely an adjustment disorder.,
A Chinese study reports higher anxiety scores in HCWs who perform direct care from cases of COVID-19, who are residence of more infected areas, and who are suspected cases themselves. Another study reports a higher rate of anxiety in nurses in comparison to doctors. General distress, depression, and insomnia are other problems reported in 72%, 50%, and 34% of HCWs, respectively. Considering that countries should be prepared for the next wave and potential future outbreaks, focusing on the mental problems of HCWs has become an important concern for governments. Although the pandemic of COVID-19 is a global concern, and peoples all over the world may experience the same problems and situations, but local estimations are also important due to affecting factors such as work shifts, ambiguities related to disease, lack of protection equipment, concerns about delivering the disease to family members, and also the level of mental preparedness., Moreover, different public health measures and the epidemic situation in each area make it necessary to evaluate HCWs' mental health status locally. Therefore, we evaluated the psychological impact of COVID-19 on HCWs in Isfahan, Iran.
| Materials and Methods|| |
This cross-sectional study was conducted in four tertiary hospitals (Khorshid, Amin, Eisabnemaryam, and Gharazi) in Isfahan, Iran, from March 16 to April 3, 2020. During the study period, these hospitals were actively allocated to COVID-19 patients. Participants include HCWs who are directly/indirectly involved with the care of confirmed or suspected cases of COVID-19.
The sample size was estimated to be 330 and calculated considering the population size of 3000 and expected frequency of 44% for psychological disorder with a power of 80% and type I error of 5%. Using convenience sampling, participants were invited to fill the online questionnaire. The questionnaire consisted of four sections. In the first section, demographic data such as age, sex (female and male), occupancy (physician, resident, medical intern, nurse, and others), type of hospital (teaching and nonteaching), having a risk factor for COVID-19 in themselves or family member (diabetes, hypertension, cardiovascular diseases, respiratory diseases, and immunosuppressive states), and years of occupancy were gathered. In the following sections, the participant answered the General Health Questionnaire-12 (GHQ-12), Medical Outcome Study Social Support Survey (MOS-SSS), and Insomnia Severity Index (ISI).
GHQ-12 is developed by Goldberg and Williams in 1988 and validated in Persian by Montazeri et al. for measuring psychological distress. The questionnaire consists of 12 items on a four-point scale (less than usual, no more than usual, rather more than usual, and much more than usual). Each item scores from 0 to 3, the total score would be 0–36, and higher scores indicate worse psychological distress. A score of 16 and more means higher psychological distress.
MOS-SSS is developed in 1991 by Sherburne and Stewart to measure the sense of social support and validated in Persian. The questionnaire contains 19 items and measures four dimensions: tangible support, emotional and informational support, affectionate support, and positive social interaction. The scoring is on the Likert scale (1: none of the time to 5: all of the time), and the total score is 19–95. The higher the score means a higher sense of social support.
ISI is a 7-item questionnaire used to assess insomnia. This questionnaire was developed by Morin and validated in Persian by Yazdi et al. Each item scores on the Likert scale (0–4), and the total score is between 0 and 28. A higher score suggests more severe insomnia. A score of 8 and more indicates some levels of insomnia.
Data were analyzed in SPSS 21.0.1 (SPSS Inc., Chicago, IL, USA). Qualitative and numeric variables were expressed as frequency distribution and mean ± standard deviation (SD), respectively. t-test and ANOVA were used for comparing variables between groups. Pearson correlation was used to evaluate the correlation between numeric variables. Multiple linear regression model was used to find the predictive factors for psychological distress. The level of significance was considered at 0.05.
This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.MED.REC.1398.735) and was conducted following the Declaration of Helsinki. Before participation, participants were given information about the aims of this study, voluntary participation, and the ability to withdraw at any time. All data were handled anonymously.
| Results|| |
In this study, 321 HCWs from major tertiary hospitals in Isfahan which were dedicated to COVID-19 patients participated in an online self-administered survey from March 16 to April 3. [Supplementary 1] shows the outbreak situation before and during the study period.
The mean age of participants was 33.5 years (SD: 7.65, range: 23–65). The mean of working experience in our study sample was 6.7 years (SD: 6.20, range: 1–30). In the study sample, 236 (73.8%) participants were female and 156 (48.6%) of them were a nurse.
The mean of GHQ in the whole sample was 13.3 (SD: 6.1, range: 2–36), and 105 (33.4%) participants had psychological distress. The mean score of ISI was 10.3 (SD: 5.95, range: 0–25), and just 123 (38.8%) participants had normal sleep. Considering the sense of social support, the mean score of MOS-SSS in our sample was 68.2 (SD: 16.26, range: 19–95). [Table 1] shows more results based on different demographic variables. [Supplementary 2] is presenting the distribution of GHQ-12 and ISI total score.
|Table 1: Demographic characteristics by General Health Questionnaire-12, Insomnia Severity Index, and Medical Outcomes Study Social Support Survey|
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The Pearson correlation analysis revealed that there is a statistically significant correlation between GHQ-12 and age (r: −0.12, P: 0.02), working year (r: −0.12, P: 0.03), ISI score (r: 0.56, P: 0.000), and social support score (r: −0.27, P: 0.000).
To define the predicting factors for psychiatric distress, multiple linear regression was performed (R2: 0.41). The results show that participants who are female, work as a resident, have a lower sense of social support, and have more severe insomnia index were more likely to have psychological problems [Table 2].
|Table 2: Risk factors for psychological distress identified by multiple linear regression analysis|
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| Discussion|| |
In our cross-sectional study, 321 HCWs working in Isfahan hospitals participate in an online survey about psychological distress at the time of the COVID-19 outbreak. About one-third of participants had some levels of psychological problems.
Our study shows that being female, young, working as a medical resident, lower sense of social support, and having insomnia are predictive factors for psychological distress.
In a meta-analysis, the prevalence of stress, anxiety, and depression in the general population in the time of COVID-19 was reported to be 29.6%, 31.9%, and 33.7%, respectively. In a study on the Iranian general population using the State-Trait Anxiety Inventory, 68% of responders had moderate-to-severe anxiety. About 40% of the Chinese youth population have some levels of psychological problems some weeks after the occurrence of COVID-19. From Chinese HCWs, 44% reported symptoms of anxiety. In Singapore, 11% of HCWs reported anxiety and 6% reported stress symptoms. In our study, we found psychological distress in 34% of HCWs, which is much lower than the frequency of stress symptoms in Iranian general population; this difference could be due to higher health literacy of HCWs. The frequency of psychological distress in our study is almost lower than theprevalence of anxiety symptoms in Chinese HCWs, but much higher than the reported prevalence in Singapore. Different factors may be a contributor to the prevalence of mental health problems, such as the behavior of the epidemic and the time of the survey in different countries.
One of the predicting factors for psychological distress in our study was being female and younger age, although not as strong as a sense of social support, insomnia, and working as a medical resident. This finding was in line with previous studies which reported that women are at higher risk for incidence of psychological symptoms in the general population, and also in HCWs. Moreover, previous studies showed that work conditions may affect women differently, for example, family-related roles of women prevail as another source of stressors. Although older adults are more susceptible to COVID-19, studies show that youngers are more susceptible to psychological distress which may be due to weaker resilience factors and lower resources in face of crisis.,
Another aspect of mental health is sleep quality. In this study, we found that only about 38% of our study population have no problem with sleep and others suffer from different levels of insomnia. Besides, we found that working in teaching hospitals is associated with insomnia but not with psychological impact. On the other hand, working as a resident (considering that residents are working in teaching hospitals) is a predictive factor for psychological problems but not for insomnia. This is in contrast to a recent study, which reports that nurses in comparison to physicians are more prone to mental symptoms which may be due to different working conditions.
Loneliness and Isolation is another factor that predisposes HCWs to stress and anxiety. Our findings in line with previous studies show that lack of social support is related to mental health problems., Lack of social support in the time of COVID-19 may be more prominent for HCWs as they have to keep the distance from their family members who are a principal source of support and they also face the loss of co-workers which is also another stressor itself., Although one reason for anxiety and stress is reported to be family concerns, the result of our study shows that this is not related to the level of risk of the family members. The lacks of enough knowledge about COVID-19 treatment and uncertainty around its progression as well as the shortage of resources have encountered HCWs with difficult situations and sometimes moral dilemmas during the pandemic.
Other important issues in worker stress are leadership styles and patterns of management communication. Hence, organizational psychological support should be mentioned. Prior pandemics have demonstrated that the context of an organization has a potent effect on psychological outcomes for the employees. In pandemics, clear protocols and preventive measures reduce the likelihood of emotional distress, as does peer support. Shanafelt et al. in their recent study on the anxiety of HCWs has found five main requests of HCWs from their employer during the COVID-19 pandemic: hear me, protect me, prepare me, support me, and care for me. Hence, psychological support of health care workers will protect them to perform their best over an extended period of Covid-19 pandemic and any other health crisis.
| Conclusion|| |
Altogether, HCWs need support, physically and mentally. They need a psychologically safe environment, robust leadership, organizational plans for staff well-being, consistent communication, and team support. Taking care of those who take care of the community is not only inevitable but also a moral duty of the health system. The result of our study has proved that designing early supportive psychological interventions to improve the mental health of HCWs is important.
The authors would like to thank all HCWs, who care for the health of the communities. This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.MED.REC.1398.735).
Financial support and sponsorship
This study was financially supported by Isfahan University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al
. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.
Krystal JH. Responding to the hidden pandemic for healthcare workers: Stress. Nat Med 2020;26:639.
Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behavior Immun 2020;88:901-7.
Maunder RG, Lancee WJ, Balderson KE, Bennett JP, Borgundvaag B, Evans S, et al
. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis 2006;12:1924-32.
Park JS, Lee EH, Park NR, Choi YH. Mental health of nurses working at a government-designated hospital during a MERS-CoV outbreak: A cross-sectional study. Arch Psychiatr Nurs 2018;32:2-6.
Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: Rapid review and meta-analysis. BMJ 2020;369:m1642.
Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al
. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168:1245-51.
Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, Sham PC, et al
. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry 2007;52:233-40.
McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KW, Sham PC, et al
. Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. Can J Psychiatry 2007;52:241-7.
Liu CY, Yang YZ, Zhang XM, Xu X, Dou QL, Zhang WW, et al
. The prevalence and influencing factors in anxiety in medical workers fighting COVID-19 in China: A cross-sectional survey. Epidemiol Infect 2020;148:e98.
Huang J, Han M, Luo T, Ren A, Zhou X. Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi 2020;38:E001-E.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al
. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
Chirico F, Nucera G, Magnavita N. COVID-19: Protecting healthcare workers is a priority. Infect Control Hosp Epidemiol 2020;41:1117.
Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al
. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 2020;173:317-20.
Ayanian JZ. Mental health needs of health care workers providing frontline COVID-19 care. American Medical Association. In JAMA Health Forum 2020;1:e20039.
Zhang SX, Liu J, Afshar Jahanshahi A, Nawaser K, Yousefi A, Li J, et al
. At the height of the storm: Healthcare staff's health conditions and job satisfaction and their associated predictors during the epidemic peak of COVID-19. Brain Behav Immun 2020;87:144-6.
Golderberg D, Williams P. A User's Guide to the General Health Questionnaire. Windsor, UK: NFER-Nelson; 1988.
Montazeri A, Harirchi AM, Shariati M, Garmaroudi G, Ebadi M, Fateh A. The 12-item general health questionnaire (GHQ-12): Translation and validation study of the Iranian version. Health Qual Life Outcomes 2003;1:66.
Cano A, Sprafkin RP, Scaturo DJ, Lantinga LJ, Fiese BH, Brand F. Mental health screening in primary care: A comparison of 3 brief measures of psychological distress. Prim Care Companion J Clin Psychiatr 2001;3:206-10.
Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32:705-14.
Khazaee-Pool M, Bahrami M, Luque JS, Pashaei T, Taymoori P, Roshani D. Validation of the Farsi version of the medical outcomes study-social support survey for mammography. BMC Public Health 2018;18:1280.
Morin CM. Insomnia: Psychological Assessment and Management. New York: Guilford Press; 1993.
Yazdi Z, Sadeghniiat-Haghighi K, Zohal MA, Elmizadeh K. Validity and reliability of the Iranian version of the insomnia severity index. Malays J Med Sci 2012;19:31-6.
Javanmard SH, Nasirian M, Ataei B, Vaseghi G, Vaezi A, Changiz T. Isfahan COvid-19 REgistry (I-CORE): Design and methodology. J Res Med Sci 2020;25:32. [Full text]
Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, et al
. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: A systematic review and meta-analysis. Global Health 2020;16:57.
Wong LP, Alias H, Danaee M, Ziaee M, Adebi F, Ziaee A, et al
. Uncovering psychobehavioral implications of SARS-CoV-2 infection in Iran. Transbound Emerg Dis 2020;67:2892-900.
Liang L, Ren H, Cao R, Hu Y, Qin Z, Li C, et al
. The effect of COVID-19 on youth mental health. Psychiatr Q 2020;91:841-52.
Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al
. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 2020;173:317-20.
Al Sayah F, Majumdar SR, Williams B, Robertson S, Johnson JA. Health literacy and health outcomes in diabetes: A systematic review. J Gen Intern Med 2013;28:444-52.
Ro JS, Lee JS, Kang SC, Jung HM. Worry experienced during the 2015 middle east respiratory syndrome (MERS) pandemic in Korea. PLoS One 2017;12:e0173234.
Li LZ, Wang S. Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom. Psychiatr Res 2020;291:113267.
Gómez-Salgado J, Andrés-Villas M, Domínguez-Salas S, Díaz-Milanés D, Ruiz-Frutos C. Related health factors of psychological distress during the COVID-19 pandemic in Spain. Int J Environ Res Public Health 2020;17:3947.
Salazar de Pablo G, Vaquerizo-Serrano J, Catalan A, Arango C, Moreno C, Ferre F, et al
. Impact of coronavirus syndromes on physical and mental health of health care workers: Systematic review and meta-analysis. J Affect Disord 2020;275:48-57.
Collins BS, Hollander RB, Koffman DM, Reeve R, Seidler S. Women, work and health: Issues and implications for worksite health promotion. Women Health 1997;25:3-8.
Ehrlich H, McKenney M, Elkbuli A. Protecting our healthcare workers during the COVID-19 pandemic. Am J Emerg Med 2020;38:1527-8.
Hou T, Zhang T, Cai W, Song X, Chen A, Deng G, et al
. Social support and mental health among health care workers during coronavirus disease 2019 outbreak: A moderated mediation model. PLoS One 2020;15:e0233831.
González-Sanguino C, Ausín B, Castellanos MÁ, Saiz J, López-Gómez A, Ugidos C, et al
. Mental health consequences during the initial stage of the 2020 coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun 2020;87:172-6.
Ornell F, Halpern SC, Kessler FH, Narvaez JC. The impact of the COVID-19 pandemic on the mental health of healthcare professionals. Cadernos de Saúde Pública 2020;36:e00063520.
Spoorthy MS, Pratapa SK, Mahant S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review. Asian J Psychiatr 2020;51:102119.
Xiao H, Zhang Y, Kong D, Li S, Yang N. The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China. Med Sci Monit 2020;26:e923549.
Greenberg N. Mental health of health-care workers in the COVID-19 era. Nat Rev Nephrol 2020;16:425-6.
Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al
. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatr 2020;7:e14.
Wu PE, Styra R, Gold WL. Mitigating the psychological effects of COVID-19 on health care workers. CMAJ 2020;192:E459-60.
Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. BMJ 2020;368:m1211.
Chan AO, Huak CY. Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med (Lond) 2004;54:190-6.
Blake H, Bermingham F, Johnson G, Tabner A. Mitigating the psychological impact of COVID-19 on healthcare workers: A digital learning package. Int J Environ Res Public Health 2020;17:2997.
Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020;323:2133-4.
[Table 1], [Table 2]