|Year : 2021 | Volume
| Issue : 3 | Page : 58-63
Effect on mental health of health-care providers during COVID-19 pandemic
Arvind Sharma1, Priyanka Dubey1, Deepali Soni1, Richa Sharma2, Aditi Bharti1, Tej Pratap Singh1
1 Department of Community Medicine, NSCB Medical College and Hospital, Jabalpur, Madhya Pradesh, India
2 Department of Emergency Medicine, NSCB Medical College and Hospital, Jabalpur, Madhya Pradesh, India
|Date of Submission||08-Feb-2021|
|Date of Decision||08-Jun-2021|
|Date of Acceptance||17-Jun-2021|
|Date of Web Publication||28-Dec-2021|
Dr. Priyanka Dubey
C/O Satyapriya Dubey, Shanichara Ward, Morchali Chouk, Behind DR, Thapak's Clinic, Hoshangabad - 461 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Health-care providers played a crucial role in responding to the public health emergency due to COVID-19 pandemic. Therefore, our study aimed to assess depression, anxiety, and stress (DAS) levels among the health-care providers in a COVID-19 dedicated health-care facility. Methodology: From the month of August to December 2020, a cross-sectional study was conducted on health-care providers who were involved in providing health-care services to COVID-19 patients in a tertiary care institute of Jabalpur by purposive convenient sampling through online Google Forms. The study tool used was validated depression, anxiety, and stress scale-21 having a good internal consistency having Cronbach's alpha value 0.85. Results: From 112 health-care providers, higher level of anxiety was found (29.46%) followed by depression (17.85%) and stress (16.07%). Mild, moderate, severe, and extremely severe anxiety were found in 18.75%, 7.14%, 1.78%, and 1.78%, respectively. Mild and moderate depression were found in 9.82% and 8.03%. Mild, moderate, and severe stress were found in 8.92%, 6.25%, and 0.89% of health-care providers, respectively. A significant association of depression, stress, and anxiety with designation of the participants was found (P < 0.001). Conclusion: To combat DAS, it is necessary to cascade awareness and knowledge should be disseminated. Regular screening of health-care providers, counseling, and stress management programs should be conducted.
Keywords: Anxiety, COVID-19, depression, health-care providers, mental health, stress
|How to cite this article:|
Sharma A, Dubey P, Soni D, Sharma R, Bharti A, Singh TP. Effect on mental health of health-care providers during COVID-19 pandemic. J Public Health Prim Care 2021;2:58-63
|How to cite this URL:|
Sharma A, Dubey P, Soni D, Sharma R, Bharti A, Singh TP. Effect on mental health of health-care providers during COVID-19 pandemic. J Public Health Prim Care [serial online] 2021 [cited 2022 Jul 5];2:58-63. Available from: http://www.jphpc.com/text.asp?2021/2/3/58/333899
| Introduction|| |
The severe acute respiratory syndrome coronavirus (SARS) pandemic originated from Wuhan city, Hubei Province, China, in December 2019. COVID-19 was declared as public health emergency of international concern by the World Health Organization.
The COVID-19 pandemic has made an intense and extensive impact on mental health of people across the globe. In addition to infection, COVID-19 pandemic has brought multiple challenges. Mental health issues are at the forefront therefore apart from the pandemic-induced mental health concerns, managing these conditions is a huge concern. Despite a fear of becoming infected, health-care providers have shown a resilience and professional dedication. The impact of the disease outbreak in mental health is usually neglected during pandemic, but their consequences are very costly. Work burden, increasing cases and deaths, inadequate personal protective equipment, lack of specific treatment, vulnerability of infection, having to stay in quarantine, media coverage, and feelings of being inadequately supported in the workplace are some of the contributing factors of mental burden in health-care providers.
“The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve suffering and save lives,” said by Dr. Tedros Adhanom Ghebreyesus, WHO Director-General. This pandemic has placed extraordinary levels of psychological stress on health workers exposed to high-demand settings for long hours, living in constant fear of disease exposure while separated from family and facing social stigmatization. Lack of definite cure for the infection made their work extra tough. Social, economic, psychiatric, and many other factors are responsible for deteriorating the health of these frontline health-care workers (HCWs) who are now being allegedly regarded as “healthcare warriors.” Experience of avoidance by their family or community due to stigma and fear can make an already challenging situation far more difficult. Many health-care professional in India have been pressurized by their landlords to evict them from residential complexes. Health-care activists have been physically attacked by mobs while trying to track connections from affected areas by coronavirus outbreak.
Depression is a mood disorder which is characterized by short-term emotional responses to a serious health condition associated with impaired daily functioning accompanied by symptoms, such as sadness and frustration, feelings of guilt, insensibility, and loss of interest. Anxiety disorders are defined as a group of mental disorders characterized by an unpleasant feeling with uneasiness or worry about future events or the fear of responding to current events. It may occur without an identifiable triggering stimulus. In stress, a person's lack of compliance with environmental conditions leads to psychological and biological changes, and the person is at risk of becoming ill.
Most may show more than one psychological presentation. These psychological disturbances may be linked to the many psychosocial stressors in the wake of the pandemic. Hence, management strategies primarily need to focus on mitigating the psychological stressors to the extent possible. The frontline personnel also need to be made aware of the various possible mental health support systems available locally if they wish to access help outside their workplace. The COVID-19 pandemic has caused major changes in our working format as health-care providers.
Stress, anxiety, and depression may be viewed as normal emotional reactions in the face of a pandemic. In previous pandemics, HCWs have experienced high levels of stress, anxiety, and low mood. Some literatures suggest high prevalence of mental health problems among the front-line workers (such as burnout, insomnia, anxiety, depression, illness anxiety, posttraumatic stress disorder, and so on) which is mediated by various biopsychosocial factors. Despite this, the mental health issues of the front-line HCWs and other health workers are often overlooked.
The literature published during the outbreak of SARS suggested that HCWs are at higher risk of developing anxiety, depression, and stress during these periods. Therefore, our study aims to assess depression, anxiety, and stress (DAS) levels among the health-care providers in a COVID-19 dedicated health-care facility.
| Methodology|| |
This is a cross-sectional, hospital-based study conducted from August 2020 to December 2020 in a COVID-19 dedicated tertiary health-care facility of Jabalpur, Madhya Pradesh. Study participants were selected from the duty rosters through purposive convenient sampling. The survey was done among 112 health-care providers which included doctors, nurses, wardboy/aayabai, and laboratory technicians. Data were collected through Goggle Forms.
Mental health screening tool used is depression, anxiety, and stress scale (DASS-21) which is based on three subscales which are depression, stress, and anxiety. Each subscale consists of seven questions. Each subscale comprises seven statements regarding how the test subject was feeling over the last week and four responses ranging from:
0-Did not apply to me at all
1-Applied to me some of the time
2-Applied to me for a considerable amount of time
3-Applied to me most of the time.
The scoring system is of the Likert type and the total score for each subscale gives the severity of that very symptom which has a range for each subscale.
The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale is sensitive to levels of chronic nonspecific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient. Scores for DAS are calculated by summing the scores for the relevant items.
Ethical permission has been obtained from the hospital authority. The purpose of the study was explained to every participant and consent was obtained from them.
Study participants were health-care providers (doctors, nurses, ward boys, aaya bai, and laboratory technicians) who were involved in COVID-19 duties.
- Health-care providers other than doctors, nurses, ward boys/aaya bais, and laboratory technicians were excluded
- People who refused to participate were excluded.
Data were checked for completeness and consistency, and the SPSS (IBM, Chicago, Illinois, U.S.A) software-version 20 (IBM Corp) was used. To determine the reliability of the DASS scale was used, Cronbach's alpha coefficient was measured. Descriptive analysis was done to summarize study participant's demographic information. Frequency tables were generated. Chi-square test was used to determine the association of DAS with sociodemographic characteristics of the participants. The statistical significance was considered with P < 0.05.
| Results|| |
In our study, the DASS-21 scale has good internal consistency having a Cronbach alpha value of 0.85. Cronbach's alpha values for each subscale of DAS came out to be 0.82, 0.84, and 0.72, respectively.
According to another study, the DASS scale has adequate internal consistency (Cronbach α: 0.761–0.906). According to another study, the reliability of DASS-21 has excellent Cronbach's alpha values of 0.81, 0.89, and 0.78 for the subscales of depressive, anxiety, and stress, respectively. It was found to have excellent internal consistency, discriminative, concurrent, and convergent validities.
In [Table 1], respondents in the age group of <30 years constituted 66.1% and in the age group of ≥30 years constituted 33.9% of the study participants. The predominant participants in this study were female (62.5%). Among 112 participants, 38.4% were doctors, 38.4 were nurses, 20.5% were wardboy/aayabai, and 2.7% were laboratory technicians.
In [Table 2], in health-care providers, anxiety was found to be most common which is 29.46% followed by depression in 17.85% and stress in 16.07%.
|Table 2: Prevalence of depression, anxiety, and stress in health-care providers (n=112)|
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[Table 3] depicts depression subscale, 9.82% of participants were reported mild depressive symptoms and moderate depression was found in 8.03%. For anxiety subscale, mild anxiety was found in 18.75%, moderate anxiety in 7.14%, severe anxiety in 1.75%, and extremely severe anxiety in 1.75%. For stress subscale, 8.92% of health-care providers were in mild stress, moderate stress was found in 6.25%, and severe stress was found in 0.89%.
|Table 3: Severity of depression, anxiety, and stress in health-care providers|
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In [Table 4], Chi-square (X2) analysis with two-tailed significance (P < 0.05) was performed to assess the statistical differences. In the age group, study participants <30 years were more stressed (21.62%) than the age group ≥30 years (7.90%). The association between age group and stress was to be insignificant (P = 0.067). In our study, males (19.04%) were found to be more stressed than females (15.71%). The association between gender and stress was found insignificant (P = 0.649). Furthermore, doctors (27.91%) were more stressed than other supporting staff (8.69%). The association between designation of the participants and stress was found to be significant (P = 0.024). Among the age group <30 years, 36.49% were found to be more anxious than the age group ≥30 years (15.79%). The association between age group and anxiety was found to be significant (P = 0.023). Females (32.86%) were found more anxious than males (23.80%). The association between gender and anxiety was found to be insignificant (P = 0.309). Doctors (51.17%) were more in anxiety in comparison with other supporting staff (84.05%). The association between designation and anxiety was found to be significant (P = 0.000). Depression was found more in among the age group <30 years (21.62%) than in the age group ≥30 years (10.52%). The association between the age of participants and depression was found to be significant (P = 0.147). Females (20%) were more depressed than males (14.29%) having no significant association (P = 0.445). Doctors (27.90%) were found more depressed than other supporting staff (88.40%). The association between designation and depression was found significant (P = 0.035).
|Table 4: Association of stress, anxiety, and depression with sociodemographic characteristics of the participants (n=112)|
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[Table 5] shows that the prevalence of depression is more in doctors (27.91%) than other supporting staff which includes nurses, wardboys/aayabai, and laboratory technicians (11.60%). Similarly, the prevalence of anxiety is more in doctors (51.17%) than nurses (15.95%). Stress was also higher in doctors (21.91%) than other supporting staff (8.70%). Therefore, DAS are more prevalent in doctors as compared to other supporting staff.
|Table 5: Depression, anxiety, and stress in relation with designation of the participants|
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| Discussion|| |
The COVID-19 outbreak has led to significant repercussions across various domains, including the economy, sporting, education, and health. This study offers important insight into the mental health impact of COVID-19 on health-care providers. Overall, out of total participants, 16.96% were in stress, 29.46% were in anxiety, and 17.85% were in depression. In a study, the rates of anxiety, depression, and stress were found to be 35.5%, 27.9%, and 72% among HCWs.
[Figure 1] shows a higher prevalence of anxiety followed by depression and stress among the participants. Anxiety can be due to fear of being infected or transmission of infection to loved ones and depression among them due to altered lifestyle, social distancing and guilt of spreading the virus to family and friends may be the issues experienced by health care workers.
|Figure 1: Prevalence of depression, anxiety, and stress among health-care providers|
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A systematic review by Salari et al. reported that the prevalence of depression was 24.3%, prevalence of anxiety was 25.8%, and prevalence of stress was found to be 45% among the hospital staff caring for the COVID-19 patients.
From [Figure 2], the above Venn diagram illustrates three circles showing percentages of DAS, that is 6.25%, 12.5%, and 6.25%, respectively. Depression and anxiety together were found in 3.75%, depression and stress together were found in 0.89%, and anxiety and stress together were found in 6.25% of participants. Symptoms of DAS together were found in 7.14% of participants.
|Figure 2: Venn diagram showing similarities and differences in depression, anxiety, and stress|
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Our study shows that the level of DAS in doctors was found to be 27.90%, 51.17%, and 30.23%, which was higher as compared to nurses (DAS – 18.60%, 23.26%, and 11.62%), wardboys/aayabai (DAS – 00%, 00%, and 4.34%), and laboratory technicians (DAS – 00%, 33.33%, and 00%). A study done by Maharaj et al. in nurses showed that the prevalence rates of DAS were found to be 32.4%, 41.2%, and 41.2%. In another study, the prevalence of depression (27.71%), anxiety (36.58%), and stress (24.24%) was found among the doctors.
In our study, the distribution of age is between 20 and 49 years. The mean age was found to be 29.04 ± 5.303 years.
Here is the graph in the x-axis showing age in years and y-axis showing frequencies (that is how many times the depression/anxiety/stress present at that particular age) [Figure 3]. The age is divided into two groups <30 and ≥30 years. Hence, in the age group <30, the prevalence of DAS is higher. More number of HCWs were found in DAS in the age <30 years (more in younger age group) than the age group ≥30 years. Another study by Dave et al. showed that the depression is significantly higher in the older age groups (>30 years).
|Figure 3: Depression, anxiety, and stress in relation with age (in years) of the participants|
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In our study, females have higher prevalence of DAS as compared to males. Another study by Lai et al. reported that nurses, women, those working in Wuhan, and frontline workers had more severe symptoms on all measurements. In a study conducted by Zhang et al., a sample of 304 health-care staff was taken from which anxiety was found in 28.0%, depression was found in 30.6%), and distress was in 20.1%. A study done by Fang et al. showed that depression score was higher among females than males. Nurses had higher depression scores than doctors.
A systemic review by Vizheh et al. showed in the results that nurses, female workers, front-line HCWs, younger medical staff, and workers in areas with higher infection rates reported more severe degrees of all psychological symptoms than other HCWs.
In a study, females showed more severe degrees of measurement of anxiety symptoms than males. Out of total of 151 participants, 141 (93.4%) participants were concerned about being exposed to COVID-19 at work and 112 (74.2%) thought they have inadequate protective equipment for safety.
In some conditions, females are more likely to get emotional like due to death of a patient and family problems. Excessive pressure and workload due to significant increase in number of patients made working life of health-care worker more stressful. In addition, doctors perceive a greater risk of owing to their exposure to the patient, added further stress. Here in our study doctors have the highest level of DAS compared to other groups of health-care providers.
| Conclusion|| |
The stigmatization experienced by HCWs like hurtful social distancing at their home, shops, and place of worship and some instances like landlords denying residential accommodation to HCWs affect the mental health. Friends and relatives may show reluctance to interact with them. Therefore, our prior concern should be to ensure positive mental health and early interventions for health-care providers in COVID-19 treatment settings. The health-care providers also need to be made aware of the various possible mental health support systems available locally. Regular monitoring should be done to find out potential DAS disorders. It is necessary to offer training and counseling to hospital staff on DAS which increases the productivity of the hospital staff and provides more effective treatment procedures for the COVID-19 patients. Primary care physicians play an important role in early diagnosis and are the first approachable person for the community. The second wave of COVID-19 infection is spreading at a much higher intensity. Therefore, due to this, primary care physicians have become overburdened which would affect their mental health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]