|Year : 2021 | Volume
| Issue : 1 | Page : 15-21
Pandemic and psychological outcomes among health-care practitioners: A cross-sectional study based on current evidence in Indian context amidst COVID-19
Sunny Garg1, Alka Chauhan1, Devesh Sharma2, Sanjeet Singh3, Kirti Bansal4
1 Department of Psychiatry, Bhagat Phool Singh Government Medical College for Women, Sonipat, Haryana, India
2 Department of Psychiatry, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
3 Department of Community Medicine, Bhagat Phool Singh Government Medical College for Women, Sonipat, Haryana, India
4 Department of Literature, Kirori Mal College, New Delhi, India
|Date of Submission||07-Oct-2020|
|Date of Acceptance||22-Nov-2020|
|Date of Web Publication||25-Mar-2021|
Dr. Sunny Garg
Department of Psychiatry, Bhagat Phool Singh Medical College for Women Khanpur Kalan, Sonipat, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: The dramatic spread of SARS-Cov-2 and the following fatalities put the health-care practitioners under high pressure and increased workload. Coping mechanisms adapted by health-care practitioners represent a challenge to their psychological resilience. This type of pandemic produces fearful behavior and increases the risk of adverse psychological responses. The aim was to study the prevalence of psychological outcomes and exploring the associated factors among health-care practitioners amidst COVID-19.
Materials and Methods: This is a cross-sectional, online survey of 588 health-care practitioners who were fighting against the COVID-19. The survey was applied in August, 2020, using a questionnaire that measures depression, anxiety, and stress. Survey included two sections, sociodemographic characteristics and Depression Anxiety Stress Scale-21 (DASS-21) scale. SPSS 22.0 software package was used for statistical analysis. Binary logistic regression analysis was used to assess the factors associated with psychological problems. Pearson's correlation was also used to assess the correlation among the psychological outcomes themselves.
Results: Out of 588 health-care practitioners, 49.65% had depressive symptoms, 41.15% had anxiety symptoms, and 30.95% were distressed. Around 25%–35% of health-care practitioners had moderate-to-severe symptoms. Mean age was 28.78 years, and mean score of DASS-21 was 31.29 (standard deviation SD = 27.07). Binary logistic regression analysis revealed that working as specialists and as frontline workers was significantly associated with different psychological outcomes (anxiety and stress). A statistically significant correlation was found between stress, anxiety, and depression.
Conclusions: This study revealed that a large number of health-care practitioners were affected severely by psychological morbidities, which required a mental health professional consultation. These negative outcomes were invisible, inconvenient, and frightening in reality. Therefore, recognition of other risk factors and planning of interventions would be beneficial in reducing the damage to psychological well-being of these practitioners.
The following core competencies are addressed in this article: Clinical knowledge, Practice-based learning and improvement, System-based practice.
Keywords: COVID-19, frontline, health-care practitioners, pandemic, psychological outcomes
|How to cite this article:|
Garg S, Chauhan A, Sharma D, Singh S, Bansal K. Pandemic and psychological outcomes among health-care practitioners: A cross-sectional study based on current evidence in Indian context amidst COVID-19. Int J Acad Med 2021;7:15-21
|How to cite this URL:|
Garg S, Chauhan A, Sharma D, Singh S, Bansal K. Pandemic and psychological outcomes among health-care practitioners: A cross-sectional study based on current evidence in Indian context amidst COVID-19. Int J Acad Med [serial online] 2021 [cited 2021 Oct 27];7:15-21. Available from: https://www.ijam-web.org/text.asp?2021/7/1/15/311878
| Introduction|| |
The 2019 novel coronavirus SARS-Cov-2 pandemic (COVID-19) is a public health emergency of international concern declared by the WHO, which is unprecedented in modern history. Previous studies have shown that pandemics have been followed by drastic individual and psychosocial impacts in the general population, which eventually become more pervasive than the disease itself., During this pandemic, as the world faces a shutdown, and individuals are encouraged to reduce their interactions, health-care workers generally need to go in the opposite direction. This can lead them to come into contact with patients and isolate themselves from the society and change their routine. With the increasing number of confirmed cases and death counts due to SARS-Cov-2 pandemic, it exerts a great deal of pressure and poses a challenge to the health-care systems.
It has been observed from the past experiences, during outbreaks of infectious diseases, health-care practitioners come to play a pivotal role in managing the patients and pushing themselves to the best of their capacity every day. Health-care practitioner being in the frontline of the system, acts as a great force in fighting against the novel coronavirus. Health-care practitioners are subjected to additional stress due to coming in direct contact with patients and their body fluids while assisting the patients with diagnosed or suspected SARS-Cov-2. Due to which chances of infection increase manifold among the health-care practitioners. By August 30, 2020, according to the Indian Medical Association (IMA), around 87,000 health-care workers had been infected and 573 of them had lost their lives. IMA also registered a total of 2006 health-care practitioners infected and 307 health-care practitioners (doctors) deaths by this novel coronavirus.
Health-care practitioners are more prone to develop negative psychological outcomes, which had also been reported during the infectious disease outbreaks in the past (SARS in 2003, Ebola in 2014, and MERS in 2015).,, Given the magnitude of COVID-19 and the stress undergone by the health-care practitioners, adverse psychological outcomes are expected to occur among these frontline health-care practitioners., These adverse psychological outcomes among health-care practitioners are usually determined by a variety of factors and can negatively affect their work efficiency or hinder their performance and long-term well-being.
A more comprehensive understanding of psychological outcomes in health-care practitioners during this period is crucial for providing psychological support, improving mental health support services, and strengthening mental health worldwide. Up to now, little is known about the psychological outcomes and psychological needs of health-care practitioners facing this global disaster in one of the most severely affected countries like India (second most affected). Based on this perspective, we aimed at conducting this cross-sectional study which investigated the prevalence of psychological outcomes such as depression, anxiety, and stress among health-care practitioners during the COVID-19 pandemic in India as well as some sociodemographic and work-related factors that are associated with these psychological problems.
| Materials and Methods|| |
Study design and settings
A cross-sectional, observational study was performed, using the various social media platforms (WhatsApp, facebook, e-mail etc.) in August 2020 in India. We chose the online survey to minimize the face-to-face interactions and to facilitate the participation of health-care practitioners who were working extensively during this emergency period. They were invited to participate in the self-administered online survey. An informed consent was provided at the beginning of survey with Yes/No question.
Health-care practitioners from different regions throughout India were recruited. All health-care practitioners working in emergency services, outpatient departments (OPDs), wards, special care units, or intensive care units where SARS-Cov-2 suspected or confirmed cases and patients with respiratory illnesses were provided consultation were selected from government and private hospitals either regardless they were COVID-exclusive (hospitals admitting, treating, and caring the patients diagnosed/suspected with SARS-Cov-2 only) or nonexclusive (treating the patients other than SARS-Cov-2). Medical students were excluded as they were not involved in clinical practice.
Methods and tools
The participants were contacted through a designated link. The link was also posted in social media group comprised only health-care practitioners. On receiving and opening the link, the participants were directed to the information about the study and informed consent. Once they provided the consent, they filled up the demographic details. Then, a set of questions appeared, which the participants were to answer. Those who did not give consent for participation in the study and did not complete the assessment were not involved in this study. It was found that this form takes around 5 min to complete it. During the study, the anonymity and confidentiality of the participants were maintained. The data were collected from August 20 to 30, and a total of 617 responses were obtained. The data were examined, and 29 responses were removed as 11 were incomplete responses and 18 respondents clicked “No” on the consent form. Hence, finally, 588 participants were enrolled in this study for further analysis.
The questionnaire was formed of the following sections:
- Sociodemographic section: This section included the data for age, gender, their designation, and status of their working place
- Depression Anxiety Stress Scale-21 (DASS-21): The depression anxiety stress scale (DASS-21) is a self-reporting tool containing 21 items that assess three constructs: depression, anxiety, and stress. Each subscale includes seven statements. Items consist of statements referring to the previous week; respondents were asked to read these statements, and rate the frequency of the negative emotions. The ratings of DASS subscales can be rated as normal, mild, moderate, severe, and extremely severe. Ratings are made on the series of 4-point Likert-type scale from 0 (did not apply to me at all/never) to 3 (applied to me very much/always). This scale does not cover the several domains of depression such as sleep, appetite, and sexual functions, so it cannot be used as a diagnostic tool but can be applied as an aid to diagnostic tool as well as to measure treatment response. This scale has high internal consistency (Cronbach's alpha score >0.7). In this scale, the final score of each item is multiplied by two to obtain the final score. Higher score indicates more severe emotional distress.
The collected data were statistically analyzed using the SPSS 22.0 version (IBM). Descriptive statistics were calculated for sociodemographic and other variables. It was analyzed using frequencies, percentages, means, and standard deviations. Binary logistic regression analysis was used to calculate the associations between sociodemographic characteristics or other variables related to COVID-19 outbreak and psychological outcomes (subscale of DASS). After controlling for sociodemographic and working conditions, Pearson's correlation coefficient was calculated to assess the associations among depression, anxiety, and stress. Statistical significance of all two-tailed tests was set at P < 0.05.
| Results|| |
Sociodemographic or participants characteristics
A total of 588 health-care practitioners from different regions in India were evaluated for the study, of whom 336 (57%) were female and 252 (47%) were male, with the average age of 28.78 years (standard deviation = 7.15 years). Out of the participants included, 240 (41%) were residents pursuing postgraduate degrees or junior residents, 230 (39%) were interns, and the rest 118 (20%) were those with postgraduate degrees or specialists. Most of the respondents (67.3%) were from the COVID-exclusive hospitals and 32.7% of participants were from the non-COVID exclusive hospitals. A large number (94%) of the health-care practitioners were in government practices. Around 52% of health-care practitioners were in direct contact and working on diagnosing, treating, or caring for the COVID-19 suspected or diagnosed patients (frontline worker) as shown in [Table 1].
|Table 1: Sociodemographic characteristics and prevalence of depression, anxiety and stress in health care practitioners (their number and percentage)|
Click here to view
Prevalence of psychological outcomes in health-care practitioners
The mean of stress subscale score (11.89 ± 10.78) was higher than the mean score of depression and anxiety subscales. Around 19% and 10% of health-care practitioners had only anxiety and only depression, respectively, as shown in [Table 2].
Around 49.65% of health-care practitioners reported depressive symptoms including 15.30% with mild depressive symptoms and 34.35% health-care practitioners with moderate/severe/very severe depressive symptoms [Figure 1]. The highest prevalence of depression was found in female (51%) health-care practitioners, mainly working as specialists (54%) working in COVID-exclusive hospitals (50%). Around 51% of frontline health-care practitioners had depressive symptoms [Table 1].
|Figure 1: Prevalence of psychological outcomes. Percentage of health-care practitioners with normal, mild, moderate, severe, extremely severe depression, anxiety, and stress|
Click here to view
About 41.15% of health-care practitioners reported anxiety symptoms including 8.50% with mild anxiety symptoms and 32.65% of health-care practitioners with moderate/severe/very severe anxiety symptoms [Figure 1]. The highest prevalence of anxiety was found in female (43%) health-care practitioners, mainly working as specialists (49%) and in frontline worker (45%). Anxiety symptoms were higher (44%) in health-care practitioners who belonged to non-COVID exclusive hospitals [Table 1].
Only 30.95% of health-care practitioners were stressed, including 6.12% who were mildly stressed and 24.83% health-care practitioners were moderately/severely/very severely stressed [Figure 1]. The highest prevalence of stress was found in male (33%) health-care practitioners, mainly working as specialists (44%) and as frontline worker (39%) in COVID-exclusive hospitals (32%) [Table 1].
Effects of sociodemographic characteristics and working condition variables on psychological outcomes of health-care practitioners
In unadjusted binary logistic regression analysis, several factors were significantly associated with depression, anxiety, and stress. Factors that were significantly associated with higher risk of anxiety included working as a specialist (odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.15–2.84) and as frontline worker (OR = 1.40, 95% CI = 1.01–1.95). Working at higher designation (junior resident < intern OR = 2.15, 95% CI 1.41–3.27; specialist < intern OR = 3.15, 95% CI = 1.93–5.12) and working as frontline worker (OR = 2.13, 95 CI = 1.48–3.06) were significantly associated with higher risk of stress in health-care practitioners as shown in [Table 3].
|Table 3: Binary logistic regression analysis: Associations between sociodemographic characteristics, variables related to COVID-19, and psychological outcomes of pandemic|
Click here to view
Correlation among levels of depression, anxiety, and stress
The calculated correlation coefficient is shown in [Table 4]. Statistically significant positive correlation was found between stress and depression (r = 0.732, P < 0.001) and stress and anxiety (r = 0.781, P < 0.001). Statistically significant positive correlation was also found between depression and anxiety (r = 0.632, P < 0.001).
| Discussion|| |
The present study showed the high prevalence of psychological effects such as depression, anxiety, and stress among different kinds of health-care practitioners involved in caring of the patients during the pandemic. This study also identified some risk factors which were significantly associated with psychological complications including the designation of health-care practitioners and working as frontline worker.
The SARS-Cov-2 like an acute crisis had an inescapable impact and complicated psychological responses on health-care practitioners. The mean age of health-care practitioners in the present study was 28.78 years, which is consistent with the another study and slightly younger than yet another study where the mean age was 36.05 years. The psychological problems were equally distributed with relative male preponderance, while most of the studies revealed that females were highly affected than their counterparts.,, Mean DASS score (31.29) and mean score of every subscale were found to be high as compared to an Indian study (27.24) done during the initial stages of COVID-19 pandemic might be due to greater increase in infection at present, burdened the health-care practitioners, and further worsened the overall mental well-being. The prevalence of depression, anxiety, and stress was found to be high in the present study, which is similar to the previous studies in different regions around the globe.,,, Compared to the results of multinational studies among health-care practitioners using the similar measurements, the proportion of depression, anxiety, and stress were relatively higher in this study,, might be due to the varying infrastructures and capabilities of health-care systems in different countries. The high levels of psychological outcomes could be due to a generalized pervading climate of uncertainty among the health-care practitioners triggered by limitations of training, job security, and fear of carrying the infection to family members. In developing countries like India, deprivation of protective gears, unsafe work environment, and poor working conditions could result in increased perception of risk and lead to lack of motivation and negative feelings. Previous studies have also suggested that high work load because of changes in duties as most of the practitioners from different specialties were assigned to work in the caring of suspected or diagnosed patients., The prevalence of psychological effects during COVID-19 pandemic is much higher than the prevalence during the SARS and MERS outbreaks (10%–30%) among the health-care practitioners., In terms of severity of psychological outcomes, in the present study, a large proportion (25%–35%) similar to a study done in India but lesser than the other study conducted in the early phase of the pandemic where 40%–50% health-care practitioners developed moderate-to-severe symptoms which is surely alarming.
Specialists having postgraduate degrees presented with more psychological problems than interns and junior residents similar to the other study done in the Indian context, but one of the studies revealed that intern and junior residents were affected more than the specialists. Another intriguing finding was that working as specialists during this pandemic was significantly associated with anxiety and stress. This could be due to the reason that most of the specialists were in direct contact with suspected or diagnosed cases of SARS-Cov-2 and were slightly elder (>35 years) and had lesser coping mechanisms in fighting against this stressful condition. Having children at home was another factor associated with anxiety and stress. Due to perceived stigma and anticipated damage to future career prospects, practitioners were more worried about being fit to practice., In this study, intern and junior residents also revealed high prevalence of the psychological outcomes which was highly surprising to us because while they were not in direct contact with diagnosed or suspected cases, these practitioners were more worried about their training or professional growth, could be the reason for the high prevalence. They were posted in OPDs and flu corners where they were in contact with other groups of patients and were highly exposed to a disease whose infectious nature is not clear. Another reason for these psychological problems in interns and junior residents was that they were always on stand for the specialists in fighting against the pandemic and were posted in emergency departments with a dynamic environment (rapidly changing and critical environment) where they could perceive high level of anxiety and stress.
The present study revealed that health-care practitioners were equally affected whether they were working in COVID-exclusive hospitals or not, with high preponderance in COVID-exclusive hospitals similar to another study done in China. Exponential increase in the number of cases and higher rate of admissions in these hospitals were the indicative factor for the higher psychological morbidities. Health-care practitioners were also under high stress in non-COVID exclusive hospitals as most of the government hospitals were changed to COVID-exclusive hospitals to increase the bed capacity, and other patients from these hospitals were forced to take the consultation from the non-COVID exclusive hospitals.
SARS-Cov-2 has not only affected the mental health of frontline health-care professionals (39%–51%) but also others who were not in the forefront (23%–48%). A study done by Amin et al. also revealed that 40%–45% of frontline workers had psychological problems during this pandemic. One of the interesting findings was that working as frontline workers was an independent risk factor for anxiety and stress, similar to a study done in China. The main reason behind the high prevalence could be lack of confidence in infection control, lack of knowledge and skills lead to development of guilt in frontline workers. In developing countries like India, frontline workers could feel stigmatized and rejected because they have to stay isolated or separated from family members and friends which leads to the loneliness and decrease in sharing their concerns with loved ones. An increasing influx of SARS-Cov-2-related morbidities also contributes to high mental pressures and may intensify the perception of personal danger.
The present study revealed that working continuously in high stressful conditions may have negative psychological outcomes such as depression, anxiety, and distress. It was observed that, during the previous outbreaks also,,, health-care practitioners endured a professional hardships. They overcame their own fears of the risk of infection and provided services largely because of professional loyalty, integrity, and obligation to perform professional duties and contribution to the quality of care.
This study was cross-sectional in nature and was conducted for a very short period. We need a longitudinal study throughout this pandemic in India to know the exact nature and causality of psychological problems. The participation of very few private health-care practitioners and voluntary nature of the study might have led to selection bias, which limits the generalizability of the findings. The results would have been better from clinical diagnostic interviews rather than a self-reported questionnaire because this questionnaire did not rely upon diagnostic assessment. The participants may understand and interpret the questions differently, which makes it difficult to assess the accurate responses.
| Conclusions|| |
The present study implied the overload of psychological problems among health-care practitioners. This study concluded that men who were more experienced (specialists) and were working in frontline in COVID-exclusive hospitals were in the high-risk group and should be monitored closely. Participation as frontline workers appears to be an important risk factor for anxiety and stress. A large number of health-care practitioners showed moderate-to-severe psychological symptoms and require consultation from mental health professionals and psychological interventions. Specific screening strategies should be applied to health-care practitioners as these psychological reactions will further affect their services to the patients. Health-care systems must show strong support for practitioners and should make some efforts to reduce the mental health stigma in clinical workplaces. This can be facilitated by deliberately adding mental health support process as an ongoing agenda.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The present study complies with the reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. Applicable EQUATOR network (https://www.equator-network.org) reporting guidelines were followed. This study protocol was reviewed and Ethics Committee approval for this study was granted by the institutional Ethics Committee with reference number UHSR/PS/20/4803 dated April 24, 2020. Consent statement was taken for participation in the study from each participant as per institutional Ethics Committee approval. Any data collected were confidential, without identifying features.
| References|| |
Li Z, Ge J, Yang M, Feng J, Oiao M, Jiang R, et al
. Vicarious traumatisation in the general public, members and non-members of medical teams aiding in COVID-19 control. Brain Behav Immun 2020;88:916-19.
Ornell F, Schuch JB, Sordi AO, Kessler FHP . “Pandemic fear” and COVID-19: Mental health burden and strategies. Braz J Psychiatry 2020 ; 42 : 232-5.
Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: Pivotal role for old style public health measures in the novel corona virus (2019-nCoV) outbreak. J Travel Med 2020;27:taaa020.
Chatterjee SS, Bhattacharya R, Bhattacharya S, Gupta S, Das S, Banerjee BB. Attitude, practice, behaviour and mental health impact of COVID-19 on doctors. Indian J Psychiatry 2020;62:257-65. [Full text]
Shigemura J, Ursano RJ, Morganstein JC, Kirosawa M, Benedek DM. Public responses to the novel 2019 corona virus (2019-nCoV) in Japan: Mental health consequences and target population. Psychiatry Clin Neurosci 2020;74:281-2.
Tam CW, Pang EP, Lam LC, Chiu HF. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline health care workers. Psychol Med 2004;34:1197-204.
Raven J, Wurie H, Witter S. Health workers' experiences of coping with the Ebola epidemic in Sierra Leone's health system: A qualitative study. BMC Health Serv Res 2018;18:251.
Lee SM, Kang WS, Cho AR, Kim T, Park JK . Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018 ; 87 : 123-7.
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 Psychiatry 2020 ; 7 : e14.
Bao Y, Sun Y, Meng S, Shi J, Lu L . 2019-nCoV epidemic: Address mental health care to empower society. Lancet 2020 ; 395 : e37-8.
Lovibond PF, Lovibond SH . The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 1995 ; 33 : 335-43.
Gupta AK, Mehra A, Niraula A, Kafle K, Deo SP, Singh B, et al
. Prevalence of anxiety and depression among the healthcare workers in Nepal during the COVID-19 pandemic. Asian J Psychiatry 2020;54:102260. [doi: 10.1016/j.ajp.2020.102260].
Elbay RY, Kurtulmuş A, Arpacıoğlu S, Karadere E . Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics. Psychiatry Res 2020 ; 290 : 113130 [doi:10.1016/j.psychres.2020.113130].
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al
. Factors associated with mental health outcomes along health care workers exposed to corona virus disease 2019. JAMA Netw Open 2020;3:e203976.
Liu S, Yang L, Zhang C, Xiang YT, Liu Z, Hu S, et al
. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020 ; 7 : e17-8.
Chew NW, Lee GK, Tan BY, Jing M, Goh Y, Ngiam NJ, et al
. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav Immun 2020 ; 88 : 559-65.
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.
Ruotsalainen JH, Verbeek JH, Marine A, Serra C. Preventing occupational stress in health care workers. Cochrane Database Syst Rev 2015;(4):CD002892. [doi: 10.1002/14651858].
Mohammed A, Sheikh TL, Poggensee G, Nguku P, Olayinka A, Ohuabunwo C, et al
. Mental health in emergency response: Lessons from Ebola. Lancet Psychiatry 2015 ; 2 : 955-7.
Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al
. The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009 ; 54 : 3012-11.
Amin F, Sharif S, Saeed R, Durrani N, Jilani D . COVID-19 pandemic – Knowledge, perception, anxiety and depression among frontline doctors of Pakistan. BMC Psychiatry 2020 ; 20 : 459.
Hassan TM, Sikander S, Mazhar N, Munshi T, Galbraith N, Groll D. Canadian psychiatrists' attitudes to becoming mentally ill. Br J Med Pract 2013;6:a619.
White A, Shiralkar P, Hassan T, Galbraith N, Callaghan R. Barriers to mental. Psych Bulletin 2006;30:382-4.
Galbraith N, Boyda D, McFeeters D, Hassan T. The mental health of doctors during the COVID-19 pandemic. BJPsych Bulletin 2020:1-4. [doi: 10.1192/bjb.2020.44].
[Table 1], [Table 2], [Table 3], [Table 4]