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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 98-104

Psychological impact and coping strategies in health-care workers during the coronavirus disease 2019 pandemic at a dedicated coronavirus disease 2019 hospital: A cross-sectional study


Department of Psychiatry, PCMC's Postgraduate Institute, YCM Hospital, Pune, Maharashtra, India

Date of Submission14-Jul-2020
Date of Decision05-Oct-2020
Date of Acceptance03-Jan-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Disha Devang Parikh
Department of Psychiatry, PCMC's Postgraduate Institute, YCM Hospital, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_208_20

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  Abstract 


Background: Health-care workers (HCWs) are on the frontline dealing with the Coronavirus Disease 2019 (COVID-19) pandemic all over the world. Several hospitals in India are now functioning as Dedicated COVID-19 Hospitals (DCH). This study has been designed to understand the psychological impact of the pandemic in HCWs at a DCH. Objectives: the objective of the study was to assess psychological impact and coping strategies in HCWs during the COVID-19 pandemic at DCH. Subjects and Methods: This is a cross-sectional observational study conducted at a DCH. The study used a semi structured questionnaire for demographic details and the tools-Depression Anxiety Stress Scale (DASS-21) and Brief COPE for assessing psychological impact and coping strategies, respectively, in HCWs willing to participate. Chi-square test was applied to establish an association between the demographic variables and psychological symptoms and Spearman's correlation coefficient was used to assess correlation between coping strategies and psychological symptoms. Results: Out of 136 participants, 43.4% (n = 59) had at least one of the symptoms among stress, anxiety, or depression on the DASS-21 scale. Resident doctors and nurses had a higher incidence of psychological symptoms (P = 0.009, χ2 = 13.58, df = 5). The presence of chronic illness was significantly associated with psychological symptoms (P = 0.036, χ2 = 4.38, df = 1). Higher values on the anxiety (ρ = 0.216, P < 0.05) and depression (ρ = 0.226, P < 0.05) subscales correlated with the increased use of avoidant coping strategies. Conclusions: There is significant psychological impact of the COVID-19 pandemic on HCWs. Regular assessment and mental health interventions must be part of the pandemic management. Building positive approach coping strategies can reduce stress and other psychological symptoms.

Keywords: Coping strategies, coronavirus disease 2019, healthcare workers, pandemic, psychological impact


How to cite this article:
Panse SN, Parikh DD, Santre MS, Wadgaonkar GP, Gholap SD, Raidurg KA, More JB, Karad AV, Meshram NS, Sikchi RS. Psychological impact and coping strategies in health-care workers during the coronavirus disease 2019 pandemic at a dedicated coronavirus disease 2019 hospital: A cross-sectional study. Indian J Soc Psychiatry 2021;37:98-104

How to cite this URL:
Panse SN, Parikh DD, Santre MS, Wadgaonkar GP, Gholap SD, Raidurg KA, More JB, Karad AV, Meshram NS, Sikchi RS. Psychological impact and coping strategies in health-care workers during the coronavirus disease 2019 pandemic at a dedicated coronavirus disease 2019 hospital: A cross-sectional study. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Jun 19];37:98-104. Available from: https://www.indjsp.org/text.asp?2021/37/1/98/312869




  Introduction Top


Today, the world and India alike are reeling under the pandemic of Coronavirus Disease 2019 (COVID-19). Since COVID-19 was declared a pandemic in March 2020 by the World Health Organization, health-care workers (HCW) are on the frontline dealing with this crisis.[1] The HCW has been called the COVID-19 warriors, but they are not immune to stress and psychological symptoms in this war against COVID-19.

Pandemics are not just a medical phenomenon; they cause disruption and affect individuals and society on many levels. Studies show depression rates usually soar after infection.[2],[3] During the outbreaks of severe acute respiratory syndrome (SARS) in 2003 and middle-east respiratory syndrome in 2015, frontline medical staff had reported high levels of stress, anxiety, and depression.[4],[5],[6]

Among the health-care providers, the frontline workers are more vulnerable to psychological stress due to several reasons.[7] They are facing excessive workload and extra work hours, working in incommodious personal protective equipment (PPE), along with frequently changing protocols and policies due to unprecedented novel coronavirus pandemic. They also feel inadequately supported and often face added stigma due to close contact with patients of a contagious disease.[4],[5],[8]

As compared to past pandemics, in the current scenario, widespread global connectivity and extensive media coverage are leading to the catastrophic reactions secondary to the outbreak.[9],[10] Recently, Lai et al. conducted a study in China involving 34 hospitals HCWs which included physicians, nurses, and other hospital staff and found 3/4th (n = 1257) of the study population of health workers were in distress, half of the participants reported symptoms of depression and a third of them reported insomnia, 2/5th of them reported anxiety symptoms.[11] A systematic review by Pappa et al. analysed 13 studies during COVID-19, majority of which were conducted in China assessing the prevalence of depression, anxiety, and insomnia among HCWs during the COVID-19 outbreak. The analysis showed high pooled prevalence for anxiety and depression at 23·2% and 22·8%, respectively.[12] As per our literature review, there is dearth of Indian studies on psychological effects of the pandemic on HCWs. Our study is one of the first to explore the psychological effects of COVID-19 on these frontline workers.

The outbreak having a global and rapid transmission has caused a burden on the public health system. To streamline and manage the COVID-19 pandemic, several hospitals in India have been converted and assigned as dedicated COVID-19 hospital (DCH) by the Ministry of Health and Family welfare, Government of India.[13] These hospitals are working exclusively focused on screening, testing and treating patients with severe COVID-19 illness. This study has been conducted in one such DCH in Maharashtra, where the COVID-19 pandemic management protocols were laid down for provision of health services exclusively for suspected and COVID-19-positive patients in a short span of time in April 2020. Since then, all doctors, nursing staff, interns and house-keeping staff at the DCH have been dealing with longer working hours wearing PPE and were often involved in emotionally and ethically fraught resource allocation decisions.

Along with changing work schedules and facing risk to infection, the medical staff at the hospital has had to function outside their individual specialties. Thus, facing various unprecedented situations, HCWs working at a DCH are vulnerable to psychological stress. Psychiatrists are uniquely situated to understand the potential mental health impact and impart psychological first aid to the COVID-19 warriors on the frontline. Hence, this study was planned to understand the psychological impact of the pandemic in HCWs and their coping strategies to combat them.


  Subjects and Methods Top


This cross-sectional observational study was conducted on doctors, nurses, and other HCWs at a DCH between April 25, 2020 and May 25, 2020, with the Institutional Review Board ethical approval (EC No.YCMH/WS/5/RV/714/2020) for this study. Two weekly reminders were sent to the participants. The study participation was voluntary. Data collection was followed by data analysis. This DCH is a 750 bedded hospital run by local Municipal Corporation, currently functioning for 500 inpatient beds due to strict social distancing norms and infection control measures. There are approximately 900 HCWs (Class 1 to Class 4) at the hospital.

Sample

The study sample consisted of HCWs at a DCH, willing to participate voluntarily and give informed consent for the study.

Study questionnaire

The study was conducted through use of Google Forms. The form was circulated among consultant doctors, resident doctor, nurses, interns, and hospital maintenance staff at DCH digitally through WhatsApp on Smartphones. The form was made available in English and Hindi languages. The Hospital maintenance staff is more well versed in Hindi. Thus, both language options were provided to the participants. The Google form link with brief introduction of study was sent to all official WhatsApp groups at the hospital at 2 weeks interval as reminders between April and May 2020. Participants were given information about the nature of the study and written informed consent of the participant was taken at the beginning of the form. The participant's brief medical history and demographic details were recorded in the semi structured pro forma on the Google form which included participant's age, gender, marital status, profession, current living situation and working profile. The study used the Depression Anxiety Stress Scale (DASS)-21 as the tool for assessing psychological impact of COVID-19 and Brief COPE inventory for evaluating coping strategies used by HCWs. Overall, it took 15–20 min to fill the entire form online.

Depression Anxiety Stress Scale-21

It is a self-report questionnaire consisting of 21 items, 7 items per subscale: Depression, anxiety, and stress. Subjects were asked to score every item on a scale from 0 (did not apply to me at all) to 3 (applied to me very much). Sum scores are computed by adding up the scores on the items per (sub) scale and multiplying them by a factor 2.[14] It has been shown to be reliable and valid with a three-factor structure.[15],[16] The cutoff scores for presence of depression, anxiety, and stress are >9, >7 and >14, respectively. The scale further classifies the symptoms as mild, moderate, severe, and extremely severe. The reliability scores of the scales in terms of Cronbach's alpha scores rate the depression scale at 0.91, the anxiety scale at 0.84 and the stress scale at 0.90 in the normative sample.[14]

Brief COPE

Brief-COPE developed by Carver et al., is a 28-item multidimensional measure of strategies used for coping or regulating cognitions in response to stressors. This abbreviated inventory is comprised items that assess the frequency with which a person uses different coping strategies. It is rated by the four-point Likert scale, ranging from “I haven't been doing this at all” (score one) to “I have been doing this a lot” (score four). The scale can determine someone's primary coping styles as either approach coping or avoidant coping. Approach coping includes the subscales active coping, emotional support, use of informational support, positive reframing, planning, and Acceptance. Avoidant coping includes self-distraction, denial, substance use, behavioural disengagement, self-blame, and venting. Humour and religion are considered as separate coping strategies. Each subscale has scores ranging from minimum of 2 to a maximum of 8. The higher score represents frequently used coping strategies used by the respondents.[17] Brief COPE has been reported to have good reliability and validity, The internal consistency (Cronbach's alpha values) for domains are active coping (α = 0.68), using emotional support (α = 0.71), using instrumental support (α = 0.64), positive reframing (α = 0.64), planning (α = 0.73), acceptance (α = 0.57), self-distraction (α = 0.71), denial (α = 0.54), substance use (α = 0.90), behavioural disengagement (α = 0.65), self-blame (α = 0.69), venting (α = 0.50), religion (α = 0.82) and humour (α = 0.73).[18] The Brief COPE Hindi version has been translated using standardized methods, validated and has been previously used in Indian studies.[19],[20]

Statistical analysis

The results obtained were tabulated and statistical analysis was done using SPSS (Statistical Package for social sciences) version 26:0 (SPSS Inc., Chicago, IL, USA). Qualitative data variables were expressed using frequency and Percentage. Quantitative data variables were expressed using mean and standard deviation. Chi-square test was used to find the association between demographic variables and psychological symptoms. Spearman's correlation coefficient was used to assess correlation between coping strategies and psychological symptoms. Significance levels for all analyses were set at the P < 0.05.


  Results Top


Demographic characteristics

The study sample included 136 HCWs at a DCH (34.6% men and 65.4% women) who voluntarily participated in the study. The distribution of age group, gender, marital status, and profession is as shown in [Table 1]. Majority of the HCWs were in the age group of 18–30 years (48.5%). Eighty participants (58.8%) were married, while 56 (41.2%) were unmarried. Among the participants, there was almost equal representation of consultant doctors and faculty at the hospital (25%), resident doctors (25%), and interns (23.5%). Other HCWs at the hospital included 26 staff nurses (19.1%) and 10 housekeeping and maintenance staff (7.3%).
Table 1: OT stands for operation theater instead of Operational technology

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With respect to current living situation, most of the HCWs (70.6%) were staying with their family. A significant proportion of the HCWs were engaged in direct management of coronavirus patients in the current working scenario such as Isolation ward of positive coronavirus (22.7%), quarantine ward of suspected Coronavirus patients (32.3%), and the ICU (12.5%). Four participants were in quarantine, and two were on voluntary leave. Twenty-two participants (16.2%) had history of chronic medical illness [Table 1]. The illnesses included hypertension, diabetes, coronary artery disease, chronic obstructive pulmonary disease, asthma, and hypothyroidism.

Psychological impact

On the DASS-21 scale, 43.4% of the participants had at least one of the symptoms among stress, anxiety or depression as per the cutoff scores. Significant stress was present in 18.4% of the HCWs. In the anxiety domain of the scale, 39% of HCWs screened positive. On the depression subscale, overall, 30.8% of HCWs had depression. Nine participants (6.6%) had both anxiety and depression, while 20 participants (14.7%) showed symptoms from all three domains [Table 2].
Table 2: Psychological symptoms on depression anxiety stress scale-21 in study participants

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Demographic factors associated with psychological symptoms

Association between demographic factors and presence of psychological symptoms was evaluated using the Chi-square test. Among the professions, resident doctors and nurses had a higher incidence of psychological symptoms as compared to the other groups of faculty doctors, interns, and housekeeping staff (P = 0.009, χ2 = 13.58, df = 5) T his included presence of either stress, anxiety or depression. The presence of chronic illness was significantly associated with psychological symptoms (P = 0.036, χ2 = 4.38, df = 1). Age, gender, marital status, current living situation, current working situation and daily work schedule did not have significant association with psychological symptoms [Table 3].
Table 3: Association between demographic variables and psychological symptoms on depression anxiety stress scale-21 in study participants

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Coping strategies

The participants in this study used approach coping strategies more frequently than avoidant strategies. One hundred and fifteen participants (84.5%) used approach strategies and the score for approach strategies was 28.66 ± 10.15, whereas the score for avoidant strategies was 19.35 ± 5.94. The scores were obtained for the individual subscales. Most frequently used approach strategies were acceptance, positive reframing, followed by active coping, and planning. Among the other coping strategies, religion was used more frequently [Table 4].
Table 4: Patterns of coping strategies in study participants on brief COPE

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Higher values on the DASS-21 on anxiety (ρ = 0.216, P < 0.05) and depression (ρ = 0.226, P < 0.05) subscales correlated with more use of avoidant coping strategies, which was statistically significant.


  Discussion Top


The present study is one of the first to investigate the psychological effects of the COVID-19 pandemic on HCWs at a DCH in Maharashtra, which is one of the most severely affected states in the country. An unpredictable and increasing number of suspected and confirmed cases of COVID-19 is likely to contribute to the stress of health-care workers.[11] Our cross-sectional study revealed a significant psychological impact among HCWs treating patients with COVID-19 at a DCH. The results show that 43.4% (n = 59) of the participants had at least one of the symptoms among stress, anxiety or depression. On DASS-21, 18.4% participants showed stress, 39% participants had anxiety, and 30.8% screened positive for depression. These findings are consistent with similar research conducted in China which has shown high incidence of psychological symptoms including stress (59%–71.5%) in health-care providers treating COVID-19 patients.[11],[21],[22] In contrast, a similar study conducted at tertiary institutions in Singapore found significantly lower incidence of psychological symptoms, which was attributed by the researchers to increased mental preparedness and stringent infection control measures after Singapore's SARS experience.[23] However, in our study, there could have been lack of mental preparedness in the subjects as the pandemic-reached significant proportion quickly and the hospital was converted to DCH in a short span of time. Overall, HCWs have a higher baseline risk for mental health problems as per studies, and working on the front lines, fears regarding personal and familial health, may amplify pre-existing psychiatric conditions.[24]

In our study, we did not find any association between age, gender or marital status and psychological symptoms. A meta-analysis of recent studies in China showed a higher incidence of psychological symptoms in female HCWs compared to males.[12],[25] Change in work patterns and social isolation also contributed to stress during the SARS pandemic.[26] However, in our study, the current living or working situation was not associated with psychological symptoms. The enhanced virtual connectivity by video calling as compared to the last decade could have possibly contributed to reducing social isolation during quarantine periods.

Although all HCWs were found to be having psychological symptoms, resident doctors and nurses had more psychological symptoms compared to the other groups of faculty doctors, interns, and housekeeping staff (P = 0.009, χ2 = 13.58, df = 5) [Table 3]. The responsibilities of direct patient care may explain the higher rates of psychological symptoms in resident doctors and nurses. Resident doctors and nurses work more closely with COVID-19 patients and work longer hours in PPE compared to the other HCWs. Recent studies conducted during the pandemic have attributed the greater risk of psychological stress to nurses' workloads and night shifts, and to their being more in contact with risky patients.[27] They are also involved in providing social support and emotional labour to patients in place of other caregivers in isolation wards which may lead to emotional burnout and vicarious traumatization.[28] Similarly, recent studies in China as well as those conducted in SARS pandemic reported that nursing staff had higher rates of psychological symptoms compared to other medical staff.[8],[12],[26]

The presence of chronic illness in HCWs was significantly associated with psychological symptoms as compared to those who did not have a chronic illness (P = 0.036, χ2 = 4.38, df = 1) [Table 3]. It has been established that thr presence of comorbidity has poorer outcomes in patients with COVID-19.[29] Thus, in HCWs with pre-existing medical comorbidities, the fear of infection though valid can be greater, leading to higher psychological impact. Further, continued psychological stress may contribute to worsening in physical health status by increasing cardio-metabolic risk and disturbing the body's physiological stress response system.[30],[31]

Effective coping strategies are essential to combat the ongoing stress. Among coping strategies, approach coping is any behavioural, cognitive or emotional activity that is directed towards a threat, whereas avoidance is any behavioural, cognitive or emotional activity directed away from a threat. In general, use of more approach and less avoidance coping has been associated with more positive outcomes.[32] In our study, 84.5% (n = 115) of HCWs were using more approach coping strategies than avoidant ones.

Most frequently used approach strategies were acceptance of the situation and positive reframing or outlook. The other approach strategies were active coping and planning. Among the avoidant strategies self-distraction, venting, and behavioural disengagement were commonly used [Table 4]. A study conducted during SARS pandemic showed similarly aligned results where the more frequently adopted coping strategies were acceptance, active coping, and positive framing.[26] Our study also showed religion as a frequently used coping strategy [Table 4]. Religion has been considered as one of the expressions of spirituality and consistently identified as a primary coping strategy in India.[33],[34]

However, in our study, the smaller subset of HCWs using more avoidant strategies (15.5%, n = 21) correlated with more severe anxiety (ρ = 0.216, P < 0.05) and depression (ρ = 0.226, P < 0.05) on Spearman correlation. Studies show avoidant coping strategies are associated with long term depressive symptoms and stress.[35],[36],[37] Thus, building positive approach coping strategies can reduce stress and other psychological symptoms and reduce vulnerability in the face of the ongoing pandemic.

Along with personal protective measures, mental health interventions are an important part of pandemic management to help reduce the psychological impact of pandemic. Mental health professionals have an important role to play in providing effective psychological interventions for the HCWs. Since June 2020, we started weekly sessions of progressive muscle relaxation for HCWs in small groups (10–12) maintaining social distancing. Separate groups were conducted for faculty, residents and nurses for addressing their psychological concerns with encouraging results and positive feedback regarding effectiveness of these interventions in reducing levels of stress and anxiety. One-to-one Supportive counselling sessions were also taken wherever indicated and HCWs were encouraged to communicate and seek guidance as and when needed. The HCWs who had severe symptoms were given in-person or video consultations and treated with medications along with counselling.


  Conclusions Top


In our study, overall, 43.4% of participants had at least one of the psychological symptoms of stress, anxiety, and depression. Resident doctors and nurses had a higher incidence of psychological symptoms. The presence of chronic illness was significantly associated with psychological symptoms. Increased use of avoidant coping strategies correlated with severe anxiety and depression. HCWs work at a position of great responsibility which could make them more vulnerable to psychological impact. Thus, ongoing psychological interventions for dealing with psychological symptoms and enhancing adaptive coping skills are vital to reduce the psychological distress of the HCWs and to enable them to effectively continue their essential roles on the frontlines.

However, our study has certain limitations. First, the data were obtained from self-reported questionnaire which is susceptible to some bias in responses. Second, HCWs at only one DCH were included and the participation was voluntary. Hence, the sample size was small. Finally, the study was cross-sectional and carried out in only one of the hospital set-up providing health services during the pandemic in the state which may limit the generalizability of the findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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