The burden on health and social care workers (HSCW) has been high and sometimes overwhelming over the course of the current COVID-19 pandemic. A new study published in October 2020 on the preprint server medRxiv * identifies the factors that predict exposure to HSCW and emphasizes the importance of an adequate supply of personal protective equipment (PPE).
HSCWs are a high risk group
Given the higher than average risk of contagion and the more difficult working conditions that required a more demanding schedule and extraordinary effort, the deterioration in the emotional and physical health of HSCW was inevitable. In addition, they are exposed to the pain of watching suffering and death on a much larger scale than usual, which is likely to create anxiety and stress.
Supportive interventions require an understanding of the risk factors for such anxiety spikes in future pandemics, including the category of HSCWs at highest risk. A general overview of risk factors in HSCWs is also helpful.
Causes of stress
Historical evidence shows the higher risk of post-traumatic stress disorder (PTSD), depression and anxiety, including among HSCWs who are involved in patient care during a pandemic. This also applies to those working with potentially infectious patients, the nursing profession, the younger age, dependent children, and the female gender.
New evidence suggests that due to such fears, mental illness is on the rise in many countries during the current pandemic, particularly due to higher infection rates and serious illness among health care workers.
Stress could be exacerbated by the inability to provide the level of care desired. This type of distress is known as “moral harm”. It is especially of great importance in areas like northern Italy where it was necessary to select patients who would receive medical treatment because of the overwhelming health services.
High infection rate of HSCWs combined with distress
Approximately 10% of COVID-19 cases in England at the height of the first wave of the pandemic have been on the front lines in HSCWs. This is related to the perceived deterioration in mental health of HCSW in the UK, as reported in an April 2020 survey, including onset of depression, anxiety and stress, and mental health issues.
Even among UK nurses, more than three quarters said they have had higher levels of stress since the pandemic began, according to a survey conducted in August 2020, with half expressing concerns about their mental health.
Broader range of studies
The current study aims to examine risk factors for mental illness in HSCWs in the UK. Unlike previous studies that looked primarily at medical professionals and a few allied paramedics, the current study identifies and compares risk factors for PTSD, depression, and anxiety among auxiliary hospital workers such as cleaners, porters, and receptionists. It also examines the impact of the pandemic on the mental health of social workers.
The current study data comes from the Frontline COVID study, in which online survey data was collected from May 27 to July 23, 2020. The median age was ~ 42 years, with over 90% being white and female.
Over three-quarters were on the front lines of health or social care for COVID-19 patients. Of these, ~ 18% had a history of confirmed COVID-19. Another ~ 13% suspected they had it. This means that almost one in three HSCWs has been under stress from feeling like they have had a potentially fatal infection.
About a third reported that they resorted to alcohol or other drugs more often than normal to reduce their stress levels. At the same time, almost the same proportion indicated that they were unable to express their fear or insecurity in relation to their supervisor or any other person in authority.
Overall, ~ 58% met the diagnostic criteria for clinically significant stress from PTSD, depression, and anxiety, indicating that these disorders were widespread in HSCWs during this pandemic phase.
Risk factors: lack of support at work
The researchers found that all HSCWs had the same degree of these disorders or symptoms, with the only significant differences between Allied health professionals and clinical support staff. The latter were consistently more affected.
They identified three variables that significantly predicted the occurrence of distress. First, a third of HSCW said they were unable to tell a manager that they were unable to handle the situation. This was associated with the highest emergency rates.
Strategies for training health care managers to be more sensitive to and support sensitive workers emerge slowly and not too early. Such interventions, including the involvement of mental health professionals, are likely to be even more urgent for newly recruited staff who have been freed from their old support systems. Other reasons for the perceived gap between healthcare workers and managers should be explored in future studies.
A second risk factor was fear of infection. HSCWs who feel unprotected from infection are more likely to stay away from their loved ones to avoid transmitting infections.
Well over half of them said they were moderately to extremely concerned about the risk of infection, while nearly 80% were very concerned about the risk of spreading the infection to others.
This is in line with previous studies which show that far more people fear passing the infection to others than they will get it.
The third risk factor was feeling stigmatized from the social perception (in over a third) that their role exposed those in contact with them to infection.
In addition to self-directed isolation, others can avoid interactions with HSCWs to minimize the chance of COVID-19 being intercepted by them. This can be all the more damaging as the HSCWs put themselves at risk to look after other classes of society. The combination of poor social support and higher levels of stress / stress is a well-known recipe for mental illness.
High risk of PTSD
PTSD was more likely among newly assigned participants, as well as nurses and midwives. It was higher in those who feared being infected and in the group with the lowest household income (between £ 30,000 and £ 59,999).
In contrast to previous studies, all categories appeared to have an equal risk of PTSD symptoms, depression, and anxiety when compared to nurses. Most groups, however, were too small to be assessed separately and were therefore grouped together in the heterogeneous group “Others”.
The importance of PPE
Almost a third of HSCWs were frustrated with unreliable PSA supplies, and this group had much higher rates of anxiety and depression in this group. The same was true of those who had any illness.
Nurses and midwives were at the highest risk of illness as nurses or allied health professionals, doctors, or non-clinical personnel. After all, those with the highest incomes had the lowest chances of developing PTSD, anxiety, or clinical illness.
The researchers point out, “These results show that it is of paramount importance to provide HSCWs with adequate PPE during an infectious disease outbreak to not only protect their physical health but also to reduce the likelihood of psychological distress to decrease.”
Implications and Future Directions
More research is needed to examine the incidence of COVID-19-related exposure in all HSCWs. The predominant makeup of white women in this group calls for more studies on the potential for disproportionate effects on HSCWs who identify as black, Asian, or other ethnic minorities, as other recent studies suggest it is.
The generalizability of the study is limited by the self-reported nature of the data and the convenience sample and should be considered in future studies.
Much of the observed stress will decrease over time if there is no intervention for most participants. Hence, strategies should take this factor into account. At the same time, it is important to identify those who need care so that their symptoms do not become chronic or severe. This distinction therefore has priority. When the potential for future pandemics and future waves of the present one is considered, the need for such studies and targeted interventions is clear.
* Important NOTE
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be considered conclusive, guide clinical practice / health-related behavior, or be treated as established information.