COVID-19 and Its Psychological Impacts on Healthcare Staff – A Multi-Centric Comparative Cross-Sectional Study

Background Since the first case of coronavirus disease-19 (COVID-19) in Pakistan was reported in February 2020, the medical and paramedical staff has been working on the frontlines to deal with this disease. They have been facing significant strain and stress due to the pandemic, affecting their social, mental, and personal life. The purpose of this study is to investigate the psychological effects of the COVID-19 pandemic, etiology, personal coping mechanisms, and the strategies that are being adopted to reduce stress by the healthcare workers (HCWs) working in COVID-19 dedicated wards (group 2) and compare it with staff working in other departments but not in COVID-19 wards amid this pandemic (group 1) in various hospitals of Lahore, Pakistan. Methods The comparative cross-sectional study was designed which included doctors, nurses, and allied health professionals from various hospitals of Lahore, Pakistan. A questionnaire was designed which consisted of five sections, and 51 questions. A Chi-square test was used to compare the responses between these two groups. Results The study questionnaire was submitted by 200 participants, 100 responses for each group (see the Appendix). In group 1, HCWs not working in COVID-19 dedicated floors were afraid of getting infected, transmitting the infection to their families and concerned about using personal protective equipment (PPE) improperly. They reported a lack of concentration and tense muscles. The coping mechanisms of this group were exercise, strict precautions at work, and social distancing measures. While HCWs serving in COVID-19 dedicated wards were concerned and afraid of putting their families at risk by working in the high-risk environment; the major stresses in this group were: lack of knowledge about proper strategies for treatment, they faced insecurity due to physical and verbal violence by caretakers of COVID-19 patients, and lack of concentration. The coping mechanism was the support of their families and taking strict precautions, with self-isolation if required, to avoid any disease transmission to their families. The proposed strategies to be implemented included teaching skills for self-rescue as well as the implementation of policies at the administrative level to reduce working hours and frequent shift rotation. Conclusion The COVID-19 outbreak posed a great deal of mental stress among HCWs working on the COVID-19 floor as well as those serving in other departments of the hospital. The HCWs from group 1 were most afraid of getting infected and putting family members at risk, experienced tense muscles and lack of concentration, coped their stress by exercise and being more vigilant, and suggested the strategies of teaching skills for self-rescue and better community awareness. While the staff from the second group were most afraid of being the source of infection and violence from the caretakers of patients, experienced tense muscles, used family support, and strict isolation measures as coping mechanisms and suggested the strategies of self-rescue and increase in wages of directly exposed healthcare workers to deal with such pandemics in future in a better way.


Introduction
In November 2019, a pneumonia outbreak of unknown cause occurred in Wuhan, China. Seafood was 1 1 2 3 1 reported to be the primary source of the disease [1]. On January 30, 2020, the COVID-19 pandemic was labeled as a public health emergency of international concern by the World Health Organization (WHO) [2]. In Pakistan, the cases started to be reported in February 2020. According to Dawn News, a total of 231,017 cases were reported till July 5, 2020. This pandemic created a lot of panic in the general public and induced stress in all healthcare workers -whether working in COVID-19 wards or any other department of the hospitals. Medical practitioners, being the front liners in every pandemic, have been facing psychological issues. As estimated from the previous pandemic of the Ebola virus in 2014, healthcare workers faced major psychiatric problems involving obsessive-compulsive disorder (OCD), paranoia, and hostility [3]. Healthcare staff is afraid of getting infected and transmitting the virus to their families. Lack of appreciation by administrative authorities and a rise in violence against medical staff further precipitate the mental distress among healthcare workers. The sudden increase in duty hours and shift rotation results in physician burnout. The behavior of their seniors and lack of support from the family leads to further nervous exhaustion. Hence, COVID-19 has a major psychological impact on the medical and paramedical staff.
Although there are many studies regarding the psychological effects of COVID-19 on the medical staff, its psychological effects in the population of medical and paramedical staff of Lahore are still unknown. Also, the interventions adopted by the healthcare workers and their impact on relieving their stress are unclear till yet. Furthermore, the steps that must be taken by the administrative authorities to mitigate such psychological conditions have also not been established yet. In our study, we will compare the prevailing psychological symptoms in HCWs; measures are taken to relieve such manifestations and the suggestions regarding actions should be considered by higher authorities for medical and paramedical staff working in COVID-19 wards and those healthcare workers who don't attend COVID-19 wards but are working in other departments of hospitals during this pandemic.

Materials And Methods
A comparative cross-sectional study was conducted including doctors, nurses, and allied health professionals working in Lahore, Pakistan to compare the psychological impacts and their causes, personal coping mechanisms, and strategies that are being adopted to minimize the effect of a pandemic on mental health amid the time of current COVID-19 pandemic.

Study participants
The sample size was calculated by an online sample size calculator by using the confidence interval of 95% and the margin of error as 5%. It was assumed that 10% of all the working medical staff had worked in COVID-19 wards while 90% of the staff was still working in other departments of the hospitals. The ratio for each group was 1:1. So, we selected the sample size of 100 for group 1 (the staff working in other departments of the hospital and have not worked in COVID-19 wards yet) and the sample size of 100 for the second group (the staff working or have worked in COVID-19 wards), making total sample size to be 200 participants.
Two groups were formulated to compare these variables: Group 1: All the medical and paramedical staff who have not worked in COVID-19 wards yet, but they are working in other departments of various hospitals of Lahore during this time of Pandemic.
Group 2: All the medical and paramedical staff who have worked or been working in COVID-19 wards in various hospitals of Lahore.  The fears faced by the medical and paramedical staff The fears faced by the medical staff during this pandemic are mentioned in Table 2. These fears in both the groups, further classified under "age group" and "gender", are compared separately for each subgroup by applying the Chi-Square test; results were significant in both groups.     In group 1, HCWs were afraid of getting infected (p = 0.026), being the source of infection for their fellows and family (p < 0.001), putting their family members at risk (p = 0.003), using PPE improperly as they had not been guided about its usage (p < 0.001), losing the patients as medical attention had been drawn to the pandemic (p < 0.001) and the lack of knowledge about the treatment of this disease (p = 0.025).
In group 2, the healthcare workers were scared of being the source of infection (p = 0.035), getting themselves infected while working in the COVID-19 wards (p = 0.033), being isolated (p = 0.029), lack of knowledge about the treatment of this disease (p = 0.006) and the violence by the caretakers of the patients infected with COVID-19 (p = 0.023).

Psychological symptoms experienced by the healthcare workers
The psychological symptoms that have been investigated in this study are listed in Table 3. These symptoms were compared in both groups and further subclassified under age-groups and gender. There were a total of eight symptoms that were investigated in the questionnaire. A total of three results were found significant after applying the Chi-Squared test.   In group 1, healthcare workers were found to be experiencing tense muscles (p = 0.017) and a lack of concentration during the pandemic (p = 0.03).
In group 2, the lack of concentration was the prevailing symptom (p = 0.051) followed by headache (p = 0.172).

Personal coping mechanisms
The personal coping mechanisms adopted by the medical and paramedical staff to get relief from such psychological effects of the pandemic that were investigated are mentioned in Table 4. These coping mechanisms were compared in both the group, further classified under age-groups and gender. There were a total of 12 coping mechanisms that were stated in the questionnaire. After applying the Chi-Square test, a   In group 1, healthcare workers directed towards exercise (p = 0.017), being more vigilant (p = 0.035), and strict isolation measures (p = 0.025) to get rid of these psychological symptoms.
In group 2, family support was the major factor to relieve their symptoms (p = 0.05). Using strict selfisolation measures to decrease the risk of spreading infection also helped to relieve the stress of transmitting the infection to their families (p = 0.037).

Strategies that should be implemented
The strategies that should be implemented by higher authorities in future pandemics to reduce its psychological effects on healthcare workers are mentioned in Table 5. These strategies were compared in both groups, further classified under age-groups and gender. There were a total of 14 strategies that were stated in the questionnaire. A Chi-Square test was applied to each strategy.  A  62  32  3  0  0  3  32  68  21  63  16  0  74  26   N  33  67  0  0  0  0  50  50  14  43  29  14  71  According to group 1, skills for self-rescue (p = 0.116), better community awareness (p = 0.242), and adequate training on infection control (p = 0.1), and strong measures to bust myths (p = 0.351) must be implemented.
As suggested by group 2, skills for self-rescue (p = 0.099), optimal increase in wages of HCWs working in high-risk units (p = 0.123), and dissemination of accurate information by media sources (p = 0.41) must be applied.

Discussion
In comparison with the general population, health care workers are facing tremendous amounts of stress as they are involved in the direct management of patients with COVID-19. Due to the increased risk of exposure, frontline health care workers may experience symptoms of mental health problems such as anxiety, insomnia, physical and mental exhaustion, and other forms of psychological distress [4]. We performed a questionnaire survey to investigate and compare the fears experienced by the health care workers, their association with the adverse physical and psychological outcomes, and the coping mechanisms adopted by HCWs. COVID-19 pandemic posed major psychological stress for the medical and paramedical staff working in various hospitals of Lahore, Pakistan. The teams of healthcare workers not directly working in COVID-19 wards feared a lot about getting infected, being the source of infection for others, increasing the risk of infection for families, using PPE improperly, poor patient outcomes due to the lack of knowledge about the treatment. They experienced the symptoms of tense muscles and lack of concentration. The personal coping mechanisms included exercise, and being more vigilant with preventive measures. The strategies advised by them were better community awareness and proper staff training on infection control. Those healthcare workers who were directly providing care to COVID-19 patients were facing the fears of getting infected, spreading the infection to other patients, and their families. They were also fearful of facing physical as well as verbal violence at the hands of the families of sick patients of COVID-19. They manifested the symptoms of lack of concentration and headache. The personal coping mechanisms that helped them to mollify their distress were the support from their family and strict selfisolation measures. The strategies, which should be adopted according to them, were teaching skills for selfrescue to the front line HCWs, optimal increase in wages, control of misinformation circulation on media, and limits on shift-rotation.
One of the fears faced by the HCWs working directly with COVID-19 patients was violence faced by them at the hands of the patient's families. It can be due to the rapid deterioration of their health status, the lack of evidence-based guidelines along with continually updated treatment regimens. The violence was partly due to the various misconceptions spread around the general masses regarding this pandemic as well as the limited treatment modalities. Another precipitating factor was the admission of the patients in isolation centers where the families were not allowed to visit them and were informed of the status of their patients by the doctors. The broad range of patient outcomes from mild infection to the requirement of ventilatory support and information spread on a hearsay basis also negatively affected the trust between the care providers and families of the patients. These HCWs also proposed conducting workshops to teach them skills for self-rescue. Skills for self-rescue include learning self emotional dependence. For the healthcare staff working under highly stressful conditions in the pandemic when they are overburdened with drastically increased shift hours and more number of patients to take care of, it is important that they need to be taught skills to rescue themselves from the psychological overburden. It also includes teaching them relaxation exercises in order to cope with their stress and increase their work performance.
Due to the current pandemic and the increased expectations from HCWs, it is no wonder the medical team members are overwhelmed by such prevailing and distressing thoughts that can be the cause of adverse psychological sequelae leading to various somatic symptoms [5]. In accordance with the observation of previous studies that were carried out in different countries (China, Italy, Singapore & India), our study reflected similar types of fears faced by the health care team members based in Pakistan [6][7][8]. Zerbini et al.
reported a similar effect that HCWs in other departments of the hospitals were afraid of getting infected from symptom-free non-tested COVID carriers, the source of infection for others during a symptom-free period [9]. The psychological strain and physical exhaustion contribute to the development of adverse physical as well as psychological outcomes in the form of anxiety, insomnia, and stress headache resulting from working long duty hours at the hospital, lack of concentration, restlessness, fatigue, muscle tension as well as panic attacks. Among the symptoms displayed by the HCWs directly working with COVID-19 patients, they reported headache, which has also been reported by Chew et al., as the most common symptom associated with psychological distress [5]. In addition to headache, lack of concentration experienced by the healthcare workers in both groups was also reported by Song et al. [10]. Moreover, previous studies have significantly reported gender of the health care professionals working in COVID-19 wards as a predictive factor for the development of severe depression, anxiety, and distress, which were more common in female healthcare workers compared to the male healthcare workers. In our study, we found no significant association of depressive symptoms with gender. Possible factors leading to these psychological problems, as reported by Que et al. in their study, are to handle the false information that has been circulating around about the pandemic, deal with the criticism from other frontline workers, being at higher risk of getting infected, and the lack of confidence attributed to the limited knowledge about the disease and its treatment. This indicates the critical role of providing psychological support to health care workers and hence strategies to reduce this psychological burden must be introduced to provide support to the health care workers during this pandemic and even after the pandemic. The personal coping mechanisms that were established in our study, i.e. support from family and colleagues, had also been identified in previous studies. Que et al. from their study results suggested that regular exercise and a higher household income may serve as protective factors against developing depression and similar results have been reported in our study where exercise was used to cope with the stress and increase in the wages of HCWs was proposed as a strategy for administrative authorities [7]. Other strategies that can help in psychological stresses including effective general public education through social, electronic, and print media, as well as reduced working hours, have also been supported by Cai et al. [11]. Blake et al. suggested the use of a digital support and learning package, which includes evidence-based guidance, to check on the psychological wellbeing of the frontline health care workers and most importantly to support their psychological well-being during and after this pandemic by providing advice from experts in mental health care via direct emails, social media, and professional networks [4].
This study had several limitations. With a limited sample size, it covers only the medical and paramedical staff working in Lahore, Pakistan. Moreover, the study was conducted two months after the pandemic started but some psychological effects take longer to express, and this study could not report on those effects. The representation of the nurses and allied health professionals was also low in our study; further studies should be conducted to answer the questions related to them. A study that can compare the psychological stresses faced by the HCWs with and without the strategies advised can help in ascertaining the efficacy of these suggestions.

Conclusions
Finally, the findings that were of most significance were the fears of getting themselves infected, putting family members at risk, violence by caretakers of patients, symptoms of tense muscles, lack of concentration, coping mechanisms of proper exercise and strict isolation measures, as well as strategies suggested by HCWs, i.e. teaching skills for self-rescue, optimal increase in wages and information disseminated by media sources and shift-rotation should be considered seriously. All these findings can be implicated in policy-making for future pandemics to reduce the mental stress and anxiety on front-line professionals. However, further studies are needed to elaborate on these effects in other cities of Pakistan.

Study questionnaire
A questionnaire, designed in the form of a Google document, was used as a quantitative data collection tool. It was sent to doctors, nurses, and allied health professionals working at different levels in various hospitals in Lahore, Pakistan. The questionnaire was divided into five sections. The first section consisted of questions related to demographics. The second section contained 10 questions regarding the fears that are being faced by healthcare workers amid the COVID-19 pandemic. The third section was based on the symptoms being experienced by healthcare workers and included eight questions. The fourth section, rooted in different possibilities that help them cope with the stress personally, consisted of 12 questions. The last section focused on strategies that should be adopted by administrative bodies to reduce such psychological issues in the future. This section had 14 questions in total. Each question from all the sections had five choices on a 5-point scale (1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree) except the Demographic section and the first two questions of the fourth section, that was answered with only two possibilities (0 = no, 1 = yes).