Mental Health Issues and Coping Mechanism adopted by Primary Healthcare Workers against COVID-19: A Study in Northwestern State of India

Introduction

The exceptional response by healthcare workers (HCWs) in the fight against COVID-19 pandemic unquestionably makes HCWs the COVID-19 warriors [1]. The pandemic demonstrated that healthcare personnel were the cornerstone of healthcare systems, and their dedication and professionalism was excellent throughout the pandemic [2]. They remained motivated and resolutely continued their work [3]. The health systems were never challenged to this extent in recent history, and the laid-out systems for business as usual was not adequate to address the demand during the COVID-19 pandemic. The resources available and the business hours were stretched to its extreme and HCWs were at the forefront in absorbing this. Despite their dedication and resolve, globally HCWs faced situational and organizational challenges often during the pandemic. due to inadequate health infrastructure, long working hours, inadequate logistics and supplies, shortage of personal protective equipment, social stigma, stressful environment, and occupational burnout [4].

India, to show gratitude towards its HCWs, the Indian Medical Association (IMA) declared ‘Save the Saviours’ as the theme for National Doctor’s Day in 2021, observed on July 1 each year [5]. Honoring the HCWs, including doctors, is important to boost their morale because they played a pivotal role in dealing with the pandemic despite varied challenges. However, the pandemic showed that doctor-to- patient ratio and insufficient medical facilities [6] exerted immense pressure on Indian healthcare system and there were incidences of violence and stigma against healthcare providers during the pandemic [7].

In the first wave, by August of 2020, about 87,000 healthcare workers were infected in six Indian states [8]. Data collected by the Indian Medical Association, shows nearly 1,800 doctors succumbed to the infection during the course of COVID-19 pandemic, 757 during the first wave, 839 during the second wave and the remaining thereafter [9]. Multiple studies show that several risk factors- age, gender, medical specialty, lack of training to deal with COVID-19, mismanagement, lack of adequate PPE, race and ethnicity, and other factors such as comorbidities were associated with increased mortality amongst HCWs including doctors [10]. A US study found that HCWs who died of COVID-19 were disproportionately older (>50 years of age), male, and Black or Asian [11] and another study found that Healthcare workers are seven times as likely to have severe COVID-19 as others engaged in ‘non-essential’ jobs [12].

COVID-19 pandemic has imposed significant physical and psychological burden on physicians and other HCWs [13]. The psychological burden and overall wellness of HCWs have received heightened attention, with research continuing to show high rates of burnout, psychological stress, and suicide [14]. A scope review in terms of stress and trauma- related symptoms in HCWs shows the prevalence ranged from 7.4% to 35%, particularly among women, nurses, frontline workers, and in workers who experienced physical symptoms [15]. Detrimental effects include high rates of infection and death, excessive financial hardships, stress related to known and particularly unknown information, and fear of uncertainty regarding continued impact  [14]. Studies indicate that up to 75% of doctors have experienced workplace violence, which often results in psychological issues, absenteeism, shattering mental peace, self-esteem, and diminished service quality [7]. The reasons also include stress due to their profession, working in the affected areas, lack of support from health authorities, inadequate time for family care, and stigma associated with COVID-19 [16, 17, 18]. In a systematic review study, the prevalence of anxiety and depression was found relatively high among healthcare workers during the COVID-19 pandemic [19]. A study in Iran found that the prevalence of anxiety and depression was significantly higher in doctors and nurses compared with other occupations [20]. Similarly in another study in India the prevalence of anxiety disorder and depression were significantly higher among those with clinical responsibilities compared to those with supportive responsibilities [21]. The current paper is analyzing such issues through the study conducted with HCWs of primary healthcare facilities in the state of Rajasthan, India, during the COVID19 pandemic.

Result of the Study

Medical doctors accounted for 8% of the staff, and ANMs (38.1%) & staff nurses (19.5%) make up majority of the surveyed HCWs. Majority of the respondents (57.4%) were females, more than three-fourth were married. Half of the respondents were in the age group of 25-30 years (Table 1). Of the surveyed, nearly three-fourths worked in rural PHCs and remaining in urban facilities. Nearly 48.2% of the staff belonged to other districts in the state and living in a rented accommodation near the facility of their posting as there was no provision of residences at the concerned facility. About 7% of staff was vulnerable due to their personal health conditions as some were either pregnant or suffering from chronic health conditions such as Diabetes Mellitus, Hypertension and Asthma. During COVID-19 pandemic these populations were categorized as high-risk populations and were asked to take extra precautions to safeguard themselves from COVID-19 infection and the resulting complications.

While HCWs remained steadfastly committed to their duties, their unwavering engagement also exposed them to increased risk of infection due to prolonged working hours, shortage of personal protective equipment, disruption to their social and family ties, and unfortunately, instances of violence from relatives of the patients and public [22, 23]. Table 2 provides apprehensions of HCWs for their families amidst the pandemic to a multi-response question. Excluding the 12.5% (34 HCWs) who had no worries, remaining 87.5% (238 HCWs) were analyzed across three distinct categories: i) HCWs stationed in their home district, ii) those posted and working in a different district and, iii) in totality. HCWs residing in districts other than their home district and away from their families exhibited heightened concerns for wellbeing of their families. Notably, among those residing in different districts, 50% expressed their worry on the uncertainty of days for reuniting with their families. In contrast, HCWs living in their home district displayed notably a lower percentage (20%). Considering all responses, over two-thirds of the respondents were occupied with the thought that their family would be worried about their wellbeing; whereas almost equal number of HCWs had fear of transmitting infection to their family members. More than half of the HCWs were worried regarding health of the elderly parents and 47.1% regarding wellbeing of their children. This underscores the complex array of anxieties that HCWs grappled with while performing their duties during the pandemic.

*Unmarried respondents are excluded; **only for married respondents, whereas, unmarried divorced and separated are excluded. Table 2: Concerns of HCWs for their families during work in COVID-19 (N=238).

Figure 1 illustrates eight distinct types of challenges that healthcare providers encountered at personal and professional level. Apart from 36.8% who had no fear of working during COVID-19 pandemic, the other HCWs mentioned one or more than one type of fear. Nearly three- fifths (76.2%) of the respondents had fear of getting infected and 55.2% of HCWs had this fear because many COVID-19 positive cases were asymptomatic and difficult to identify, whereas 53.4% were uncertain about when the pandemic would be over. Technical issues like inadequate testing of COVID-19 (40.1%), issues of social stigma such as fear of facing resistance from the community (37.2%), and people distancing from them (38.9%) also contributed to declining morale amongst the HCWs. Compounding these challenges, the prevalence of various myths and rumors concerning COVID-19 in the community (34.8%) contributed in further heightening psychological and mental distress amongst them. These psychological burdens added an additional layer of complexity to the already demanding roles being undertaken by HCWs during this unprecedented time. Figure 1 highlights the multifaceted nature of the challenges faced by HCWs beyond the professional duties, delving into personal fears, uncertainties, and the detrimental effects of social and psychological factors.

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Several studies suggest that while working in the pandemic HCWs were susceptible to distress and negative health outcomes including anxiety, poor quality sleep, and feelings of isolation [24, 25]. Analysis of a multi-response question Table 3 illustrates how pandemic affected the personal life of HCWs. Many (56.3%), were not able to spend adequate time with family or were not able to visit home (46%) during the pandemic. The impact on personal wellbeing was further evident, with 41% of HCWs expressing they had less time available for rest. Moreover, 45% indicated that they struggled to dedicate enough time to personal care routines, including timely meals. An additional 28% faced challenges in managing routine activities such as laundry and cleaning due to time constraints.

On the positive front, a substantial (72%) of the HCWs reported that they acquired new skills relevant for work/ profession and 58% learnt new skill for day-to-day life. It can be concluded that although during pandemic the family time, personal care, and routine management of HCWs was compromised; they exhibited adaptability and capacity to embrace new opportunities for growth and skill acquisition.

The myriad of challenges arising from COVID-19, both in personal and professional space, subjected the HCWs to go through a range of mental health issues manifesting as emotional distress and burnout, emotional fatigue, anxiety disorders, depression, insomnia, acute stress and post- traumatic stress disorders, and other psychological problems [26]. The current study shows that more than half of the HCWs experienced depression ‘sometimes’ followed by anger (47%), boredom (45%), irritability (39%) and fear (35%) (Figure 2). Depression and fear were reported ‘often’ by 11% of the respondents while irritability and anger were reported by 9% each. 85% respondents had never experienced ‘stigma and discrimination’ followed by insomnia (70%), confusion (66%), fear (54%) and irritability (52%). These findings show the pervasive impact of COVID-19 pandemic on HCWs’ mental well-being and sheds light on the complex interplay between various circumstances faced by HCWs that impact their mental well-being.

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Mental health issues in HCWs when analyzed against the background characteristics, age and type of residence, were found to be significantly associated. With increasing age proportion of HCWs who ‘Never’ experienced any symptom rises from 9.52% in the 20–24year age group to 24.32% in those aged >35 years (Table 4). Also, the proportion of ‘Never’ was higher among those who were living on rent or in their own house in comparison to those who were living in staff residences provisioned by the government. Among other characteristics, no significant relationship was observed, but the proportion of HCWs who had ‘Never’ experienced any fear was higher among HCWs who were male, married and working in their home districts.

58% of the HCWs reported any one of the mental health issues ‘Sometime’, 32% ‘Often’ and 9.6% did not experience any issues at all. There were variations in experiencing mental health issues among the HCWs; the HCWs who were engaged in field activities, 92.4% of ANMs, 92.5% of Staff Nurses and 100% of the LHVs experienced mental health issues more frequently than those who worked primarily in facility setting such as lab technicians (80%) and medical officers (81.8%), pharmacists being an exception (91%). This could be because LHVs, ANMs and staff nurses were mostly engaged in surveillance, quarantine, contact tracing contacts and counseling in the field. In summary it can be concluded that age and residence type stand out as the key influencers along with nature of work that determine the occurrence and frequency of considered mental health issues amongst various cadres of health care providers that were interviewed in this study.

Table 4: Any mental health symptom by background characteristics of HCWs (N=272). #Never refers to those who never experienced any mental health issue ##Often refers to those who has experienced atleast one mental health condition ###Sometimes refer to those who have experienced atleast one mental health condition but have not experienced any mental health condition often To adopt safe behaviors and maintain physical wellbeing during the pandemic, HCWs employed range of coping strategies [27], which encompass activities such as engaging in leisurely pursuits such as watch TV, read books, and sufficient sleep [4] to manage their negative emotions. In addition to personal coping mechanisms, HCWs also implemented proactive measures that played a pivotal role in the overall response to the pandemic. These measures include adequate planning, timely sharing of information, provisioning of PPE kits, along with training [28].

In our study many of the HCWs were practicing one or more types of coping mechanisms like exercise, meditation and yoga to manage the stress. On careful examination of data, it becomes apparent that a considerable 44.9% exercised, followed by 29.4% practicing yoga and 22.8% practicing meditation (Table 5). An analysis by health care provider type indicates that MPWs demonstrated the highest tendency to engage in daily exercise (67.7%), followed by pharmacists (63.6%); nurses (41.5%) and ANMs (32.4%) showed low levels of participation in physical exercise, medication and yoga. This could be because ANMs were mostly in the field and also had to undertake household chores. However, the stress management activities like exercise, yoga, meditation etc. were found useful for mental wellbeing [29, 30, 31]. Almost all the staff reported that they tried to get sufficient sleep to reduce stress. Many HWCs elicited about taking hot water bath, drinking hot water and taking green leafy vegetables to improve health.

Discussion

The HCWs were engaged in an array of critical COVID-19 prevention and treatment activities, which included triaging of patients with symptoms of influenza like illness (ILI), referral, community surveillance, tracing the contacts of COVID-19 infected patients, door-to-door surveys, assisting the testing teams, monitoring home quarantined patients, arranging ambulance services for critical patients, setting- up teleconsultations, counseling services and awareness generation [32]. HCWs across all tiers of the healthcare system were engaged in similar activities. However, the workload on healthcare workers of primary healthcare facilities underwent a staggering surge. They had to navigate through these tasks while continuing to do their usual jobs within the framework of national health programs. The study illustrates that HCWs of primary healthcare facilities faced tough and overwhelming times, as well as distinctive mental health challenges because of COVID-19. It is reasonable to assume that HCWs were more informed than the general population, but still working in COVID-19 led to sufficient fear and anxiety and stress among them. Interestingly, HCWs who were living in their own house, showed mental health issues more often than those who occupied government provisioned residences or in rented housing. Likewise, the HCWs who were deployed in their home district expressed more mental health issues than those who were posted in districts other than their home district. This suggests that the HCWs working in proximity to their families harbored heightened concerns, potentially stemming from the fear of transmitting the infection to their family members. Working in the challenging environment induced anxiety among healthcare workers particularly concerning the safety of their aged parents and children.

This study shows the need to support HCWs who are comparatively young, which may be due to their lack of experience, as prevalence of mental issues was inversely correlated with age. In case of HCWs of rural and urban facilities, the difference in proportion of staff who had never experienced mental health issues were not very acute but a higher proportion of HCWs at urban facilities had mental health issues more often, which could be associated with overwhelming of their facilities (PHCs) in the urban areas. Also, early on during the pandemic, the infection was spreading in urban areas at a higher pace, coinciding with timing of the study.

Conclusion

COVID-19 showed us the vulnerabilities in mental health of healthcare providers working in primary healthcare institutions and the pressing need to address them. Although this assessment was conducted with a small number of healthcare providers in a limited geographical area, its findings show the urgency to create institutional support mechanisms for HCWs to prepare them for similar public health emergencies in future. HCWs had shown that despite all the formidable challenges, they toiled hard and extended unceasing care to the patients.

Acknowledgement

We are thankful to the various stakeholders and respondents who participated in this research study. We also extend our thanks to our funders- Lords Education and Health Society (LEHS).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.