Psychological Impacts among Health Care Personnel during COVID-19 Pandemic: A Systematic Review

Introduction: The COVID-19 outbreak is a health emergency, in which health care personnel (HCP) face psychological consequences, working as frontline workers. Therefore, we conducted this study to find out associated psychological impacts among HCP during COVID-19 pandemic. Methods: This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. The reviewed studies were searched from PubMed, MEDLINE, CINAHL and Google scholar electronic database using the Medical Subject Heading (MeSH) terms. Results: We searched through 2676 articles, 19 of which were finally included, most of them were cross-sectional and descriptive studies with 12910 participants. HCP were found to be exposed to a variety of psychological problems; anxiety symptoms were reported in 33% (3081 of 9269), depression 28% (2681 of 9487), post-traumatic stress disorder (PTSD) 41% (2933 of 7167), sleep problems 26% (903 of 3442), stress 13% (487 of 3496) and fear 67.3% (392 of 582). The severity of impacts was often mild to moderate. The nurses were twice as likely to develop these symptoms. The factors associated with psychological impacts were fear of infection to self and family members, lack of resources and facilities at workplace, demanding work conditions, working closely with COVID-19 clients in intensive care unit and pre-existing medical and psychological problems. Conclusion: Psychological impacts was mild to moderate among majority of HCP during COVID-19 pandemic. The outcome of this review is to provide some utilitarian information for making supportive policies and strategies to improve the psychological wellbeing of frontline HCP during this pandemic.


Introduction
Severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2) infection never spared any of the country across the globe, affected more than 220 countries around the world. Globally approximately 189 million confirmed cases found with more than four million deaths and nearly three crore confirmed cases with four lakh deaths were reported in India till May 2021 by COVID-19 virus, originated from Wuhan city China. 1 Government of all countries continuously trying to flatten the curve but it was remained same because of difference of geographic disease burden, requirement of physical distance in between country and outside the country also. To reduce the impacts or spread of SARS-CoV-2, many public health efforts and multilevel emergency response plans were activated and containment and mitigation measure are implemented. Unfortunately, these measures are helpful in limiting the transmission of COVID -19 pandemic also contributing in negative effects on mental health of individuals. 2 A physical and mental health impact was reported among general population as well as among health care workers, who were in direct contact with infected patients. Frontline health care workers were continuously working with COVID-19 positive patients so they were more prone to psychological distress compared to general population. 3 There were the various reasons of psychological problems among health care workers, such as containment red zone areas which includes strict quarantine and need to adhere social distancing, as well as high mortality, insufficient medical supplies, fears of infection, uncertain quarantine duration, stigma and discrimination. Along this less support from public or government and adopted negative coping strategies leads many psychological and mental health problems among health care personnel (HCP). 4 During SARS pandemic 2003 in Hong Kong nearly 68% health care workers showed high level of stress and 57% experienced psychological distress. 5 It was evident that health care workers face many challenges and psychological impact during Middle East respiratory syndrome pandemic in 2015. 6 Health care workers are integral to the global response to current pandemic. They play a significant role in every setting to manage the current situation. The mental and physical health crisis among the health care workers increasing rapidly and it is becoming itself epidemic. The health care workers are often tend to feel that every new COVID-19 diagnosis means long working hours, less sleep, more mental and physical stress which can lead to weakened immune system. 7 Thus, as above literature illustrate that, the cases of psychological impacts were increasing at the time of pandemic due to various reason or lack of intervention or support among health care workers. From the beginning of pandemic, many studies have been conducted on psychological impact of COVID-19 among the health care workers, but have not been sufficiently explored. Therefore, in this systematic review researcher strived to integrate the findings of different study and throw a light on prevalence, severity, nature and associated factors of psychological impact faced by the health care workers during this pandemic. So, considering an important health issue, the researcher undertook this systematic review with aim to highlight psychological impacts among HCP during COVID-19 pandemic. It was anticipated, the outcome of this review to provide some utilitarian information for making supportive policies and strategies to improve the psychological status of HCP in frontline during the pandemic.

Materials and Methods
This systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) check list. Also Joanna Briggs Institute appraisal tool was used. 8 We performed a systematic literature review to identify all international research related to psychological impact of COVID-19 among HCP.
The research studies included in this systematic review were 1. Primary data with individual study; 2. Focusing on HCP (including nurses, doctors, allied health personals, pharmacist, technician's laboratory workers); 3. Reporting psychological impact outcome (depression, anxiety, insomnia, post traumatic syndrome and stress) from original research; 4. Publish in peer review journals; 5. Be written in English; 6. Letters commentaries, editorials, reviews and grey literature were excluded in this study.
The two researchers (MKB, RVA) extracted data from all the relevant included studies independently. Then data were re-checked and disparity were solved through concord (AJ, RVA). The researchers (MKB, RDA) prepared a summary of selected variable included first author and publication year, country, investigated topic, HCP category involved, sample size, psychological impact outcome, quality assessment and key findings.

Results
The initial literature search through electronic database and manual yielded 2680 articles, of which 19 relevant articles were included in this systematic review ( Figure 1).
The systematic review consists of nine cross-sectional studies, five descriptive studies, three exploratory studies, whereas, one observational cohort study and one longitudinal study. The number of total participants in these studies were 12 910 from different categories of HCP. As per population concern, in the cross-sectional studies, total participants number range between 118-1139. Furthermore, the number of participants ranged in descriptive studies were 128-1330, in exploratory studies was 133-933, in longitudinal study and observational cohort study 2195 and 472 respectively. Out of total 19 studies 4,9-26 , four from India, three from China, two studies each from Singapore, Oman, Saudi Arabia and Turkey and rest of the studies one each from Nepal, Bangladesh, south east Ireland, and Italy ( Table 1).
Most of the studies 17 (89.47 %) investigated psychological impacts among more than one HCP categories, whereas, one study each directly focused on doctor and nurses. The psychological impact was assessed by using one or more several validated measures i.e., Impact Event Scale Revised (IES-R) used by 10 studies, generalized anxiety disorder (GAD) scale used by seven studies, Physical Health Questionnaire (PHQ) used by seven studies. Furthermore, Depression Anxiety Stress Scale -21 (DASS-21) used by six studies and Insomnia Severity Index (ISI) used by three studies ( Table 1).
The risk and quality of the cross-sectional studies and other studies were assessed with Joanna Briggs Institute (JBI) 8 appraisal tool, in which majority of studies scoring five or higher whereas, the most of studies indicated low risk of bias (Table 2).

Psychological Impact among HCP
This systematic review identifies the five major psychological impacts: anxiety, depression, posttraumatic stress disorder (PTSD), stress and insomnia on HCP during COVID-19 pandemic. Whereas, only one of the selected study findings showed that, the overall mental disturbance, in which 36% (358 of 994) HCP had sub threshold mental disturbance whereas 6.2% (62 of 994) had severe mental disturbance. 9

Depression
In term of depression, it was identified among 28% (2681 of 9487) HCP. 4,10,11,15,17,18,[21][22][23][24][25][26] with range of between 10.6% to 70.76%. 13,14 Furthermore, 33% (724 of 2195) nurses had severe level of depression. 15 The review further revealed that, HCP who were working in ICU had moderate to severe depressive symptoms compare to HCP working in other than ICU. 17 Moreover, the frontline HCP had 1.5 times more risk of developing symptoms of anxiety, stress and poor sleep quality as compared to non-frontline HCP. 22,25,26 Whereas, Inadequate training of HCP was associated with high proportion of anxiety and depression. 13

Post-traumatic Stress Disorder
In concern to PTSD, 41% (2933 of 7167) HCP had a symptom of this psychological impact. 4,10,11,15,18,25,26 Moreover, the PTSD symptoms were present between 7.6% to 56% HCP. 4,10,15 Even more, a study finding reported that, 97.9% (845 of 863) HCP identified with one or more symptoms of PTSD. 4 and the severity of PTSD was moderate to severe reported among 50.67% (34 of 67) HCP. 10 Furthermore, 65% (1427 of 2195) nurses had severe PSTD symptoms. 15,26 Moreover, the nurses had two times more risk of developing symptoms of PSTD and depression with respect to doctors. 15

Stress
In this systematic review, stress was identified amongst 13% (487 of 3496) HCP 4,10,11,12,22 with varies range between 5.2% to 41.3%. 13,14 Furthermore, a greater number of nurses reported work related stress. 15 Besides, HCP who worked closely to COVID-19 patients showed high level of stress as compared to those, who were not in close contact. 16

Other Psychological Impacts
In term of COVID-19 fear, 67.3% (392 of 582) HCP perceived as a public fear and threat, the most common threat was "fear of infection" and "doing high risk job". 4,5,15 Furthermore, a study compared the health care workers with or without physical symptoms in which, those who had physical symptoms were screened positive for depression, anxiety, stress, and PTSD. 10 Moreover, the nurses, who had co-morbidities or psychological problems, confirmed cases of their family members, relatives and friends developed PTSD, anxiety, depression and stress symptoms. 15,18,24,25 Nurses had more anxiety symptoms compare to doctors, as well as had high proportion of depression, severe insomnia symptoms compare to other profession. 24,26 Moreover, young HCP (< 40 year) and who lost their patients were reported higher level of depression, anxiety, and PTSD symptoms like intrusive thought, hyperarousal and avoidance by others. 14 whereas, only one study reported that younger HCP showed less symptoms of depression compare to old HCP. 24 In term of gender, female HCP experienced high level of anxiety, depression, stress and somatization symptoms as compare to males 9,20,24,25 whereas a study also showed high psychological impacts among males (P < 0.03). 19 Two study findings, reported that there was a positive significant association between anxiety and depression, between anxiety and Perceived Stress Scale (PSS) and between PSS and depression. 13,20 The HCP with severe mental disturbance expressed an urgent need to seek psychological care services directly from professionals. 9 Discussion COVID -19, was an emergency situation with unique challenges to all HCP. It disturbed their physical and mental dimension, as well as, it hampered their daily life style on routine duties. In health care setting, being infected and fear of uncertainty in life had put major impact on their mental health. 2 Similarly, providing care to infected patient during COVID-19 situation generated high level of stress and fear and most of HCP were highly distressed due to fear of infection to family members by themselves. 13 The major finding from this review that, most of HCP faced anxiety, depression, stress and sleep pattern disturbance and insomnia symptoms under psychological aspect of mental health. The similar trends observed in Singapore, in which, out of 1257 health care workers identified symptoms of depression 50.4% (634), anxiety 44.6% (560), insomnia 34% (427) and stress 71.5% (899) 27 and fear was among 41.6% (175 of 421). 28 Similarly in this review also, over all 33% (3081 of 9269) HCP had anxiety,

Associated Factors of Psychological Impact among Nurses
Most of studies in review revealed that, one third of nurses had symptomatic depression, anxiety, and insomnia, while over one-fifth of nurses had presented PTSD symptoms. Moreover, the associated factors behind this such as, switch in work pattern for nurses in covid crisis, change of physical condition, and uncertainty of fighting against the pandemic. 25 Whereas, As compared with physician, nurses were just doubled increased the risk of developing symptoms of post-traumatic distress and anxiety. 15 Furthermore, associated factors of PTSD were chronic disease to self, had confirmed cases among their relatives and friends. 12 Even more, intensive care nurses and psychiatric nurses affected with highest deterioration in sleep quality as well as moderate-to-severe depressive symptoms as compare other HCP. 15,18,21 Consequently, stigma experience among nurses, history of medication for mental health problems, inadequate precautionary measure in the workplace significantly associated with higher odd symptoms of anxiety, depression and insomnia. 23

COVID-19 Fear among HCP
The most fear among HCP were fear of infection to self and family members due to demanding work conditions, fear of uncertainty in life and dealing with the death and dying. 15 Even more HCP justify that, there was public fear for inappropriate current situation of covid in different areas of community as well as social stigma of COVID-19. 4 Moreover, associated fear of being avoided by others, the burden of change in the quality of work, worrying whether the family will be cared for in their absence or not. 19 A similar trends observed in Singapore and Spain studies that reported, fear due to inappropriate measure, heavy workload, fear of infection to self and family members. 29,30 Gender Associated Psychological Impact The review studies also showed that female gender more sensitize to this covid situation. With respect to anxiety, female, who had pre-existing psychological problems and perceived fear of getting infected experienced more traumatic related to COVID-19. 15 Furthermore, female gender with history of psychiatric illness emerged as risk factors for mental distress. 25 With this same trend, a study was conducted at Spain in which also showed that female HCP have more risk of developing symptoms of anxiety, depression and stress. 29,31 Other Associated Factors of Psychological Impact Other associated factors for psychological impact, such as younger generation (less than 40 years), reported a high level of stress, whereas, older HCPs experienced more positive well-being 14 . The psychological impact was highly significant in comorbid HCPs, Married HCPs, as well as who all posted in highly infected red zone and highly designated post. 18,19 The most of studies used standardized scales to identify psychological impacts among HCP. The outcome of this review focused on distinct psychological impacts and various associated factors affecting frontline HCP. Majority of studies used online mode for data collection and most of the studies were cross sectional. There was a lack of prospective studies. Different version of scales was used to assess the psychological outcome. Geographical factors may influence due to social and cultural factors among the study location.

Conclusion
The most common symptoms of anxiety, depression, PTSD, insomnia and fear were present among majority of HCP, nurses and female HCP had double risk for developing these symptoms. This outcome is to provide some utilitarian information for making supportive policies and strategies to improve the psychological wellbeing of frontline HCP and nurses during this pandemic. Thus, there was immediate need of response strategies as like behaviour counselling, training, emergency communication, protective environment, interaction with family members and job satisfaction. It can build a greater reliance diverted to positive dimension and reinforce them to work hard in this pandemic crisis of COVID-19.