key: cord-252343-a85wz2hs authors: Skoda, Eva-Maria; Teufel, Martin; Stang, Andreas; Jöckel, Karl-Heinz; Junne, Florian; Weismüller, Benjamin; Hetkamp, Madeleine; Musche, Venja; Kohler, Hannah; Dörrie, Nora; Schweda, Adam; Bäuerle, Alexander title: Psychological burden of healthcare professionals in Germany during the acute phase of the COVID-19 pandemic: differences and similarities in the international context date: 2020-08-07 journal: J Public Health (Oxf) DOI: 10.1093/pubmed/fdaa124 sha: doc_id: 252343 cord_uid: a85wz2hs BACKGROUND: Healthcare professionals (HPs) are the key figures to keep up the healthcare system during the COVID-19 pandemic and thus are one of the most vulnerable groups in this. To this point, the extent of this psychological burden, especially in Europe and Germany, remains unclear. This is the first study investigating German HPs after the COVID-19 outbreak. METHODS: We performed an online-based cross-sectional study after the COVID-19 outbreak in Germany (10–31 March 2020). In total, 2224 HPs (physicians n = 492, nursing staff n = 1511, paramedics n = 221) and 10 639 non-healthcare professionals (nHPs) were assessed including generalized anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-2), current health status (EQ-5D-3L), COVID-19-related fear, subjective level of information regarding COVID-19. RESULTS: HPs showed less generalized anxiety, depression and COVID-19-related fear and higher health status and subjective level of information regarding COVID-19 than the nHPs. Within the HP groups, nursing staff were the most psychologically burdened. Subjective levels of information regarding COVID-19 correlated negatively with generalized anxiety levels across all groups. Among HPs, nursing staff showed the highest and paramedics the lowest generalized anxiety levels. CONCLUSIONS: In the context of COVID-19, German HPs seem to be less psychological burdened than nHPs, and also less burdened compared with existing international data. The COVID 19 pandemic reached Germany in late February 2020. It brought not only objective medical challenges for healthcare professionals (HPs), but also reports and findings from other more affected countries. Due to exponentially increasing case numbers and large numbers of patients requiring intensive care, those more affected countries are facing unexpected challenges. Countries such as China, Italy, Spain, Brasil and the USA were and are currently reaching the limits of their healthcare systems in the context of this pandemic: something that was previously unimaginable in industrialized countries. 1 Such a development seems to have been avoided in Germany but is not completely ruled out for the future. In the face of an ever-renewing European and a further worldwide escalation, there is no shortage of uncertainty and concern among HPs. It is already known from countries other than Germany that HPs are under elevated psychological stress during the COVID-19 pandemic and show increased levels of various psychometric values, including anxiety and depression. 2-5 Existing evidence, e.g. from China, already shows the extent of the psychological burden on HPs. Front-line healthcare workers were identified as bearing a particularly heavy psychological burden. 2,6 However, these studies were conducted during the extreme stress phase of the COVID-19 epidemic in China. Only few data in the context of other studies suggest that, e.g. in the UK, a heightened psychological burden for the HPs may exist. 7 There is, as yet no comparable data, especially from a time when the health system is still mainly coping normally, alongside already population-wide uncertainty, particularly in Europe. The German situation to this point is 2-fold: Continuing and past restrictions in public life, contact restrictions, empty supermarket shelves and daily updated increasing case numbers are still coupled with a hospital system that is and was largely still able to cope normally. This is combined with mortality rates, which are, for the moment, low when compared internationally. 8, 9 Though, the German population shows itself already burdened in terms of generalized anxiety, depression and distress, which is in line with evidence from other countries, 10,11 customized low-threshold interventions, offline as well as online, are needed and already implemented. [12] [13] [14] The aim of this study was to close the research gap and provide initial findings on psychological burden of German HPs after the COVID-19 outbreak. It is hypothesized that the group of HP in Germany will mirror the existing, population-wide elevated psychological burden 15 to an even greater extend by being in the 'front line', as already could be observed in previous studies in other countries. 2,3 A nationwide, online-supported cross-sectional survey was conducted. Participants were recruited via online channels and official channels e.g. websites of clinics. The survey period was from the 10-31 March 2020. It was during this period that the first increased numbers of COVID-19 cases in Germany, increasingly restrictive government regulations, the closure of European borders and the restriction of individual freedoms occurred. In total, 12 863 people completed the questionnaire, of which we identified 2224 people in the medical sector as HPs and 10 639 as non-healthcare professionals (nHPs). HPs were from three different groups: physicians, nursing staff and paramedics. The sample description can be seen in Table 1 . All participants gave their written consent to participate in the survey and the evaluation of the collected data. The study was conducted in accordance with the ethical guidelines from the Declaration of Helsinki and was approved by the local ethics committee of the faculty of medicine. Details of general socio-demographic variables were asked. Validated psychometric instruments were used to assess psychological burden. The Generalized Anxiety Disorder-7 (GAD-7) to measure generalized anxiety symptoms over the course of the last 2 weeks (GAD-7, 7 items, 4-point Likert Scale meaning 0 = never to 3 = nearly every day), 16 the Patient Health Questionnaire-2 (PHQ-2) to screen for depression symptoms over the course of the last 4 weeks (PHQ-2, 2 items, 4-point Likert Scale meaning 0 = never to 3 = nearly every day) 17 and the visual analogous scale of the EuroQol EQ-5D-3L scale to assess current health status (ranging from 0 [worst imaginable health status] to 100 [best imaginable health status]). 18 Additionally, based on scientific and media reports, multiple items and item scales were formed in expert consensus with regard to 'COVID-19-related fear' (one item, 7-point Likert scale meaning 1 = very low to 7 = extremely high), 'the subjective level of information regarding COVID-19' (3 items: I feel informed about COVID-19; I feel informed about measures to avoid an infection with COVID-19; I understand the health authorities' advice regarding COVID-19. Seven-point Likert scale, meaning 1 = complete disagreement to 7 = complete agreement). Scale reliability for was tested using Cronbach's α for internal consistency. 'The subjective level of information regarding COVID-19' showed high internal consistency (Cronbach's α = 0.801). The descriptive and inferential statistics were performed with R3.6.1 (R Core Team, 2019). Sum scores for the GAD-7 and PHQ-2 and mean scores for all other scales were calculated. To assess the hypotheses, the 95% confidence of the association measures are reported; for each difference between the groups after having assessed the global mean difference in the respective scale. Hence, the assumptions were assessed based on their precision. [19] [20] [21] Generally, test statistics and P values are not reported given that at this sample size even the slightest deviation from equivalence results in extremely low P values. When the confidence interval (CI) of the effect size covers 0, we assume there is no effect. As soon as this is the case, we use the guidelines by Sawilowsky 22 to evaluate the importance of the effect; a Cohen's d ∼0.2 is considered a small, a d ∼0.5 is considered medium-sized and d ∼0.8 is regarded as large effects. Due to the large sample size and the intuitive and common interpretation of the effect sizes, parametric methods were also used for violation of the normality assumption. 23 For mean comparisons Welch's t-test with the Cohen's d association measure was used, for multiple mean comparisons and between-subject analysis of variance with the association measure η 2 with subsequent t-tests for post hoc comparisons with Tukey error correction. A complete summary of all post hoc group comparisons after calculation of the variance analyses and post hoc tests can be assessed in the supplementary materials. To clear the association of subjective level of information regarding COVID-19 and other variables, Spearman correlations between variables were performed. To subsequently test the interdependence of variables a robust linear Mestimator regression was performed (rlm from the R package MASS, 2002). All Spearman correlations including confidence between the measures are provided in the supplemental material. Following the results of the correlation analyses, prevalence ratios for the amount of participants with moderate generalized anxiety in relation to the subjective level of information regarding COVID-19 were explored. Levels of generalized anxiety were divided by using the GAD-7 sum score of ≥10 24 as a split into low levels of generalized anxiety (<10) and moderate to high levels of generalized anxiety (≥10). This was compared with a pre-COVID-19 standard population, where 5.9% of the population scored above ≥10. 25 The subjective level of information regarding COVID-19 was split by the median into high (≥median) and low (