key: cord-0690119-9gosypbl authors: Cag, Yasemin; Erdem, Hakan; Gormez, Aynur; Ankarali, Handan; Hargreaves, Sally; Ferreira-Coimbra, João; Rubulotta, Francesca; Belliato, Mirko; Berger-Estilita, Joana; Pelosi, Paolo; Blot, Stijn; Lefrant, Jean Yves; Mardani, Masoud; Darazam, Ilad Alavi; Cag, Yakup; Rello, Jordi title: Anxiety among front-line health-care workers supporting patients with COVID-19: A global survey date: 2020-12-20 journal: Gen Hosp Psychiatry DOI: 10.1016/j.genhosppsych.2020.12.010 sha: eb2fcb184d50ee717a8fd6012cb83a7817785dff doc_id: 690119 cord_uid: 9gosypbl OBJECTIVE: We aimed to explore anxiety status across a broad range of HCWs supporting patients with COVID-19 in different global regions. METHOD: This was an international online survey in which participation was on voluntary basis and data were submitted via Google Drive, across a two-week period starting from March 18, 2020. The Beck Anxiety Inventory was used to quantify the level of anxiety. RESULTS: 1416 HCWs (70.8% medical doctors, 26.2% nurses) responded to the survey from 75 countries. The distribution of anxiety levels was: normal/minimal (n = 503, 35.5%), low (n = 390, 27.5%); moderate (n = 287, 20.3%), and severe (n = 236, 16.7%). According to multiple generalized linear model, female gender (p = 0.001), occupation (ie, being a nurse dealing directly with patients with COVID-19 [p = 0.017]), being younger (p = 0.001), reporting inadequate knowledge on COVID-19 (p = 0.005), having insufficient personal protective equipment (p = 0.001) and poor access to hand sanitizers or liquid soaps (p = 0.008), coexisting chronic disorders (p = 0.001) and existing mental health problems (p = 0.001), and higher income of countries where HCWs lived (p = 0.048) were significantly associated with increased anxiety. CONCLUSIONS: Front-line HCWs, regardless of the levels of COVID-19 transmission in their country, are anxious when they do not feel protected. Our findings suggest that anxiety could be mitigated ensuring sufficient levels of protective personal equipment alongside greater education and information. Thousands of healthcare workers (HCWs) around the world have contributed to the augmented response needed to tackle the coronavirus disease (COVID- 19) pandemic. The demand to healthcare systems has increased globally and providing an adequate response has involved HCWs in many cases working long hours under often stressful conditions with limited resources. In addition, front-line HCWs experienced shortage of protective personal equipment (PPE), which could have exposed them to a higher risk of contracting the infection during their working hours even in the most developed countries. COVID-19 contamination was also a concern of potentially transmitting the virus to their families and loved ones [1] . There have been reports of HCWs being quarantined at healthcare facilities unable to return home [2] . Information regarding the transmission, the PPEs required, the treatment algorithms can be confusing, contradicting, and rapidly changing: in one article HCWs reported an even higher level of stress and potentially anxiety in the face of an increasing number of COVID-19 cases and the absence of specific treatment algorithms and without being able to provide the care deemed essential [3] . The leadership has frequently responded late to the needs and challenges of those providing the response at the frontline and thus, the governments have been urged to arrange mental health support for frontline medical staff [4] . These and other factors may have placed physical and psychological stresses on HCWs, but the extent to which HCWs are affected is yet to be fully elucidated. Previous studies showed severe consequences for the mental health of HCWs responding to outbreaks of infection, these included significant psychological distress both during and after the epidemic [5] [6] [7] . It was shown that HCWs were 2 to 3 times more likely to have posttraumatic stress (PTS) symptoms when quarantined, located in high-risk areas such as the severe acute respiratory syndrome (SARS) wards or had friends and relatives that had contacted SARS during the SARS outbreak in China [5] . Currently, data are still limited on the J o u r n a l P r e -p r o o f Journal Pre-proof risk factors linked to mental health problems in HCWs working in a pandemic and for the evidence on how best to protect the mental health of HCWs during acute outbreaks [8] . These are crucial because when identified could guide the development of effective preventive and interventional strategies. Hence, the health leaders will identify, which HCWs may be disproportionately affected and require more targeted interventions. We therefore conducted an international online survey to determine the level of anxiety among HCWs and to investigate its individual and health system-related predictors in different settings and regions. We aimed to rapidly contribute to new evidence in order to best support the mental health of HCWs globally and to draft potential conclusions and guidance for future studies and research and for planning now and in the long-term. Ethical consent was obtained from the ……….University School of Medicine, ……..(2020/0229). We designed an online structured survey (Appendix) with input from the project advisory group. Beck Anxiety Inventory was already available and in use in all three languages in which survey was disseminated. For the rest of the survey, the questions were prepared in English, Italian, and Turkish, and it was tested before being released among the authors for language and content. The translation was done according to standard methods for health-related questionnaires for use in multinational clinical trials which involved forward and back translation [9] . The survey was made of 3 main parts (Supplementary material): -demographics (age, gender, nationality, etc.) -Beck Anxiety Inventory which had been validated in various manuscripts and cultures to measure the level of anxiety. -correlation questions to establish potential causes of the measured level of anxiety. (https://infectdisiri.com./). The survey was anonymous and distributed using direct invites to the ID-IRI members and relevant colleagues. In addition, authors of the study used their own social networks and targeted HCWs, particularly nurses and clinicians of any grade and in any setting with the use of a snowballing technique [10, 11] . The survey took 10 minutes to complete online. Participants consented to participating in the research by completing the survey, and an introductory letter highlighted these consenting procedures and plans for the dissemination of results. A follow-up email was sent to non-responders. Participation in the survey was on the voluntary basis and the data were submitted via Google Drive. The primary outcome of the study was to detect the cardinal parameters leading to anxiety in HCWs serving to COVID-19 patients. The Beck Anxiety Inventory (BAI) [12] was used to quantify the level of anxiety of respondents. This 21-item instrument designed to assess level of anxiety has been shown to be applicable for the general population [13] [14] [15] [16] . The questions pertained to physical, emotional and cognitive aspects of anxiety and fear of losing control that the subject had faced the previous week. Each item is rated on a four-point Likert scale ranging from 0 = not at all to 3 = severe. The total score ranged from 0 to 63. Score of 0-7 are categorized as normal/minimal anxiety, 8-15 as mild anxiety, 16-25 as moderate anxiety, and 26-63 as severe anxiety [17] . Kolmogorov-Smirnov test was used for normality assumption. Internal consistency between responses to the BAI questions were investigated by using coefficient of Cronbach's alpha. The differences between the categories of the predictor variables with regard to BAI score were compared by using One-Way ANOVA model. In order to find out exactly which categories were different from each other, post hoc Tukey HSD test which will allows us to explore the difference between multiple group means while also controlling for the familywise error rate was used. Together with the factors that were found to have a statistically significant correlation with BAI on univariate analysis, variables that were clinically important were also included in the generalized linear model. The relation between the BAI score and continuous variables were evaluated by Pearson correlation analysis. Type I error was accepted as 0.05 and all statistical analysis were done in SPSS (version 22). During the study period, 1416 HCWs responded to the survey from 75 countries, with 75.9% living in high-income, 20.6% in upper-middle income, 3.5% in lower-middle income Table) . Response rate was 40% to direct ID-IRI email and WhatsApp® list which represented the 40% of the total J o u r n a l P r e -p r o o f Journal Pre-proof sample. The remaining was completed using a link to the ID-IRI platform from the social networks of the authors of the study, where the response rate was 80%. general practitioner (n=114, 8%), surgery (n=81, 5.7%), internal medicine (n=77, 5.4%), diagnostics (n=36, 2.5%), hemato-oncology (n=30, 2.1%), pediatrics (n=33, %), emergency medicine (n=23, 1.6%), pulmonary diseases (n=10, 0.7%), and others (n=136, 9.6%). The median period of time the respondent had been working as a HCW was 12 years (7-20 years). The distribution of anxiety levels in 1416 HCWs were as follows: Normal/minimal (n=503, 35.5%), low (n=390, 27.5%); moderate (n=287, 20.3%), and severe (n=236, 16.7%). The reliability coefficient (Cronbach's alpha) of the 21-item Anxiety scale was found to be 0·936, highlighting that internal consistency was high. Our data show that BAI scores decreased significantly with older age of the HCW (r=-0.300, p=0.0001). Before the modelbuilding strategy, a scatter plot was drawn between age and total BAI score. A linear decrease trend was observed in the relationship between age and BAI score (Figure 1 According to multiple generalized linear model (Table-4 soaps (p=0.008), and coexisting chronic disorders (p=0.001) and psychological problems (p=0.001) were associated with increased anxiety. Moreover, BAI score decreased with increasing age (p=0.001) and when the age increases by 1 year, the BAI score seemed to decrease by 0.216 point. Older age and greater length of time in the medical profession were not collinear. The correlation between older age and greater length of time in the medical profession was r = 0.882. R-squares did not change when the run time was removed from the model (2nd P column) P values also showed slight changes, i.e. they changed insignificantly. BAI score increased with increasing income levels of countries where they live in (p=0.048). This large international study reports that frontline HCWs were anxious about the pandemic, with severe levels of anxiety in one of six HCWs who responded, regardless of levels of COVID-19 transmission in their countries of origin. The perceptions reflect concerns regarding preparation and resources. Our findings suggest that some individual variables identify subjects at high risk that should target preventive mental health support. Our findings suggest that higher levels of stress are perceived when they do not feel protected. Thus, interventions to improve training and education, and ensure adequate resources such as PPE, could have been better considered. The survey was able to reach doctors and nurses in the general hospital who were exposed to COVID-19 patients. Furthermore, representation was collected from 75 countries and in several regions of the world not well represented in the current literature. This study highlighted that two-thirds of HCWs reported varying levels of anxiety, but 20% moderate, and 17% showed severe anxiety levels. There was no link between anxiety levels and the number of COVID-19 deaths in country, however HCWs in countries seeing high death rates were likely to report key concerns about their own institutions/health-care settings. Anxiety scores significantly increased with the gender (female staff), younger ages, lack of J o u r n a l P r e -p r o o f Journal Pre-proof knowledge on COVID-19, occupation (being a nurse compared to being a medical doctor), insufficient medical supplies (PPE, disinfectants, liquid soaps), the HCWs' own coexisting medical and mental health problems, and living in higher income countries. These data suggest that more could be done to ensure potentially inexperienced younger HCWs and nursing staff are better supported during pandemics, alongside the critical need to give them access to PPE equipment and to ensure that HCWs feel protected. A key focus of healthcare institutions should be to ensure that sufficient education and information is provided and targeted at HCWs, particularly the youngest and most inexperienced. Our findings therefore confer with a recent systematic review, that reported health-care services having positive, safe and supportive learning environments were facilitators of intervention to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic [18] . Anxiety arising from exposure to life-threatening viral infections is a significant challenge to HCWs [19] . During outbreaks, HCWs are forced to cope with high emotional stress due to the risk of exposure, extreme workloads and moral ethical dilemmas. Rapid transmission of the virus and high rates of mortality are likely to have influenced the mental health of HCWs. There have been recent studies carried out to investigate the mental pressure of COVID-19 on HCWs, mainly from China, which report similar concerns raised by HCWs. For example, one cross-sectional study carried out with HCWs in the beginning of the pandemic in China, reported that women, nurses, other front-line workers, and those based in Wuhan were at higher risk of developing mental health symptoms [20] . In another study from the US, authors reported that nurses and advanced practice providers in particular were experiencing COVID-19-related psychological distress, concurring with our findings [21] . In a study, evaluating the psychological impact of the SARS epidemic on hospital employees in China, post-traumatic stress (PTS) symptom levels were associated with age, with younger people (<50 years) more Table 1 . Descriptive values the participants and the countries Strengthening ICU health security for a coronavirus epidemic Am I Part of the Cure or Am I Part of the Disease? Keeping Coronavirus Out When a Doctor Comes Home End-of-life decisions and care in the midst of a global coronavirus (COVID-19) pandemic NHS staff need access to mental health services, says Labour The psychological impact of the J o u r n a l P r e -p r o o f Journal Pre-proof SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk Prevalence of psychological symptoms among Ebola survivors and healthcare workers during the 2014-2015 Ebola outbreak in Sierra Leone: A cross-sectional study Potential mental health consequences for workers in the Ebola regions of West Africa -A lesson for all challenging environments Preventing occupational stress in healthcare workers Literature Review of Methods to Translate Health-Related Quality of Life Questionnaires for Use in Multinational Social research 2.0: Virtual snowball sampling method using Facebook An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts An Inventory for Measuring Clinical Anxiety: Psychometric Properties The Beck Anxiety Inventory in a non-clinical sample Turkish Version of the Beck Anxiety Inventory: Psychometric Properties. n.d The Italian versions of the Beck Anxiety Inventory and the Beck Depression Inventory-II: Psychometric properties and discriminant power Psychometric Properties of a Spanish Version of the Beck Anxiety Inventory (BAI) in General Population Psychological Corporation Harcourt Brace & Company Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review Mental Health and the Covid-19 Pandemic Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers SCCM COVID-19 Rapid-Cycle Survey 2 Report Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe Critical Care Clinician Reports on Coronavirus Disease Symptoms of burnout in intensive care unit specialists facing the COVID-19 outbreak Mental Health and Psychosocial Problems of Medical Health Workers during the COVID-19 Epidemic in China Author statements: Yasemin Cag MD: Conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing -review & editing. Hakan Erdem MD: Conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing -review & editing. Aynur Gormez MD: Conceptualization, formal analysis, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing -review & editing. Handan Ankarali MD: Data curation Conceptualization, formal analysis, investigation, methodology, resources, supervision, visualization, writing -review & editing. João Ferreira-Coimbra MD: Investigation, resources, visualization, writing -review & editing PhD: Conceptualization, data curation, formal analysis, investigation, methodology