key: cord-0691738-0w4zi0v0
authors: Ching, Siew Mooi; Ng, Kar Yean; Lee, Kai Wei; Yee, Anne; Lim, Poh Ying; Ranita, Hisham; Devaraj, Navin Kumar; Ooi, Pei Boon; Cheong, Ai Theng
title: Psychological distress among healthcare providers during COVID-19 in Asia: Systematic review and meta-analysis
date: 2021-10-14
journal: PLoS One
DOI: 10.1371/journal.pone.0257983
sha: af9782e981dec5cdb1833dfbec37661a4ac206fb
doc_id: 691738
cord_uid: 0w4zi0v0

INTRODUCTION: COVID-19 pandemic is having a devastating effect on the mental health and wellbeing of healthcare providers (HCPs) globally. This review is aimed at determining the prevalence of depression, anxiety, stress, fear, burnout and resilience and its associated factors among HCPs in Asia during the COVID-19 pandemic. MATERIAL AND METHODS: We performed literature search using 4 databases from Medline, Cinahl, PubMed and Scopus from inception up to March 15, 2021 and selected relevant cross-sectional studies. Publication bias was assessed using funnel plot. Random effects model was used to estimate the pooled prevalence while risk factors were reported in odds ratio (OR) with 95% CI. RESULTS: We included 148 studies with 159,194 HCPs and the pooled prevalence for depression was 37.5% (95%CI: 33.8–41.3), anxiety 39.7(95%CI: 34.3–45.1), stress 36.4% (95%CI: 23.2–49.7), fear 71.3% (95%CI: 54.6–88.0), burnout 68.3% (95%CI: 54.0–82.5), and low resilience was 16.1% (95%CI: 12.8–19.4), respectively. The heterogeneity was high (I2>99.4%). Meta-analysis reported that both females (OR = 1.48; 95% CI = 1.30–1.68) and nurses (OR = 1.21; 95%CI = 1.02–1.45) were at increased risk of having depression and anxiety [(Female: OR = 1.66; 95% CI = 1.49–1.85), (Nurse: OR = 1.36; 95%CI = 1.16–1.58)]. Females were at increased risk of getting stress (OR = 1.59; 95%CI = 1.28–1.97). CONCLUSION: In conclusion, one third of HCPs suffered from depression, anxiety and stress and more than two third of HCPs suffered from fear and burnout during the COVID-19 pandemic in Asia.

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The COVID-19 pandemic is both a worldwide healthcare crisis and financial disaster at the biggest scale that has emerged in the last century. With the emergence of new COVID-19 virus variants, COVID-19 is even more infectious and can spread more rapidly through various inter-continentals [1, 2] . To date, about 171 million individuals had contracted the infection caused by this novel coronavirus and more than 3.5 million have succumbed to this virus across 222 countries [3] .

There has been increasing concern that COVID-19 has infected nearly 570,000 healthcare providers (HCP) and killed more than 2500 of them in the Americas alone [4] . In the Asia Pacific region, a total of 12,454 HCP have been infected with the novel coronavirus while 171 have succumbed to this virus as of June 11, 2020 [5] .

In performing their duties of arresting the spread of COVID-19, the HCP are risking their lives due to a higher risk of virus exposure, high workload demand, irregular or long working hours and increased psychological distress such as depression, anxiety, stress, occupation burnout, fear, low resilience as well as fatigue [1] . In addition, the HCP were barred from taking leaves and separated from their loved ones for up to weeks or even months. Wearing the full personal protective equipment or gear (PPE) that is very uncomfortable for long hours continuously every day while managing patients diagnosed with COVID-19 is extremely exhausting, particularly that this has become a routine task in their daily work. Literature reported that factors associated with personal-, work-, and patient-related burnout among HCPs were those that had direct involvement in COVID-19 management, underlying medical illness, and receiving inadequate psychological support in the workplace [6] . Those with higher total points in the coping score were significantly associated with reduction in anxiety and depression scores [7] . Other significant factors associated with psychological distress inluding but not limited to thought of resignation and reluctant to work, fear of infecting family members, frequent change in infection prevention and control protocol or guideline, and poor social support [8] . All of the aforementioned factors had been determined as factors that are leaving negative psychological impacts on the healthcare workers in Asian countries [8] [9] [10] .

HCPs experiencing anxiety and depression have impaired physical and mental health and it may affect their wellbeing and work efficacy. In other word, the psychological consequences may contribute to a poorer quality of life among HCPs and suboptimal performance of delivered care. Experiencing these psychological hardships in the long run, can lower the immunity and put HCPs at a higher risk of being infected [11] . Furthermore, HCPs with pre-existing depression may suffer a higher mortality rate if they are hospitalised with COVID-19 [12] . Thus, it is very important to create the awareness on the degree of psychological distress that are encountered by HCPs amidst the COVID-19 pandemic in order to help reduce the incidence of occupation-related burnout and deaths. This can then serve as a platform for the government and policy makers to allocate funding to promote and provide psychosocial support for HCPs during this COVID-19 pandemic which will ultimately led to a better patient care. Recent systematic review involving 32 studies reported on the prevalence of mental health 6. After full-text articles have been assessed for eligibility, those outcomes were grouped into category of severities which were different from our operational definition.

We performed the study selection according to the PRISMA guidelines. Studies identified using the search strategies were transferred into Endnote software (version 19) for screening, removing duplication and data extraction. Two authors (CSM and NKY) screened the title and abstract to determine the eligibility of the studies. For those potentially eligible articles, further screening on the full text had been performed to determine the availability of data and whether the articles fulfilled the selection or inclusion criteria (types of studies, participants, setting and outcomes). Any doubt on eligibility was resolved by discussion with a third author (KWL). Finally, those full-text articles which fulfilled all selection criteria were kept for data extraction and subsequent quantitative analysis.

The participants were HCPs (doctors, dentists, nurses, nurse assistants, midwives, medical assistants, pharmacists and other allied healthcare workers). Exposure was referred to actively providing healthcare-related services in conditions that are high risk for COVID-19 transmission and there is no comparator for the current systematic review. The main outcome for this review was pooled prevalence of depression, anxiety, depression, burnout, fear and resilience among HCPs.

We used Microsoft Excel to perform the data extraction and recording. The following data were extracted independently by two authors (SMC and KYN) and recorded as: Author information, publication year, country of the study, mean age or median of participants, study design, sample size, number of HCPs with and without symptoms of depression, anxiety, stress, burnout, fear and resilience, screening tool for assessment of depression, anxiety, stress, burnout, fear and resilience, sociodemographic and any clinical characteristics of the respondents.

We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist to perform quality assessment on all the included articles [16] . Two authors (CSM and NKY) individually assessed the study quality, and discrepancies were resolved by discussion with third investigator (LKW). STROBE check list consists of 22 items that assessed 6 components in cross-sectional studies. One point would be rewarded for a positive response for each of the items making the total score ranging from 0 to 22. Each article was graded as 'low risk of bias' if STROBE score �14/22; or 'high risk of bias' if the score is <14/22 [16] . The STROBE scoring for this systematic review is presented in Appendix A. Studies were included in the analysis regardless of STROBE score and grades. The summary of the quality grade is reported in Table 1 .

Psychological distress in this systematic review covers depression, anxiety, stress, fear, burnout, and low resilience symptoms. Presence of depression symptom was applied to those who scored points that belonged to mild to severe depression domain categories. Similarly, this 

We use the Open Meta Analyst and StatsDirect to perform the meta-analyses [17, 18] . We used a random-effects model (DerSimonian and Laird Method) to calculate the pooled prevalence from multiple studies [19, 20] . The numerator would be the total number of cases summed up of HCPs with positive symptoms; denominator would be total number of HCPs in that study.

Values of numerator and denominators of all studies were used to derive the pooled prevalence of outcome variables. The random-effects model was used so that the findings were generalisable and more representative presuming that the studies were randomly selected from a bigger population [21] . We used I 2 statistics index to assess the heterogeneity across the studies. I 2 index is categorised as low if < 25%, moderate 25-50%, and high > 50%) [20] .

Subgroup analyses are useful to examine the between-group differences in terms of the prevalence as a possible cause of heterogeneity across studies. The prevalence of depression, anxiety, stress, burnout, fear and resilience among HCPs in Asia was determined by subgrouping the countries. The data were further examined by subgrouping the gender and occupational subtype of HCPs. The risk factors for depression, anxiety, stress, burnout, fear and resilience were reported in odds ratio (OR) with a 95% confidence interval (CI).

We performed sensitivity analysis by using leave-one-out meta-analysis to examine how each particular study alters the overall performance of the rest of the studies especially the pooled prevalence estimates and heterogeneity.

We assessed the potential publication bias by visually checking the Funnel plot followed by conducting the Begg's test and Egger's regression test. In Egger's test, a p-value < 0.01 was defined as an indicator for publication bias [22] . After removing the duplicate records, we performed screening on 1241 articles. Finally, we included 148 studies for systematic review and meta-analysis after further evaluation of eligibility. Table 1 summarizes the main characteristics of 148 studies. A total of 159,194 healthcare providers from 23 different Asia countries were involved in this systematic review and meta-analysis. Almost half (n = 70) of the studies were conducted in China [8, 11, , followed by 15 studies in India [10, [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] , 11 studies in Turkey [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] , 10 studies in Saudi Arabia [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] , 6 studies in Pakistan [126] [127] [128] [129] [130] [131] , 4 studies in Indonesia [132] [133] [134] [135] and Nepal [136] [137] [138] [139] respectively, 3 studies in Malaysia [140] [141] [142] , Singapore [143] [144] [145] , Japan [146] [147] [148] and Iran [149] [150] [151] respectively with 2 studies in Oman [152, 153] , Jordan [154, 155] , Philippines [156, 157] and Bangladesh [158, 159] respectively. Besides, Korea [160] , Qatar [161] , and Iraq [162] which each had one study, there were also some multinational studies that were conducted, with 2 of them involving several countries in Asian Pacific [9, 163] and another one involving both Egypt and Saudi Arabia [164] (Table A4 in S4 Table) . About two thirds (n = 98) of the studies reported the data on depression [8, 23-27, 29- 100, 103, 104, 106-108, 111, 113, 115-117, 120, 123, 124, 127, 129-133, 137, 138, 140, 141, 143-146, 149, 151-154, 158-161, 163-165] . Different type of tools or scales were used to diagnosed depression in different papers from different Asian countries (Table 1 and S4 Table) , such as 2-item Patient Health Questionnaire (PHQ-2), 9- A total of 117 out of 148 studies described the anxiety data in terms of frequency or percentage [8, 10, 11, 24-27, 103-114, 116-118, 120, 122-135, 137-141, 143-145, 149, 151-154, 156-165] . Tools that were used to screen for anxiety were Depression There were 40 studies which reported on data regarding stress, using five different type of scales which were Depression-Anxiety-Stress Scale-21 (DASS-21), Safety Attitudes Questionnaire (SAQ), Perceived Stress Scales (PSS), Stanford Acute Stress Reaction Questionnaire (SASRQ), and State and Trait Anxiety Inventory (STAI) [30, 31, 39, 56, 59, 77, 78, 91, 92, 99-102, 104, 106, 107, 113, 120, 123, 124, 127, 129-133, 138, 140, 141, 143, 144, 150, 152, 153, 155, 160, 161, 164, 165] .

Only 7 studies investigated data on burnout in term of its' frequency or percentage. The most common tools used to screen burnout among healthcare providers was Maslach Burnout Inventory (MBI), followed by ProQOL Scale of Chinese version, and Oldenburg Burnout Inventory (OLBI) [9, 34, 43, 87, 142, 144, 160] . A validated questionnaire form was adopted from Michelle Post, Public Welfare, Vol. 39, No. 1, 1981, American Public Welfare Association to examine the prevalence of burnout.

On the other hand, 5 studies reported data on fear, using five different scales which were Besides, two studies that reported on low resilience data were using the Connor-Davidson Resilience Scale (CD-RISC) as screening tool [11, 96] .

A summary of pooled prevalence of mental illnesses among healthcare providers during COVID-19 pandemic is shown in Table 2 and S1-S5 Figs. The overall pooled prevalence of mild to severe depression among HCPs is 37.5 (95% CI = 33.8-41.3). (Fig 2) Jordan recorded the highest prevalence of depression among HCPs at 78.0% (95% CI = 75.6-80.4), followed by a multicentre study involved Egypt and Saudi Arabia at 69.0% (95% CI = 64. 6-73.4) , and Iran at 59.6% (95% CI = 37.4-81.9). Pooled prevalence of depression of 52 studies in China was reported as 36.5% (95% CI = 31.7-41.2) while that in Malaysia was 26.6% (95% CI = 17.9-35.3) (S1 Fig). The pooled prevalence of mild to severe anxiety among HCPs in Asian countries was 39.7% (95% CI = 34.3-45.1). (Fig 3) Jordan, again recorded the highest prevalence of anxiety at 70.8% (95% CI = 68.2-73.4) among HCPs while the lowest prevalence of anxiety was found in a study conducted across the Asian Pacific region. Prevalence of anxiety in China was 31.9% (95% CI = 27.8-36.0), which is almost similar with Malaysia at 30.2% (95% CI = 27.9-32.6).

The overall pooled prevalence of mild to severe stress was found to be 36.4% (95% CI = 23.2-49.7) (Fig 4) , with the highest prevalence reported in Iran at 99.8% (95% CI = 99.1-100.4) whereas the lowest prevalence was reported in Korea at 4.3% (95% CI = 0.6-8.1).

Pooled prevalence of moderate to severe burnout among HCPs in Asia was 68.3% (95% CI = 54.0-82.5) (Fig 5) which was relatively higher as compared to others mental health issues aforementioned. Korea was ranked number one for the pooled prevalence of burnout at 90.4% (95% CI = 85.1-95.8), followed by Malaysia at 85.2% (95% CI = 80. 4-89.9 ) and Singapore at 68.2% (95% CI = 66.5-69.8); while China had the lowest prevalence at 58.0% (95% CI = 30.5-85.6) among the 5 countries that were investigated for the prevalence of burnout.

The pooled prevalence of mild to severe fear was 71.3% (95% CI = 54.6-88.0) (Fig 6) . The highest prevalence of fear was found in Bangladesh at 99.9% (95% CI = 99.5-100.2) while the lowest prevalence was found in China at 53.4% (95% CI = -20.6-127.5).

Low resilience had the pooled prevalence of 16.1% (95% CI = -12.8-19.4) (Fig 7) , with 16.2% (95% CI = 12.4-20.0) and 15.8% (95% CI = 9.3-22.4) being reported in China and India, respectively. Similarly females (50.6%; 95%CI = 43.5-57.6) generally were more anxious than males (41.2%; 95%CI = 32.0-50.4) while analysing the gender subgroup for anxiety. Nurses, assistant nurses and midwives (43.1%; 95%CI = 36.6-49.7) had the highest prevalence for anxiety, followed by doctors and dentists (39.6%; 95%CI = 34.5-44.7), and finally by allied healthcare personals and pharmacists (38.6%; 95%CI = 26.2-51.0).

For the prevalence on stress, the female population (48.1%; 95%CI = 31.6-64.5) was still having higher prevalence than male population (40.4%; 95%CI = 22.8-57.9). Almost half of those who worked as nurses, assistant nurses and midwifes (45.4%; 95%CI = 29.4-61.4) Table 4 showed the subgroup analysis of the odds ratio of psychological distress according to the risk factors. From this meta-analysis, it was found that odds of depression were increased in females (OR = 1.48; 95%CI = 1.30-1.68) and those who worked as nurses, assistant nurses or midwives (OR = 1.21; 95% CI = 1.02-1.45). Those who worked as doctors, dentist, allied healthcare or pharmacist were found to be the protected against depression (p-value <0.001).

In 

We performed sensitivity analysis by omitting every single study step-by step from the metaanalytic model. The result reported no major changes in terms of the pooled prevalence of psychological distress (Fig A6.1 

To date, this is the first systematic review with meta-analysis on psychological distress among HCPs amidst the COVID-19 pandemic in Asian region with country-based estimates. We identified 148 cross-sectional studies from 23 Asia countries and quantitatively determined the subgroup pooled prevalence according to gender and occupations in this region. The pooled prevalence for depression was 37.5% (95%CI: 33. 8 Among all the psychological distress, fear appeared to be the most common psychological reaction among HCPs whom continued to provide healthcare services during the COVID-19 pandemic, followed by burnout, anxiety, depression and finally by stress. More than two thirds of the HCPs were having fear amidst the COVID-19 pandemic. Our findings is similar to the findings of the previous review in Asia which the prevalence of fear among HCPs ranged between 67% [166] to 77.1% [13] . There are many reason for HCW's fear in this pandemic, one of the most common issues face by HCPs are there are fear of failing to provide adequate care for patients, non-limited to only COVID-19 due to limited supply of resources as well as manpower to handle the frequent sudden rise in COVID-19 cases that often strain the healthcare facility capacity [167] . Another possible explanation for the high prevalence of fear among HCPs were due to the fear of carrying the virus back home and infecting family and friends as well as fear of stigmatization [168] . It is also could be due to the fear of being infected and need to be quarantined, thereby further exacerbating the pre-existing inadequate numbers of HCWs at the frontline combating COVID-19 [169] . Another reason for fear among HCPs was because they were lacking in Personal Protection Equipment (PPV) rations and had unfamiliarity in using PPV, especially at the beginning of the pandemic. They may have had no training for infection prevention and control protocols especially at the beginning of the pandemic. All these factors may end up with many HCPs succumbing to this virus while providing care to the patients [170, 171] . Burnout was the second most common psychological distress faced by HCPs. The possible explanation could be due to the irregular or long working hours and high workload demand [1] . Furthermore, HCWs need to adapt to the IPC strategies by putting on PPE before starting to work and showering before going home. All this required additional time in preparation and cleaning and can cause fatigue in the long run [172] . This is not surprising on why another systematic review by de Pablo et al., 2020 reported that only 34.4%(95%CI = 19.3-53.5%) of the HCPs suffered from burnout which is lower compared with our finding of 68.3% [172] . The possible explanation for the difference in prevalence of burnout could be due to the fact that the study by de Pablo et al., 2020 examined burnout among HCWs exposed to SARS/ MERS/COVID-19 whereas our systematic focused mainly on COVID-19. Despite SARS/ MERS/COVID-19 are all caused by different strains of coronavirus, however there is an apparent difference in the influence on human imposed by these different coronaviruses' strains. For instance, the mortality rate of COVID-19 is 4.9%, which is higher than SARS (0.96%) and much lower than MERS (34.4%). The duration of the SARS pandemic (cumulative of 8,422 cases) was relative shorter which was brought under control in only 9 months (1 November 2002-31 July 2003) and outbreak of MERS only lasted for two months in both Saudi Arabia (n = 402 cases) and South Korea (n = 150 cases). However, COVID-19 has been around us for more than one year now and the emergence of new variants that are still evolving and its effect largely remains unpredictable, adds to its own pandora box. In view of the influence exerted by COVID-19 is much more devastating than SARS and MERS, therefore HCWs suffer burnout more easily in handing COVID-19 cases than in handling cases of SARS and MERS.

Our review showed that about one third of the HCPs suffered from depression with pooled prevalence of 37.5%, anxiety (39.7%) and stress (36.4%). However, our pooled prevalence of depression was higher comparing with two other systematic reviews by Hossain MM et al and Gonzalo Salazar de Pablo et al where the pooled prevalence of depression ranges from 17.9%-29.9% and anxiety, 22.2% to 43.6% [12, 171] . The pooled prevalence of anxiety in our review fell in between of these two reviews which ranged from 22.2 to 43.6% [12, 171] .

Among the 148 papers reviewed, 98 of them examined the prevalence of depression among HCP, with China reporting most number of cases (22, 772) of depression since the outbreak of COVID-19. Prevalence of this parameter in China was found to be 36.5%. Prevalence of depression in Malaysian HCP was relatively lower at 26.6% (95%CI: 17.9-35.3; p-value<0.001). The possible reason could be due to the fact that these cross-sectional studies were conducted at the very beginning stage of the outbreak in China before the pandemic was declared, where very little was known about the virus and hence the Chinese healthcare workers were generally experiencing greater mental disturbances. Jordan, Egypt from the subdivision of Asian continent, Arab Saudi and Iran were the countries with the prevalence of depression and, anxiety of more than 50% when compared with other countries in Asia. The possible explanation could be due to the fact that most of the research were conducted between March to July 2021 at the time that Middle East countries were having the COVID-19crisis. Most of the countries (Jordan, Egypt, Arab Saudi and Iran) had full lockdown or night-time curfew. The reason for the rapid rise in cases were largely due to large religious gatherings, wedding celebrations and other social events where control measures were not sufficiently enforced [173] . The possible reasons were that there was a lack ofhealthcare facilities and equipment to deal with COVID-19 pandemic [174] . Furthermore, the human resources were also insufficient and below the recommendation of WHO as some of HCPs have left the countries following the country's own politic instability [175, 176] . With a weakened healthcare system, the COVID-19outbreak had posed a major challenge on the mental health of HCPs and it explained why the prevalence of depression and anxiety were generally higher as compared with other countries in Asia [177] .

On the other hand, we also found that the prevalence of anxiety among healthcare workers in China, India, and Malaysia were 31.9% (95%CI: 27.8-36.0), 44.2% (95%CI: 32.6-55.9) and 30.2% (95%CI: 27.9-32.6), respectively. The lower prevalence of both anxiety and depression in Malaysia as compared with other countries could be due to the studies were conducted during Conditional Movement Control Order (CMCO) period when the condition of outbreak in Malaysia was considered to be relatively under-control, and background of the causative virus had been learnt from China. Besides, the fact that the data was not merely focusing on COVID-19 hospitals but also involving non-COVID centres could have led to the lower anxiety prevalence in Malaysia [140, 142] .

With the COVID-19 pandemic hitting many health care facilities that were unprepared to handle it, many healthcare providers who were standing at the frontline were working and pushing themselves to the limit [28] . Pooled prevalence of burnout was found to be 68.3% (95% CI: 54.0-82.5) in our systematic review and meta-analysis, ranging from the lowest prevalence of 58.0% in China to the highest prevalence of 90.4% reported in Korea. Korea has the highest prevalence of burnout as the study was conducted specifically among the the Infectious Disease physicians. This is not unexpected as their work burden is much higher during the COVID-19 pandemic [160] .

A cross-sectional study conducted by Dong et al in China revealed that despite the long working hours, healthcare workers were mostly (n = 4,120, 89.2%) motivated and feeling positive towards their task at hand, and remained committed to their professions. During the outbreak period in China around early 2020, Chinese nationals from all over the country, with or without medical background, showed exemplary courage and actively volunteered to assist at Wuhan, the epitome of the COVID-19 pandemic [178, 179] . There was also an increment in healthcare providers' salaries by the Chinese government at the same time. Their firm belief to their professions and strong social support from their nation were believed to be factors contributing to the lowest burnout prevalence among Asian countries [28] . Whereas, in Malaysia, the high prevalence of burnout among nurses could be due to the reduction in their off days as a consequences of more intense shift hours, and being overworked, coupled with a low salary [142] .

When analysing the subgroup of associated risk factors of psychological distress, it was found that both females and nurses population were more at risk of getting mental distress Internally, females' nature generally belongs to the sentimental type and they usually experience hormonal changes which would then affect their mood and emotion [180] . Other than playing a role as a medical professional, most of the time females were also housewives for their family [8] . They tend to be a multitasker where they must take care of their family members' health and well-being as well as going out for marketing in crowded areas to purchase necessities. A lot of time they were lacking support from family and were bombarded with many negative news circulated on social media, which can create negative feelings and make them more tired and prone to psychological illness [181] [182] [183] . Besides, it was found that the majority of the nurses were females (95.6%) [184] . Furthermore, nurses generally had longer contact hours with COVID-19 patients than doctors and were working longer hours than usual [36] . Other than taking care of the patients, they had to deal with their families who might be more frustrated, angry, anxious or worried due to lack in family time [142] . These were consistent with the findings from a systematic review by Thatrimontrichai et al which concluded that females, nurses, having direct contact with infected patients, working longer hours and possessing less working experience were the main risk factors leading to mental disturbances among Chinese healthcare workers [13] .

High heterogeneity was found in this systematic review, and possible reasons include variation from the participants' characteristics, outcome level and research setting [185] . Firstly, the high heterogeneity for the overall prevalence of psychological distress found in this study could be due to differences in the screening methods and diagnostic criteria in different countries with different ethnicities and research settings (S4 Table) . For example, different screening tools were used to determine burnout such as Maslach Burnout Inventory (MBI) ProQOL Scale of Chinese Version and Olenburg Burnout Inventory (OLBI); whereas scales like Patient Health Questionnaaire (PHQ), Depression-Anxiety-Stress Scale-21 (DASS-21), Beck Depression Inventory (BDI), Hamilton depression rating scale (HAMD), etc were used for depression screening. Next, different categories for the severity of disease were reported in different studies. Moreover, even though in the same country, there were different diagnostic criteria applied for psychological distress studies. For example, in China, ten different diagnostic tools were used to detect depression compared with three diagnostic tools used in India, which give rise to a broad range of prevalence of depression in China (31.7%-41.2%) and India (27.9%-39.3%). In our meta-analysis, there was a wide gap in terms of sample size in all 148 studies, ranged from 100 to 14,825 in this review. All these factors would explain why there was a high heterogeneity for the prevalence of psychological distress, for instance, depression in this study.

Multiple factors contributed to publication bias, comprises of study design, sample size, decision of authors, journal editors and reviewers [186] . We had excluded all the unpublished data and studies with a sample size of below 100 in this review. However, we need to weigh the advantage and disadvantages as those published studies have gone through a rigorous review process, which gave a more reliable result compared with those unpublished data. Furthermore, we also excluded studies with outcomes that did not fulfil our operational definition of psychological distress. This systematic only included manuscripts wrote in English due to constraint of resources.. Thus, we had to interpret the results of this systematic review carefully within the context of its limitations level and research setting [185] .

This review paper highlights the psychological distress of HCPs in the menacing era of the COVID-19 pandemic. Such HCW's mental burden either have not been acknowledged or have been underestimated because most of the healthcare systems have currently focused on coping with the pandemic as its main target. Foremost,psychological distress among HCPs should be given priority and urgent action is needed to reduce the psychological impacts on HCPs, in order to ensure continuation of effective services to patients amidst the COVID-19 pandemic.

There are some limitations in this review paper. Firstly,our review paper depended on collecting and compiling the published data where the papers that were analysed were mostly periodic, in which only the psychological state of HCPs over a certain period of time were reflected. However, with the progression of time, different conditions of outbreak over the period of one year and shifting to new environments, the targeted population's mental health may have changed. Thus, the psychological impact among healthcare providers amidst the COVID-19 pandemic should ideally be assessed longitudinally. Secondly, high heterogeneity was not an unexpected finding in our review as data were gathered from various studies that were conducted differently in terms of study designs, data collection tools, different study setting and location as well as having varied demographic features of participants. Therefore, our results needs careful interpretation. Thirdly, only English language written articles were recruited in this review, therefore this can result in publication bias. Future studies on interventions to improve the psychological health of HCPs is needed urgently in order to maintain their physical health and productivity in continuing the fight against this pandemic.

In conclusion, the global COVID-19 pandemic has had a devastating impact on the mental health of HCPs. This systematic review synthesizes the quantitative evidence of psychological distress among HCPs in Asian countries, which showed that one third of HCPs suffered from depression, anxiety and stress and more than two third of HCPs suffered from fear and burnout during the COVID-19 pandemic in Asia. Meta-analysis reported both females and nursse were at increased risk of having depression and anxiety. Female HCPs was also at a higher risk of getting stress when compared with the male HCPs. Urgent action are needed to implement a multicultural level interventions to support HCPs in order to reduce the burden of psychological distress during this very challenging COVID-19 pandemic. 

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Sleep disturbances among medical workers during the outbreak of COVID-2019

Sleep disturbance and psychological profiles of medical staff and non-medical staff during the early outbreak of COVID-19 in Hubei Province

COVID-19 outbreak-related psychological distress among healthcare trainees: a cross-sectional study in China

The self-psychological safety maintenance and its influencing factors of community frontline staff during COVID-19 pandemic

Psychological impact of healthcare workers in China during COVID-19 pneumonia epidemic: a multi-center cross-sectional survey investigation

The psychological status of 8817 hospital workers during COVID-19 epidemic: a cross-sectional study in Chongqing

Study of the mental health status of medical personnel dealing with new coronavirus pneumonia

Anxiety and depression in frontline health care workers during the outbreak of Covid-19

The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey

Factors associated with insomnia among Chinese front-line nurses fighting against COVID-19 in Wuhan: a cross-sectional survey

Prevalence and influencing factors on fatigue of first-line nurses combating with COVID-19 in China: a descriptive cross-sectional study

Impact of burnout, secondary traumatic stress and compassion satisfaction on hand hygiene of healthcare workers during the COVID-19 pandemic

The prevalence and risk factors of psychological disturbances of frontline medical staff in china under the COVID-19 epidemic: workload should be concerned

Prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against COVID-19 in Gansu. Front Psychiatry

The mediation effects of coping style on the relationship between social support and anxiety in Chinese medical staff during COVID-19

Attitude, practice, behavior, and mental health impact of COVID-19 on doctors

Depression, anxiety and stress" in a cohort of registered practicing ophthalmic surgeons, post lockdown during COVID-19 pandemic in India

Anxiety and sleep disturbances among health care workers during the covid-19 pandemic in India: cross-sectional online survey

Psychological health among armed forces doctors during COVID-19 pandemic in India

Survey of prevalence of anxiety and depressive symptoms among 1124 healthcare workers during the coronavirus disease 2019 pandemic across India. Med J Armed Forces India

Burnout and resilience among frontline nurses during COVID-19 pandemic: a cross-sectional study in the emergency department of a tertiary care center

Psychological impact of COVID-19 on ophthalmologists-in-training and practising ophthalmologists in India

Burnout among healthcare workers during COVID-19 pandemic in India: results of a questionnaire-based survey

Stress-related disorders in health-care workers in COVID-19 pandemic: a cross-sectional study from India

Multi-centric study of psychological disturbances among health care workers in tertiary care centers of Western India during the COVID-19 pandemic

Comparative analysis of perceived stress in dermatologists and other physicians during national lock-down and COVID-19 pandemic with exploration of possible risk factors: a web-based cross-sectional study from Eastern India

Weathering the storm: psychological impact of COVID-19 pandemic on clinical and nonclinical healthcare workers in India

Mental health and quality of life among healthcare professionals during the COVID-19 pandemic in India

Prevalence and predictors of stress, anxiety, and depression among healthcare workers managing COVID-19 pandemic in India: a nationwide observational study

Psychological effects of nurses and midwives due to COVID-19 outbreak: the case of Turkey

An evaluation of depression, anxiety, and stress levels of frontline healthcare professionals during COVID-19 pandemic in Turkey

State anxiety levels of nurses providing care to patients with COVID-19 in Turkey

The evaluation of knowledge, attitudes, depression and anxiety levels among emergency physicians during the COVID-19 pandemic. Signa Vitae

The evolution of the changes in the clinical course: a multicenter surveyrelated impression of the ophthalmologists at the peak of the COVID-19 pandemic in Turkey

The impact of COVID-19 on healthcare workers' anxiety levels

Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey

Evaluation of the effect of COVID-19 pandemic on anxiety severity of physicians working in the internal medicine department of a tertiary care hospital: a cross-sectional survey

Worry, severity, controllability, and preventive behaviours of COVID-19 and their associations with mental health of Turkish healthcare workers working at a pandemic hospital

The effect of the COVID-19 pandemic on functioning of neurosurgery clinics and the anxiety levels of neurosurgeons in Turkey

The relationship between psychological resilience, burnout, stress, and sociodemographic factors with depression in nurses and midwives during the COVID-19 pandemic: A cross-sectional study in Turkey

Psychological factors associated with the spread of coronavirus disease 2019 (COVID-19) among nurses working in health sectors in Saudi Arabia

Mental health outcomes amongst health care workers during COVID-19 pandemic in Saudi Arabia. Front Psychiatry

Prevalence and predictors of anxiety among healthcare workers in Saudi Arabia during the COVID-19 pandemic

Psychological distress amongst health workers and the general public during the COVID-19 pandemic in Saudi Arabia

Effect of 2019 coronavirus pandemic on ophthalmologists practicing in Saudi Arabia: a psychological health assessment

Health care worker burnout during the COVID-19 pandemic: a cross-sectional survey study in Saudi Arabia

Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study

Hospital preparedness, resilience, and psychological burden among clinical nurses in addressing the COVID-19 crisis in Riyadh, Saudi Arabia. Public Health Front

Psychological Impact of the COVID-19 pandemic on dental interns in Riyadh, Saudi Arabia: a cross-sectional survey

The psychological impact of COVID-19 pandemic on health care workers in a MERS-CoV endemic country

COVID-19 and anxiety amongst doctors: a Pakistani perspective

Assessing the impact of covid-19 on the mental health of healthcare workers in three metropolitan cities of pakistan

Anxiety among doctors during COVID-19 pandemic in secondary and tertiary care hospitals

Psychological impact of COVID-19 pandemic on postgraduate trainees: a cross-sectional survey

Psychosocial impact of COVID-19 on healthcare workers at a tertiary care cardiac center of Karachi Pakistan

Impact of COVID-19 on the mental health of healthcare professionals in Pakistan

Determinants psychological distress of indonesian health care providers during COVID-19 pandemic

Psychological impact among health workers in effort to facing the COVID-19 in indonesia

Anxiety and resilience of healthcare workers during COVID-19 pandemic in Indonesia

Generalized anxiety disorder associated with individual work performance of Indonesian medical personnel during COVID-19 outbreak

Psychological distress among health service providers during COVID-19 pandemic in Nepal

Mental health impacts among health workers during COVID-19 in a low resource setting: a cross-sectional survey from Nepal. Glob Health

Stress, anxiety, depression and their associated factors among health care workers during COVID -19 pandemic in Nepal

Prevalence of psychological effect of COVID-19 on medical professionals in a tertiary care center

Doctors' mental health in the midst of covid-19 pandemic: the roles of work demands and recovery experiences

Mental health status of university healthcare workers during the COVID-19 pandemic: a post-movement lockdown assessment

Assessment of burnout among emergency medicine healthcare workers in a teaching hospital in Malaysia during COVID-19 pandemic

A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak

Burnout and associated factors among health care workers in Singapore during the COVID-19 pandemic

The psychological impact of COVID-19 on 'hidden' frontline healthcare workers

Anxiety, depression, and resilience of healthcare workers in Japan during the coronavirus disease 2019 outbreak

The psychological effects of COVID-19 on hospital workers at the beginning of the outbreak with a large disease cluster on the Diamond Princess cruise ship

The psychological impact of 'mild lockdown' in Japan during the COVID-19 pandemic: a nationwide survey under a declared state of emergency

Anxiety and depression in health workers and general population during COVID-19 in Iran: a cross-sectional study

Survey of immediate psychological distress levels among healthcare workers in the COVID-19 epidemic: a cross-sectional study

Anxiety and depression and the related factors in nurses of Guilan University of Medical Sciences hospitals during COVID-19: a web-based cross-sectional study

Factors associated with mental health outcomes across healthcare settings in Oman during COVID-19: frontline versus non-frontline healthcare workers

The mental health of female physicians and nurses in oman during the COVID-19 Pandemic

Mental health status of the general population, healthcare professionals, and university students during 2019 coronavirus disease outbreak in Jordan: a cross-sectional study

Acute stress disorder, coping self-efficacy and subsequent psychological distress among nurses amid COVID-19

Prevalence and predictors of coronaphobia among frontline hospital and public health nurses. Public Health

COVID-19 anxiety among front-line nurses: predictive role of organisational support, personal resilience and social support

Psychological burden of the COVID-19 pandemic and its associated factors among frontline doctors of Bangladesh: a cross-sectional study

Prevalence of anxiety and depressive symptoms among physicians during the COVID-19 pandemic in Bangladesh: a cross-sectional study

Psychological distress among infectious disease physicians during the response to the COVID-19 outbreak in the Republic of Korea

Factors associated with mental health outcomes among medical residents exposed to COVID-19

COVID-19-related anxiety disorder in Iraq during the pandemic: an online cross-sectional study. Middle East Curr Psychiatry

Asian-Pacific perspective on the psychological well-being of healthcare workers during the evolution of the COVID-19 pandemic

Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic?

Mental health and health-related quality-of-life outcomes among frontline health workers during the peak of covid-19 outbreak in Vietnam: a cross-sectional study

Mental health of medical staff during the coronavirus disease 2019 pandemic: a systematic review and meta-analysis

Centers for Diseases Control and Prevention. Strategies to mitigate healthcare personnel staffing shortages 2021

Fear and avoidance of healthcare workers: an important, under-recognized form of stigmatization during the COVID-19 pandemic

Predictive factors associated with fear faced by healthcare workers during COVID-19 pandemic: a questionnaire-based study

Global burden of COVID-19 pandemic on healthcare workers

Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China

Impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis

Statement by WHO's Regional Director on an upsurge in the number of COVID-19 cases in the Eastern Mediterranean Region

COVID-19 crisis response in MENA countries 2020

World Health Organization. Physicians density (per 1000 population) 2021

Report on the health of refugees and migrants in the WHO European Region: no public health without refugee and migrant health

COVID-19, crises and fragility 2020

Chinese medical students' interest in COVID-19 pandemic

A new generation of volunteers emerges in the Chinese city at the epicenter of the coronavirus crisis

Sex differences in anxiety and depression clinical perspectives

The impact of social media on panic during the COVID-19 pandemic in Iraqi Kurdistan: online questionnaire study

The role of social media in spreading panic among primary and secondary school students during the COVID-19 pandemic: an online questionnaire study from the Gaza Strip

What social media told about us in the time of COVID-19: a scoping review

A large-scale survey on trauma, burnout, and posttraumatic growth among nurses during the COVID-19 pandemic

Investigating clinical heterogeneity in systematic reviews: a methodologic review of guidance in the literature

Publication bias in meta-analysis: its causes and consequences