key: cord-1014905-00o8pkyk authors: Xu, X.; Zhang, S. X.; Afshar Jahanshahi, A.; Li, J.; Bagheri, A.; Nawaser, K. title: The Mental Health of Healthcare Staff during the COVID-19 Pandemic: It Depends on How Much They Work and Their Age date: 2020-08-21 journal: nan DOI: 10.1101/2020.08.18.20173500 sha: 15cbb2e066fb67d49eaf04a229becfa42bc32ebf doc_id: 1014905 cord_uid: 00o8pkyk Background: Healthcare staff are the forefront of fight against COVID-19 and they are under enormous pressure due to the fast growth in the number and severity of infected cases. This creates their mental issues such as distress, depression and anxiety. Exploring healthcare staff's mental health during the pandemic contributes to improving their persistence in the growing challenges created by COVID-19 and enabling effective management of their mental health. Methods: An online survey of 280 healthcare staff in all the 31 provinces of Iran was conducted during April 5 to 20, 2020. The survey assessed staff's distress, depression and anxiety in the COVID-19 pandemic. Results: Nearly a third of healthcare staff suffered from distress, depression and anxiety. Females and more educated healthcare staff were more likely to experience distress. Compared to personnel who did not have COVID-19, those who were unsure whether they had COVID-19 were more likely to experience distress and depression. The number of COVID-19 cases among the staff's colleagues or friends positively predicted their anxiety. Compared to radio technologists, doctors were less likely to experience distress and anxiety. Technicians and obstetrics experienced less anxiety. Analysis the interaction between weekly working days and age of the staff indicated the chance of experiencing distress and depression varied greatly by working days among younger but not older healthcare staff. Conclusion: Exploring the potential predictors of mental health issues assists healthcare organizations to develop approaches to prevent and decrease the issues among staff and improve their task performance in sever crises such as COVID-19, so they can stay motivated in the COVID-19 pandemic. It is useful to identify more working characteristic predictors for healthcare staff at different ages. Healthcare staff have been under enormous physical and mental pressures since the beginning of the COVID-19 pandemic. In the pandemic, healthcare staff face tremendous workloads, long and irregular working hours, and shortages of personal protective equipment (PPE) [1] . They also experience emotional and moral dilemmas from being isolated from their families during the pandemic [2, 3] . All of these factors may eventually lead to mental health issues [4, 5] . For instance, one nurse committed suicide because of the overload stress in Italy [6] . "Staff are being exposed to high levels of personal risk, long hours in difficult environments clad in PPE, and also the possibility of something known as moral injury, which is the distressing awareness you may feel when you know you can't meet all the needs of the people you are trying to care for" [7] . While such issues are acute in many countries [8, 9] , this paper aims to specify some unique predictors of healthcare staff's mental health disorders in Iran as the second country that experienced COVID-19 and the virus spread in all of the country very fast. In predicting mental health issues created and/or developed by COVID-19, this current research focused on socio-demographic [10, 11] and clinical predictors of healthcare staffs [12] . This survey is one of the very first attempts that investigated working characteristic predictors of healthcare staff's mental health during the COVID-19 pandemic. Furthermore, this study is the first, to the best of our knowledge, to examine comprehensive predictors of healthcare staff's mental health by measuring socio-demographic, clinical and working variables. While previous studies have suggested the risk factors as the predictors of mental health among healthcare staff [13, 14, 15] , our study particularly investigated working characteristics [16] such as job function, working institute and the number of working days per week to predict distress, depression and anxiety of healthcare staff in Iran. We also tested how the interaction between weekly working days and age of the staff predicts these mental health issues. These unique predictors provide evidence to help psychological service to identify healthcare staff who may need support. Our study surveyed healthcare staff in Iran during April 5-20, 2020 This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Written informed approval was provided by all survey participants prior to their enrolment. In order to access more participants under the constraints created by the COVID-19 pandemic, we shared the survey links on the social media channels (Instagram, Whatsapp and Telegram) which are very popular All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . https://doi.org/10.1101/2020.08.18.20173500 doi: medRxiv preprint among Iranian and asked the responding healthcare staff to share the survey with their colleagues. All of the participants completed the survey voluntarily and anonymously, and they were free to leave the survey at any time. The final sample comprised 280 healthcare staff across all the 31 provinces of Iran. Our predictor variables included socio-demographic variables, clinical variables and working characteristic variables. Socio-demographic characteristics were selfreported by all participants including age (that ranged from 20-30, 30-40, 40-50, to 50-60 years old), gender (male or female), education level (categorical variable ranging from 1 = under diploma, 2 = diploma with 12 years of education, 3 = student or graduate with 2 academic years, 4=student or graduate from university, 5 = student or graduate with a master degree, 6 = student or graduate with a doctoral degree). Clinical variables included: chronic disease, infected situation and number of colleagues or friends diagnosed with COVID-19. Drawing on previous research finding that people who have comorbidity may experience more mental health disorder than others in the COVID-19 pandemic [18], we asked the participants in this survey whether they had chronic disease using a categorical variable (1=yes, 2=not sure, 3=no). The participants were also asked whether they had been infected with COVID-19 within the past two weeks (1=yes, 2=not sure, 3=no). Lastly, the participants reported the number of their colleagues or friends diagnosed with COVID-19 within the past two weeks. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . https://doi.org/10.1101/2020.08.18.20173500 doi: medRxiv preprint Working characteristic variables consisted of three items. Because medical protective equipment are different by the job function [19] , we asked the healthcare staffs to indicate their job function (a categorical variable ranging from 1 to 9, where 1= a doctor, 2= a nurse, 3= a technician, 4= a radio technologist, 5= a medical student and an intern, 6= a healthcare administrator, 7= a supporting staff such as facility or cleaning staff, 8= a volunteer and 9= a obstetric staff). We also asked the participants their working institute (private, public, or government sector) and how many days a week they worked as a proxy for working days (1 day to 5 days) because the variables were suggested to affect healthcare workers' mental health. The three outcome variables measured in this study were distress, depression, and anxiety. The Kessler Psychological Distress Scale (K6) with Cronbach's alpha of 0.79 [20] was used to assess the participants' distress during the COVID-19. The 4-item Patient Health Questionnaire (PHQ-4, with a score of 0-12) was also employed to measure the severity of depression and anxiety among the participants. PHQ-4 is an ultra-brief self-report questionnaire consisting of a 2-item depression scale (PHQ-2) and a 2-item anxiety scale (GAD-2). The cutoff scores for detecting symptoms of distress, depression and anxiety were 13, 3 and 3 respectively. Participants who scored higher than the cutoff threshold were characterized as having the symptoms of the diseases. We translated the measures from English into Farsi, the official language of Iran. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . https://doi.org/10.1101/2020.08.18.20173500 doi: medRxiv preprint Our empirical analysis was performed using Stata 16.1 software. The statistical significance level was assessed by p < .05, 2-tailed. Multivariable logistic regression was used to determine potential risk threats of distress, depression and anxiety. In the statistical regression results, we presented descriptive analysis with odds ratios (ORs) and 95% confidence intervals (CIs) to show the potential association between risk predictors and outcome variables. We also performed a margin analysis to further investigate the interaction between the participants' working days and age that predict their distress, depression and anxiety. reported that they were unsure if they were infected by the virus. Over half of the participants (53.0%, 161) reported that their colleagues or friends were infected by COVID-19 with a mean of 3.86 (min: 0; max: 150). Because the number of colleagues or friends infected by the virus is a count, we transformed it by taking its log. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . Regarding the participants' job functions, 15.0% (42) were doctors, 20.4% (57) were nurses, 9.0% (25) were technicians, 22.1% (62) were radio technologists, 3.6% (10) were medical students and interns, 13.2% (37) were healthcare administrators or interns, 3.6% (10) were supporting staff (i.e., facility or cleaning staff), 2.8% (8) were volunteers and 10.3% (29) were obstetrics staff. Most the healthcare staff were from a public healthcare organization (74.7%, 223) and worked at least three days a week (72.2%, 202). preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . https://doi.org/10.1101/2020.08.18.20173500 doi: medRxiv preprint less likely to experience anxiety disorder. Our analysis also showed that existing chronic health issues and the type of healthcare organization (private, public or government sector) did not significantly predict distress, depression and anxiety. Significant results are presented in figure 1 . Secondly, the results demonstrated that the interaction between the participants' working days and age significantly predict their distress (OR=1.03; 95% CI: 1.00 to 1.06; p=0.047) and depression (OR=1.03, 95% CI: 1.00 to 1.06; p=0.026). Figure 1 shows the participants' working days per week and age predict their distress and depression. By further conducting a margin analysis, we found that 41% of the healthcare staff who were 20 years old and worked only one day per week had the highest likelihood of distress (95% CI: 23% to 65%; p=0.000) and 61% of them experienced depression (95% CI: 40% to 82%; p=0.000). Furthermore, the healthcare staff who were 20 years old but worked five days a week had 19% (95% CI: 19% to 36%; p=0.023) chance of having distress disorder and 24% (95% CI: 7% to 40%; The findings of our study revealed that nearly a third of all of the healthcare staff in Iran reported symptoms of distress, depression and anxiety during fighting with COVID-19 pandemic. Additionally, gender and education qualification were significant predictors of the healthcare staffs' distress. The participants who were All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . https://doi.org/10.1101/2020.08.18.20173500 doi: medRxiv preprint unsure if they have been infected by COVID-19 reported a more risk of distress and depression compared to those who were sure that they have not been infected by the virus. In addition, our survey suggested that the number of COVID-19 cases among colleagues or friends positively predicted anxiety disorder of the participants. Compared to radio technologists, doctors had less possibility of distress and anxiety while technicians and obstetrics staff had less possibility of anxiety. Our study demonstrated that the interaction between the number of working days a week and age predicts the respondents' distress and depression, with the chance of having distress and depression varying greatly by the number of working days among younger but not older healthcare staff. In contrast to previous research, our study failed to find a significant effect of some demographic variables on the mental health of the healthcare staff. While, age, gender and education qualification predicted mental health among healthcare staff in China [21, 22, 23] , in Italy [24] , in Brazil [25] and in other countries [26] during the COVID-19 pandemic, we could not find a significant association between the variables. In addition, previous studies indicated having a chronic disease was shown to be a risk factor that significantly affects mental health of staff [27, 28] , but we did not find a significant relationship between the variables. Our study also revealed that doctors were less likely to suffer from distress and anxiety than radio technologists, because radio technologists were more likely exposed to the risk of COVID-19 infection due to their frequent and close engagement in the process of diagnosing patients. These findings showed that the possible predictors of the mental health of All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . https://doi.org/10.1101/2020.08.18.20173500 doi: medRxiv preprint healthcare staff during a pandemic from socio-demographic variables, clinical variables and working characteristic variables vary across countries [29, 30, 31] . These predictors of the mental health of healthcare staff mentioned previously vary for different mental health symptoms in one pandemic. Moreover, our study showed that the participants' age significantly predicted distress and depression differently when we focused on their working days per week. Our findings suggest that hospitals and psychological service organizations should pay more attention to their younger healthcare staff. Previous studies have shown that younger adults experienced greater mood swings during the SARS outbreak due to their inadequate experience of facing a changing environment [32] . During the COVID-19 pandemic, younger healthcare staff exhibited the same condition when they worked fewer days a week. Hence, hospitals in Iran may consider training more working days a week for younger healthcare staff. Our study has several limitations that open new agendas for future studies. First, we focused on healthcare staff in Iran who were very busy during the COVID-19 pandemic. Therefore, we examined limited variables related to mental health of healthcare staff using K6 and PHQ-4 to measure distress, depression and anxiety. Second, our sample size is also relatively small. Future studies should examine the factors that determine mental health of healthcare staff using a lager sample size. Finally, we attempted to include samples from different provinces of Iran. However, our sample is limited to a small proportion of healthcare staff in each province of Iran. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted August 21, 2020. . Therefore, future studies should examine if geographic location or the actual density of COVID-19 cases in each province affect the healthcare staff's experience of mental diseases. This survey is also cross-sectional. Therefore, future longitudinal studies to examine the factors that affect healthcare staff's mental health highly contribute to our knowledge of healthcare mental health during pandemic crises. Identifying potential risk predictors for healthcare staff assists psychological service institutions better alleviate the mental health issues of staff during the COVID-19 pandemic. Importantly, this study demonstrated that it is imperative to pay more attention to female and highly educated healthcare staff, and some clinical predictors should also be recognized. The interaction of healthcare staff's number of working days a week and age play an important role in predicting their distress and depression disorders. Therefore, it is imperative to further investigate healthcare staff's potential working characteristics during the COVID-19 pandemic and help the staff maintain their professional and personal strength in the prolonged COVID-19 pandemic. All rights reserved. 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