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Introduction
Designing special interventions aimed at protecting the mental health of healthcare has become a particularly crucial public health issue during the COVID-19 pandemic1. Measuring the impact of psychological distress in this vulnerable population may help in the design of these interventions2.
Previous studies carried out during the SARS (Severe-Acute Respiratory Syndrome) epidemic of 2003 confirmed the presence of adverse psychological reactions among healthcare workers3-5. Healthcare workers reported fear getting infected, and of passing the infection to their family, friends, and colleagues; they also reported feelings of uncertainty and stigmatization. In addition, they showed increased levels of subjective stress, anxiety, and depressive symptoms5. Also, in 2003, hospital employees exposed to SARS (due to quarantining themselves, or to working in high-risk settings such as SARS wards), as well as those who reported having friends or family members with SARS, were more likely to show symptoms of post-traumatic stress, compared to those without any exposure6.
In 2020, in the Wuhan region, the original epicenter of COVID-19 pandemic, it has been described that front-line healthcare workers, exposed to patients with COVID-19, reported a significantly higher rate of anxious symptoms, depression, insomnia and malaise, compared to unexposed healthcare workers7.
In Latin America some studies have been carried out to determine the psychological effects of the COVID-19 pandemic on the general population8,9. However, data on the psychological impact of the pandemic in Latin American healthcare workers are not available.
The aim of the present study is to describe the psychological impact of COVID-19 among healthcare workers in Paraguay. Findings may provide helpful evidence that could become the basis of strategies designed for the prevention and promotion of mental health in healthcare workers.
Methodology
This is a preliminary study carried out in five tertiary referral centers in the departments of Central, San Pedro and Caaguazú, Paraguay, during the two-month period from April to June 2020. The participants included healthcare workers, with age ranging from 18 to 65 years. The tertiary referral hospitals included in this pilot study were the following: “Hospital de Clínicas” in the city of San Lorenzo; General Hospital of the Department of San Pedro, in the city of Santa Rosa del Aguaray; Regional Hospital of the city of Coronel Oviedo, IPS Hospital of the City of Coronel Oviedo, and Regional Hospital of the city of Pedro Juan Caballero. All the participants were selected using an intentional, non-probabilistic sampling. 125 participants, 25 from each hospital, were included.
The study was approved by the Ethics Committee of the Faculty of Medical Sciences of the National University of Asunción. Informed consent was obtained verbally and in writing by each participant before starting the research recruitment and data collection. Confidentiality of the information was ensured. However, personal contact information was also collected in order to provide further assessment and management if required.
Demographic data included occupation (nurse, doctor, others), sex (male or female), age (21-30, 31-40, 41-50, 51-60 years old), marital status, educational level (undergraduate, graduate or postgraduate), place of residence (urban or rural), type of hospital (secondary, tertiary), and area of work.
Healthcare workers responded to questions regarding their exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including occupational exposure or a friend and/or family member with COVID-19. Occupational exposure was considered as high for those workers practicing in high-risk settings (COVID-19 ward, emergency department, respiratory medicine department, or X-ray imaging) during the pandemic. COVID-19 diagnosis was considered as well as having been in direct contact with a COVID-19 positive patient either at work, home, or in any other setting.
The present study detected symptoms of depression, anxiety and post-traumatic stress disorder, employing instruments with a validated Spanish version: The Patient Health Questionnaire (PHQ-9, range 0-27)10,11, and the 7- item Generalized Anxiety Disorder scale (GAD-7, range, 0-21)12. For the assessment of PTSD (Post- Traumatic Stress Disorder) symptoms, the PCL-C PTSD- checklist was used13, with a score ≥50 indicating significant symptoms of PTSD14-16.
Because of social distancing rules and the lockdown instituted by the government, data were collected through Google forms, sent by various digital platforms of communication, including e-mails, or digital version of a self-administered form, through Epi-info 7, provided through a tablet. Data were transferred into a Microsoft Excel electronic spreadsheet, version 19.
Results
In the present pilot study, 125 healthcare workers were selected and completed the survey. Of them, 68 (54.8%) were doctors, 37 (29.8%) nurses, 7 (5.6%) biochemists, 3 (2.4%) obstetricians, and 9 (7.3%) other healthcare workers.
Most participants were females (86 (68.8%)), with an average age of 33.8 years old (SD ± 7.4); 71 (56.8%) were single, 83 (66.4%) reported a postgraduate educational level, 52 (41.6%) with a junior level of work experience. 71 (57.3%) were considered to be high-risk healthcare workers due to practicing in COVID-19 wards, emergency departments, respiratory medicine departments or X-ray imaging. Most of participants were from urban areas (118 (94.4%)). 61 (48.8%) participants presented depressive symptoms, and 68 (54.4%) reported anxious symptoms. A small group reported symptoms of post-traumatic stress (9 (7.2%)). Detailed results are shown in Table 1.
Table 1: Characteristics of the sample (n=125).
| Characteristics | n (%) | PTSD symptoms# n (%) | Depressive Symptoms§ n (%) | Anxiety Symptom* n (%) |
|---|---|---|---|---|
| Sex | ||||
| Male | 39 (31.2) | 4 (10.2) | 15 (38.5) | 20 (51.2) |
| Female | 86 (68.8) | 5 (5.8) | 46 (53.5) | 48 (55.8) |
| Total | 125 (100) | 9 (7.2) | 61 (48.8) | 68 (54.4) |
| Age (years old) | ||||
| 33.8 ± 7.4 | 31.4 ± 4.1 | 33.5 ± 7.5 | 33.6 ± 7.3 | |
| Marital Status | ||||
| Married | 38 (30.4) | 1 (2.6) | 15 (39.5) | 22 (57.9) |
| Divorced/Separated | 7 (5.6) | 1 (14.3) | 6 (85.7) | 5 (71.4) |
| Domestic Partnership | 5 (4.0) | 0 (0) | 0 (0) | 0 (0) |
| Single | 71 (56.8) | 7 (9.9) | 38 (53.5) | 40 (56.3) |
| Widow | 4 (3.2) | 0 (0) | 2 (50) | 1 (25) |
| Residence | ||||
| Rural | 7 (5.6) | 0 (0) | 3 (42.8) | 3 (42.8) |
| Urban | 118 (94.4) | 9 (7.6) | 58 (49.1) | 65 (55.1) |
| Educational Level | ||||
| Technician | 2 (1.6) | 0 (0) | 1 (50) | 1 (50) |
| Graduate student | 1 (0.8) | 0 (0) | 1 (100) | 0 (0) |
| Graduate completed | 39 (31.2) | 1 (2.6) | 20 (51.3) | 23 (58.9) |
| Post graduate (specialty doctor) | 59 (47.2) | 8 (13.5) | 25 (42.3) | 29 (49.1) |
| Post graduate (internship) | 16 (12.8) | 0 (0) | 9 (56.2) | 9 (56.25) |
| Post graduate (MSc) | 8 (6.4) | 0 (0) | 5 (62.5) | 6 (75) |
| Occupation | ||||
| Nurse | 37 (29.8) | 2 (5.4) | 18 (48.6) | 19 (51.3) |
| Biochemist | 7 (5.6) | 0 (0) | 4 (57.1) | 5 (71.4) |
| Doctor (Physician) | 68 (54.8) | 6 (8.82) | 30 (44.1) | 37 (54.4) |
| Obstetrician | 3 (2.4) | 0 (0) | 2 (66.7) | 1 (33.3) |
| Other | 9 (7.3) | 0 (0) | 7 (77.7) | 4 (44.4) |
| Work Experience | ||||
| Junior level (less than 5 years) | 52 (41.6) | 5 (9.6) | 27 (51.9) | 26 (50) |
| Intermediate level (5 -10 years) | 31 (24.8) | 4 (12.9) | 14 (45.1) | 18 (58.1) |
| Senior level (more than 10 years) | 42 (33.6) | 0 (0) | 20 (47.6) | 24 (57.1) |
| Frontline Healthcare workers | ||||
| Yes | 71 (57.3) | 7 (9.8) | 33 (46.5) | 38 (53.5) |
| No | 53 (42.7) | 1 (1.9) | 28 (52.8) | 30 (56.6) |
| Positive COVID-19 Diagnosis | ||||
| Yes | 33 (26.4) | 5 (15.15) | 17 (51.5) | 20 (60.6) |
| No | 92 (73.6) | 4 (4.3) | 44 (47.8) | 48 (52.2) |
| Relatives or Friends with Positive COVID-19 Diagnosis | ||||
| Yes | 14 (11.2) | 2 (14.3) | 7 (50) | 7 (50) |
| No | 111 (88.8) | 7 (6.3) | 54 (48.6) | 61 (54.9) |
| Tertiary Hospital | ||||
| “Hospital de Clínicas” - San Lorenzo | 25 (20) | 4 (16) | 14 (56( | 14 (56) |
| Regional Hospital of Coronel Oviedo | 25 (20) | 2 (8) | 8 (32) | 13 (52) |
| Regional Hospital of P.J. Caballero | 25 (20) | 3 (12) | 16 (64) | 15 (60) |
| General Hospital of San Pedro | 25 (20) | 0 (0) | 8 (32) | 8 (32) |
| IPS Hospital of Coronel Oviedo | 25 (20) | 0 (0) | 15 (60) | 18 (72) |
| Work area | ||||
| Consulting room | 49 (39.2) | 4 (8.1) | 26 (53.1) | 27 (55.1) |
| Laboratory | 7 (5.6) | 0 (0) | 3 (42.8) | 5 (71.4) |
| Respiratory ward | 10 (8.0) | 2 (20) | 5 (50) | 5 (50) |
| ICU | 1 (0.8) | 0 (0) | 0 (0) | 0 (0) |
| Emergency Department | 37 (29.6) | 2 (5.4) | 17 (45.9) | 22 (59.5) |
| Surgery | 8 (10.4) | 1 (7.7) | 9 (69.2) | 8 (61.5) |
| Other | 13 (10.4) | 0 (0) | 1 (12.5) | 1 (12.5) |
| Resting place after work shifts | ||||
| Temporary lodging | 6 (4.8) | 1 (16.7) | 4 (66.7) | 4 (66.7) |
| Home | 119 (95.2) | 8 (6.7) | 57 (47.9) | 64 (53.8) |
| Availability of Personal Protective Equipment | ||||
| Never | 10 (8.0) | 1 (10) | 7 (70) | 5 (50) |
| Rarely | 10 (8.0) | 1 (10) | 4 (40) | 2 (20) |
| Sometimes | 13 (10.4) | 1 (7.7) | 8 (61.5) | 7 (53.8) |
| Almost always | 47 (37.6) | 3 (6.4) | 18 (38.3) | 29 (61.7) |
| Always | 45 (36.0) | 3 (6.7) | 24 (53.3) | 25 (55.6) |
#PTSD: Post-Traumatic Stress Disorder. COVID-19: Coronavirus Disease in 2019. #PTSD-checklist. §The Patient Health Questionnaire (PHQ-9). *Generalized Anxiety Disorder scale (GAD-7)
Discussion
The present cross-sectional pilot study included 125 participants and revealed a high prevalence of psychological symptoms among healthcare workers involved in the management of patients with COVID-19 in Paraguay. Approximately half of the subjects reported symptoms of anxiety and depression, while less than 10% presented symptoms of post-traumatic stress.
To the best of our knowledge, this is one the first studies in Latin America on the prevalence of symptoms of post-traumatic stress, depression and anxiety in healthcare workers occupationally exposed to SARS-CoV-2. A study involving 204 Latin American surgeons has shown that 22% (n = 45) of them had a score over 10 in the PHQ-9); they were not assessed for anxious or post-traumatic stress symptoms17.
The prevalence of 7.2% of PTSD symptoms is similar to previous studies conducted during the SARS pandemic, which was in the range between 5% and 10%, and also similar to the prevalence of severe PTSD symptoms (6.2% to 10.5%) found in recent studies in China4,7,18. In addition, frontline healthcare workers occupationally exposed to COVID-19 had a higher prevalence of post-traumatic stress symptoms, similar to a previous study conducted during the COVID-19 pandemic7.
In our sample, a large proportion presented symptoms of anxiety and depression, 54.4% and 48.8%, respectively. The prevalence rates of depressive and anxious symptoms are similar to those described in the studies conducted during the SARS epidemic and other reports published during the COVID-19 pandemic5,7: higher rates of anxiety and depression in frontline healthcare workers (especially in nurses) were found compared to healthcare workers not-occupationally exposed workers to SARS-CoV-219-21. Limitations of this study include a small sample size and a disproportionately large representation of doctors7,20.
The higher prevalence of symptoms of depression and anxiety in females is in line with previous studies in healthcare workers and in the general population. This suggests a vulnerability of females to suffer from psychological distress during high stress situations such as epidemics or pandemics22.
Regarding the limitations of the study, the cross-sectional nature, the sample size and the non-probabilistic sampling are worth noting. We hope that the full study with a larger sample size and detailed statistical analyses will shed light on the prevalence of psychological distress and post-traumatic stress in healthcare workers and its association or lack of association with occupational exposure to SARS-CoV-2.
This preliminary study was conducted among Paraguayan healthcare workers exposed or not exposed to COVID-19. Workers exposed to COVID-19 reported a high prevalence of symptoms of depression, anxiety. This suggests that prevention of mental health issues and psychological distress among healthcare workers is mandatory23.
Our following research study will add more details and information regarding the unexplored psychological impact of COVID-19 among healthcare workers in Paraguay.
