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The COVID-19 outbreak had a severe impact on health care workers' psychological health. It is important to establish a process for psychological assessment and intervention for health care workers during epidemics.
We investigated risk factors associated with psychological impacts for each health care worker group, to help optimize psychological interventions for health care workers in countries affected by the COVID-19 pandemic.
Respondents (n=1787) from 2 hospitals in Korea completed a web-based survey during the period from April 14 to 30, 2020. The web-based survey collected demographic information, psychiatric history, and responses to the 9-item Stress and Anxiety to Viral Epidemics (SAVE-9), 9-item Patient Health Questionnaire (PHQ-9), and 7-item Generalized Anxiety Disorder-7 (GAD-7) scales. We performed logistic regression to assess contributing factors as predictor variables, using health care workers’ depression as outcome variables.
Among 1783 health care workers, nursing professionals had significantly higher levels of depression (PHQ-9 score: meannurse 5.5, SD 4.6; meanother 3.8, SD 4.2;
Psychological support and interventions should be considered for health care workers, especially nursing professionals, those who are single, and those with high SAVE-9 scores.
COVID-19 is a highly contagious respiratory disease first reported in December 2019 in Wuhan, Hubei Province, China [
Health care workers on the frontlines play a major role in preventing the spread of COVID-19 by implementing the government’s strong countermeasures. Despite their heroic efforts during the early phase of the pandemic, their mental health faces a considerable threat. In other disasters, health care workers take care of patients who have been hurt, but they are not themselves affected directly by the disaster. In contrast, health care workers can be directly affected during epidemics. For health care workers who are in close contact with patients with confirmed or suspected COVID-19, lack of personal protective equipment, work overload, poor infection control, and pre-existing medical conditions were identified as risk factors for the disease [
As of July 2021, the COVID-19 pandemic has been ongoing for more than a year and a half. Psychological problems and exhaustion are not only a burden on health care workers but could also affect society as a whole, by threatening essential health care services or resulting in severe staff shortages. It is, therefore, important to establish a process for psychological assessment and intervention for health care workers affected by epidemics. Studies have assessed psychological symptoms using well-known scales such as the 7-item Generalized Anxiety Disorder scale (GAD-7), 9-item Patient Health Questionnaire (PHQ-9) [
In this study, we aimed to assess the stress and anxiety response of health care workers specific to the COVID-19 pandemic, by using the Stress and Anxiety to Viral Epidemics-9 (SAVE-9) scale [
This study was conducted among health care workers at the Asan Medical Center, a tertiary hospital (2705 beds; 7970 health care workers) in Seoul, and the Uijeongbu St. Mary’s Hospital, a secondary hospital (716 beds; 1800 health care workers) in Uijeongbu, Gyeonggi province, South Korea. During the outbreak, due to the rapid increase in the number of confirmed COVID-19 cases in Uijeongbu St. Mary’s Hospital, the entire hospital was placed in isolation for 3 weeks starting from March 1, 2020. During cohort isolation, outpatient departments were closed, and the discharge of in-patients was withheld. Wards exposed to patients with confirmed COVID-19 were quarantined and only essential medical staff were allowed to enter the wards. Quarantined individuals were regularly tested for COVID-19, and those who tested negative remained in quarantine, whereas those who tested positive were transferred to a designated COVID-19 treatment institution. On May 11, 2020, the hospital was restored to full functionality.
A patient who had visited Uijeongbu St. Mary’s Hospital on March 25, 2020, was admitted to the emergency room of Asan Medical Center on March 26, 2020, and was confirmed to have COVID-19 on March 31, 2020. Afterward, 4 wards were placed in cohort isolation and 57 health care workers were quarantined. Cohort isolation in the wards was lifted on April 15, 2020, and Asan Medical Center the COVID-19 intensive care medical institution status was removed on April 19, 2020.
The survey was conducted from April 14 to 18, 2020, at Uijeongbu St. Mary’s Hospital and from April 20 to 30, 2020, at Asan Medical Center. We used a cross-sectional, anonymous survey design to assess the psychological impact on health care workers. We advertised this study through notice boards at the 2 hospitals, and 1787 health care workers responded voluntarily. To avoid face-to-face contact, respondents completed the questionnaires through a web-based survey platform. Respondents were not compensated for their participation. This study was approved by the Asan Medical Center institutional review board (2020-0580, UC20RADI0090). Written informed consent was waived, as the respondents could declare, while answering the web-based survey, whether or not they agreed to the use of their information for the study.
Health care workers were classified into 5 groups based on the International Standard Classification of Occupations 2008 revision (ISCO) [
The SAVE-9 scale was developed to assess work-related stress and anxiety response of health care workers to the COVID-19 pandemic [
PHQ-9 is a self-administered, 9-item questionnaire used to assess depression. Each item is scored on a 3-point scale from 0 (not at all) to 3 (nearly every day). Scores can range from 0 to 27, with higher scores reflecting greater symptom severity. A PHQ-9 score >10 indicates depression [
GAD-7 is a self-administered, 7-item questionnaire specific to general anxiety. Each item is scored on a 3-point scale from 0 (not at all) to 3 (nearly every day). Scores can range from 0 to 21, with higher scores reflecting greater symptom severity. In this study, a score ≥5 was used for mild anxiety [
Sex, age, marital status, type of health care job, and years of employment were collected. Additionally, respondents were asked whether they had a current or previous diagnosis of depression, anxiety, or insomnia.
Statistical analyses were performed using SPSS software (version 21.0 for Windows; IBM Corp). The clinical characteristics were summarized as mean (SD) values. To calculate frequency, the number of each sample was divided by the total number of samples in each health care worker group. The student
A total of 1023 Asan Medical Center health care workers and 764 Uijeongbu St. Mary’s Hospital health care workers participated in the web-based survey. We analyzed data from 1783 health care workers (
Among the 5 categories of health care workers, nursing professionals were younger (75.1% of juniors in nursing professionals, 60.2% in all workers excluding nursing professionals,
Demographic characteristics of the respondents.
Variables | ASAN medical center (n=1019), n (%) | Uijeongbu St. Mary’s Hospital (n=764), n (%) | All (n=1783), n (%) | ||
|
|
|
<.001 |
|
|
|
Male | 211 (20.7) | 216 (28.3) |
|
427 (23.9) |
|
Female | 808 (79.3) | 548 (71.7) |
|
1356 (76.1) |
|
|
|
<.001 |
|
|
|
20-29 years | 309 (30.3) | 287 (38.5) |
|
596 (33.4) |
|
30-39 years | 387 (38.0) | 222 (29.8) |
|
609 (34.2) |
|
40-49 years | 253 (24.8) | 161 (21.6) |
|
414 (23.2) |
|
50-59 years | 70 (6.9) | 74 (9.9) |
|
144 (8.1) |
|
60-65 years | 0 (0.0) | 1 (0.1) |
|
1 (0.1) |
|
|
|
.304 |
|
|
|
Single | 529 (52.3) | 410 (53.7) |
|
939 (52.7) |
|
Married | 482 (47.7) | 354 (46.3) |
|
836 (46.9) |
|
|
|
<.001 |
|
|
|
Medical doctors | 192 (18.8) | 100 (13.1) |
|
292 (16.4) |
|
Nursing professionals | 596 (58.7) | 369 (48.3) |
|
967 (54.2) |
|
Health associate professionals | 126 (12.4) | 120 (15.7) |
|
246 (13.8) |
|
Health management and support personnel | 83 (8.1) | 85 (11.1) |
|
168 (9.4) |
|
Health service provided not elsewhere classified | 20 (2.0) | 90 (11.8) |
|
110 (6.2) |
Past psychiatric history (yes) | 129 (12.7) | 49 (6.4) | <.001 | 178 (10.0) | |
Years of employment (year) | 9.9 (9.0) | 9.5 (9.3) | .369 | 9.7 (9.1) | |
|
|
|
|
|
|
|
Patient Health Questionnaire–9 | 4.9 (4.6) | 4.4 (4.4) | .006 | 4.7 (4.5) |
|
Generalized Anxiety Disorder–7 | 3.7 (4.0) | 3.0 (3.7) | <.001 | 3.4 (3.9) |
|
SAVE-9a | 20.3 (5.7) | 20.2 (7.0) | .642 | 20.3 (6.3) |
|
Anxiety subcategory of SAVE-9 | 14.2 (4.2) | 14.7 (4.9) | .046 | 14.4 (4.5) |
|
Work-related stress subcategory of SAVE-9 | 6.1 (2.3) | 5.5 (2.7) | <.001 | 5.8 (2.5) |
aSAVE-9: Stress and Anxiety to Viral Epidemics-9.
Clinical characteristics of respondents by health care worker category.
Variables | Nursing professionals (n=967) | Medical doctors (n=292) | Health associate professionals (n=246) | Health management and support personnel (n=168) | Health service provided not elsewhere classified (n=110) | All workers excluding nursing professionals (n=816) | |
|
|||||||
|
Junior | 718 (75.1) | 215 (73.9) | 152 (62.3) | 77 (46.7) | 43 (39.8) | 487 (60.2) |
|
Senior | 238 (24.9) | 76 (26.1) | 92 (37.7)a | 88 (53.4)a | 65 (60.2)a | 321 (31.8)a |
Sex (female) | 933 (96.5) | 122 (41.8)a | 114 (46.3)a | 103 (61.3)a | 84 (76.4)a | 423 (51.8)a | |
Past psychiatric history | 90 (9.3) | 33 (11.3) | 18 (7.3) | 27 (16.2)b | 10 (9.2) | 88 (10.8) | |
Marital status (married) | 396 (41.1) | 140 (48.1)c | 143 (58.6)a | 94 (56.3)a | 63 (57.3)d | 440 (54.2)a | |
Years of employment | 10.1 (8.6) | 6.6 (7.4)a | 10.3 (11.0) | 11.5 (10.4) | 10.4 (9.4) | 9.2 (9.7) |
a
b
c
d
Clinical symptom assessment of the participants by category of health care worker (n=1783)
|
Nursing professionals (n=967) | Medical doctors (n=292) | Health associate professionals (n=246) | Health management and support personnel (n=168) | Health service provided not elsewhere classified (n=110) | All workers excluding nursing professionals (n=816) | ||||||||
|
5.5 (4.6) | 2.9 (3.4)b | 3.8 (4.2)b | 4.6 (4.7) | 4.4 (4.5) | 3.8 (4.2)b | ||||||||
|
|
|||||||||||||
|
|
Junior | 138 (19.2) | 11 (5.1) | 15 (9.8) | 11 (14.3) | 5 (11.6) | 42 (8.6) | ||||||
|
|
Senior | 33 (13.9) | 4 (5.3) | 10 (10.9) | 8 (9.1) | 9 (13.8) | 31 (9.7) | ||||||
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|
|||||||||||||
|
|
Male | 4 (11.8) | 9 (5.3) | 9 (6.8) | 9 (13.8) | 0 (0.0) | 27 (6.9) | ||||||
|
|
Female | 168 (18.0) | 6 (4.9) | 16 (14.0) | 10 (9.7) | 14 (16.7)c | 46 (10.9) | ||||||
|
|
|||||||||||||
|
|
Married | 56 (14.1) | 7 (5.0) | 14 (9.8) | 9 (9.6) | 9 (14.3) | 39 (8.9) | ||||||
|
|
Single | 115 (20.3)d | 8 (5.3) | 10 (9.9) | 10 (13.7) | 5 (10.6) | 33 (8.9) | ||||||
|
4.0 (4.1) | 2.0 (3.0)b | 3.0 (3.9)f | 3.4 (4.0) | 2.7 (3.1)g | 2.7 (3.6)b | ||||||||
|
|
|||||||||||||
|
|
Junior | 257 (35.8) | 34 (16.3) | 37 (24.3) | 30 (39.0) | 8 (18.6) | 109 (22.7) | ||||||
|
|
Senior | 85 (35.7) | 11 (14.5) | 23 (25.0) | 26 (30.2) | 18 (27.7) | 78 (24.5) | ||||||
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|
|||||||||||||
|
|
Male | 12 (35.3) | 23 (14.1) | 25 (18.9) | 18 (27.7) | 1 (3.8) | 67 (17.4) | ||||||
|
|
Female | 333 (35.7) | 22 (18.0) | 36 (31.6) | 39 (38.6) | 25 (29.8)h | 122 (29.0)h | ||||||
|
|
|||||||||||||
|
|
Married | 142 (35.9) | 27 (19.3) | 39 (27.3) | 33 (35.1) | 17 (27.0) | 116 (26.4) | ||||||
|
|
Single | 202 (35.6) | 18 (12.5) | 22 (21.8) | 24 (33.8) | 9 (19.1) | 73 (20.1)h | ||||||
SAVE-9i score | 21.6 (5.9) | 17.2 (6.1)b | 20.2 (5.9)b | 18.9 (6.3)b | 18.2 (6.8)b | 18.6 (6.3)b | ||||||||
|
15.4 (4.2) | 12.0 (4.6)b | 14.7 (4.3) | 13.4 (4.5)b | 13.3 (4.8)b | 13.3 (4.6)b | ||||||||
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|||||||||||||
|
|
Junior | 15.6 (4.1) | 11.6 (4.7) | 14.8 (4.1) | 13.8 (4.9) | 13.6 (5.2) | 13.1 (4.8) | ||||||
|
|
Senior | 14.7 (4.4)j | 13.0 (4.3) | 14.5 (4.7) | 13.1 (4.0) | 12.9 (4.6) | 13.5 (4.5) | ||||||
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|||||||||||||
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|
Male | 14.1 (5.8) | 11.3 (4.6) | 14.2 (4.4) | 12.8 (4.8) | 11.1 (3.9) | 12.5 (4.7) | ||||||
|
|
Female | 15.4 (4.1) | 12.9 (4.4)k | 15.3 (4.1) | 13.7 (4.2) | 13.9 (4.9)l | 13.9 (4.5)h | ||||||
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|
|||||||||||||
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Married | 15.4 (4.0) | 12.8 (4.4) | 14.6 (4.6) | 13.7 (4.2) | 13.9 (4.5) | 13.7 (4.5) | ||||||
|
|
Single | 15.4 (4.3) | 11.3 (4.6) | 14.9 (3.9) | 13.0 (4.7) | 12.3 (5.2) | 12.7 (4.7)h | ||||||
|
6.3 (2.5) | 5.3 (2.2)b | 5.5 (2.4)b | 5.5 (2.4)m | 5.0 (2.6)b | 5.4 (2.4)b | ||||||||
|
|
|||||||||||||
|
|
Junior | 6.4 (2.5) | 5.4 (2.2) | 5.5 (2.4) | 5.7 (2.6) | 5.0 (2.7) | 5.4 (2.4) | ||||||
|
|
Senior | 5.7 (2.4)h | 5.0 (2.3) | 5.5 (2.5) | 5.4 (2.3) | 4.9 (2.6) | 5.2 (2.4) | ||||||
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|
|||||||||||||
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Male | 5.8 (3.0) | 4.9 (2.4) | 5.2 (2.3) | 5.1 (2.7) | 3.5 (2.0) | 4.9 (2.4) | ||||||
|
|
Female | 6.3 (2.5) | 5.8 (1.9)h | 5.9 (2.5) | 5.8 (2.2) | 5.4 (2.7) h | 5.8 (2.3)h | ||||||
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|
|||||||||||||
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Married | 5.9 (2.4) | 5.3 (2.2) | 5.8 (2.4) | 5.5 (2.7) | 5.4 (2.7) | 5.5 (2.4) | ||||||
|
|
Single | 6.5 (2.6)h | 5.3 (2.3) | 5.2 (2.4) | 4.3 (2.4) | 4.2 (2.4) | 5.2 (2.4) |
aPHQ-9: Patient Health Questionnaire–9.
b
c
d
eGAD-7: Generalized Anxiety Disorder-7.
f
g
h
iSAVE-9: Stress and Anxiety to Viral Epidemics-9.
j
k
l
m
Compared with those of medical doctors and other groups, nursing professionals SAVE-9 scores were higher (
Hospital (Asan Medical Center: adjusted OR 1.45, 95% CI 1.06-1.99), nursing professionals (adjusted OR 1.37, 95% CI 1.02-1.98), single workers (adjusted OR 1.51, 95% CI 1.05-2.16), higher stress and anxiety to the viral infection (high SAVE-9 score: adjusted OR 1.20, 95% CI 1.17-1.24), and past psychiatric history (adjusted OR 3.26, 95% CI 2.15-4.96) were positively associated with depression (
Among respondents, 534 (29.9%) health care workers were classified as having high anxiety using the GAD-7 total score (GAD-7 score >5). Among health care workers who were classified as not having high anxiety (n=1240), 400 (22.4%) health care workers were newly screened as having stress and anxiety due to the viral epidemic based on SAVE-9 scores (κ=0.351,
Stress and Anxiety to Viral Epidemics–9 score distributions for health care worker groups.
Logistic regression analysis to explore predictor variables for depression.
Explanatory variables | Crude ORa (95% CI) | Adjusted OR (95% CI) | ||
Asan Medical Center (vs Uijeongbu St. Mary’s Hospital) | 1.43 (1.08-1.89) | .013 | 1.45 (1.06-1.99) | .021 |
Junior (vs senior) | 1.36 (1.01-1.84) | .049 | 1.20 (0.81-1.79) | .363 |
Female (vs male) | 2.39 (1.62-3.55) | <.001 | 1.11 (0.68-1.80) | .684 |
Single (vs married) | 1.46 (1.11-1.92) | .007 | 1.51 (1.05-2.16) | .025 |
Nursing professionals (vs others) | 2.20 (1.65-2.95) | <.001 | 1.37 (1.02-1.98) | .041 |
SAVE-9b score | 1.19 (1.16-1.23) | <.001 | 1.20 (1.17-1.24) | <.001 |
Past psychiatric history | 2.47 (1.71-3.56) | <.001 | 3.26 (2.15-4.96) | <.001 |
aOR: odds ratio.
bSAVE-9: Stress and Anxiety to Viral Epidemics–9.
The results demonstrated that nursing professionals were more depressed, anxious, and stressed by the viral epidemic than other health care workers during the first phase of the COVID-19 pandemic. Marital status (being single) as well as anxiety and work-related stress associated with the viral epidemic were risk factors for depression among health care workers. The mean SAVE-9 score among health care workers was 20.3 (SD 6.3). Given that our previous study [
Consistent with the findings of previous studies, we found that nursing professionals were more likely to feel stress or anxiety than other health care workers [
Compared with health care workers who were single, all married workers, excluding nursing professionals, scored higher on GAD-7. Owing to high medical knowledge regarding the high infectivity of the virus and the relatively insufficient medical supplies at the beginning, health care workers had high safety concerns. Married workers may worry not only about their own protection but also about the safety of their family members, including children. This finding is consistent with those of previous studies that noted that the concern for the health of oneself and one’s family was significantly higher among married workers [
However, among nursing professionals, there was no difference in GAD-7 scores of ≥5 according to marital status (single: 35.6%, married: 35.9%), compared to 26.4% of married workers and 20.1% of single workers in all other health care worker groups. Nursing professionals had higher overall depression, anxiety, and virus-related stress and anxiety than other health care workers. The Korean government’s emphasis on social distancing made it necessary for participants to submit daily results of viral symptoms monitoring and to be only at home or the hospital. Living as health care workers may have exerted a lot of pressure on them socially to improve the COVID-19 situation. Among single workers, this semicompulsory sequestration was compelled, and they experienced a greater change in life than married workers. As they could not perform daily activities to reduce their stress, their perceived negative emotions increased, and positive emotions remained relatively low [
In this study, we measured anxiety symptoms among health care workers by using the SAVE-9 scale, which is used for assessing anxiety measures specific to the viral epidemic, and GAD-7 scale, which is used for measuring nonspecific anxiety. In previous SARS and MERS outbreaks, health care workers were exposed to protracted epidemics, and the unfavorable conditions resulted in a high prevalence rate of burnout and depression [
This study has some limitations. First, this was a cross-sectional study; therefore, we can suggest only associations between mental problems and COVID-19 in health care workers but not causal relationships or underlying mechanisms. Second, the survey was conducted only in 1 hospital in Seoul and 1 in Uijeongbu. Thus, the sample may have been biased. In addition, the responses might be biased, as this study utilized a self-report web-based questionnaire. Nevertheless, as the job type distribution of the sample mirrored that of the health care workers at study sites, it can be considered as substantially representative in these hospitals. Third, the questionnaire was conducted in mid-April 2020, immediately after the end of the cohort isolation. The psychological status of health care workers at the onset or peak of Korea’s COVID-19 crisis was, therefore, not assessed. Future research should focus on specific groups, incorporating according to the stage of the epidemics. We will have to collect more comprehensive data on the psychological status of health care workers in other infectious disease outbreaks. Fourth, we were unable to classify workers as parent-facing, contact, frontline health care workers, or those with a history of COVID-19 positivity or quarantine. Lai et al [
Despite these limitations, our study indicates that all health care workers were at psychological risk of COVID-19 and that they worried about health problems for themselves, their family, and their colleagues. Especially nursing professionals, who are the major health care workers in the medical system and work at the frontline of patient care, can easily be depressed and frustrated. In addition, their marital status (being single), past psychiatric history, and higher level of anxiety specifically in response to the viral epidemic also influence their depressive symptoms. We were able to measure anxiety response and work-related stress among health care workers during this pandemic using SAVE-9, which focuses on viral epidemic–related stress and anxiety.
Generalized Anxiety Disorder-7
International Standard Classification of Occupations
Middle East respiratory syndrome
Patient Health Questionnaire-9
Stress and Anxiety to Viral Epidemics-9
severe acute respiratory syndrome
We would like to extend our thanks to all the health care workers of Asan Medical Center and Uijeongbu St. Mary's Hospital who voluntarily participated in the survey. We would like to thank Editage for English language editing. This work was supported by the Framework of International Cooperation Program managed by the National Research Foundation of Korea (FY2020K2A9A1A01094956).
None declared.