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6 April 2020

Psychological Impact of the COVID-19 Pandemic on Health Care Workers in SingaporeFREE

Publication: Annals of Internal Medicine
Volume 173, Number 4
Background: In response to the coronavirus disease 2019 (COVID-19) pandemic, Singapore raised its Disease Outbreak Response System Condition alert to “orange,” the second highest level. Between 19 February and 13 March 2020, confirmed cases rose from 84 to 200 (34.2 per 1 000 000 population), with an increase in patients in critical condition from 4 to 11 (5.5%) and no reported deaths in Singapore (1). Understanding the psychological impact of the COVID-19 outbreak among health care workers is crucial in guiding policies and interventions to maintain their psychological well-being.
Objective: To examine the psychological distress, depression, anxiety, and stress experienced by health care workers in Singapore in the midst of the outbreak, and to compare these between medically and non–medically trained hospital personnel.
Methods and Findings: From 19 February to 13 March 2020, health care workers from 2 major tertiary institutions in Singapore who were caring for patients with COVID-19 were invited to participate with a self-administered questionnaire. In addition to information on demographic characteristics and medical history (Table 1), the questionnaire included the validated Depression, Anxiety, and Stress Scales (DASS-21) and the Impact of Events Scale–Revised (IES-R) instrument (2, 3). Health care workers included “medical” (physicians, nurses) and “nonmedical” personnel (allied health professionals, pharmacists, technicians, administrators, clerical staff, and maintenance workers). The primary outcome was the prevalence of depression, stress, anxiety, and posttraumatic stress disorder (PTSD) among all health care workers (Table 2). Secondary outcomes were comparison of the prevalence of depression, anxiety, stress, and PTSD, and mean DASS-21 and IES-R scores between medical and nonmedical health care workers. The Pearson χ2 test and student t test were used to compare categorical and continuous outcomes, respectively, between the 2 groups. Multivariable regression was used to adjust for the a priori defined confounders of age, sex, ethnicity, marital status, presence of comorbid conditions, and survey completion date.
Table 1. Participant Characteristics at Baseline
Table 1. Participant Characteristics at Baseline
Table 2. Prevalence of Depression, Anxiety, Stress, and PTSD and Mean DASS-21 and IES-R Scores in Medical and Nonmedical Health Care Personnel (n = 470)
Table 2. Prevalence of Depression, Anxiety, Stress, and PTSD and Mean DASS-21 and IES-R Scores in Medical and Nonmedical Health Care Personnel (n = 470)
Of 500 invited health care workers, 470 (94%) participated in the study; baseline characteristics are shown in Table 1. Sixty-eight (14.5%) participants screened positive for anxiety, 42 (8.9%) for depression, 31 (6.6%) for stress, and 36 (7.7%) for clinical concern of PTSD. The prevalence of anxiety was higher among nonmedical health care workers than medical personnel (20.7% versus 10.8%; adjusted prevalence ratio, 1.85 [95% CI, 1.15 to 2.99]; P = 0.011), after adjustment for age, sex, ethnicity, marital status, survey completion date, and presence of comorbid conditions. Similarly, higher mean DASS-21 anxiety and stress subscale scores and higher IES-R total and subscale scores were observed in nonmedical health care workers (Table 2).
Discussion: Overall mean DASS-21 and IES-R scores among health care workers were lower than those in the published literature from previous disease outbreaks, such as severe acute respiratory syndrome (SARS). A previous study in Singapore found higher IES scores among physicians and nurses during the SARS outbreak, and an almost 3 times higher prevalence of PTSD, than those in our study (4). This could be attributed to increased mental preparedness and stringent infection control measures after Singapore's SARS experience.
Of note, nonmedical health care workers had higher prevalence of anxiety even after adjustment for possible confounders. Our findings are consistent with those of a recent COVID-19 study demonstrating that frontline nurses had significantly lower vicarious traumatization scores than non–frontline nurses and the general public (5). Reasons for this may include reduced accessibility to formal psychological support, less first-hand medical information on the outbreak, and less intensive training on personal protective equipment and infection control measures.
As the pandemic continues, important clinical and policy strategies are needed to support health care workers. Our study identified a vulnerable group susceptible to psychological distress. Educational interventions should target nonmedical health care workers to ensure understanding and use of infection control measures. Psychological support could include counseling services and development of support systems among colleagues.
Our study has limitations. First, data obtained from self-reported questionnaires were not verified with medical records. Second, the study did not assess socioeconomic status, which may be helpful in evaluating associations of outcomes and tailoring specific interventions. Finally, the study was performed early in the outbreak and only in Singapore, which may limit the generalizability of the findings. Follow-up studies could help assess for progression or even a potential rebound effect of psychological manifestations once the imminent threat of COVID-19 subsides.
In conclusion, our study highlights that nonmedical health care personnel are at highest risk for psychological distress during the COVID-19 outbreak. Early psychological interventions targeting this vulnerable group may be beneficial.

References

1.
Ministry of Health Singapore. Updates on COVID-19 (coronavirus disease 2019) local situation. Ministry of Health, Singapore. Accessed at www.moh.gov.sg/covid-19 on 13 March 2020.
2.
Lovibond SHLovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd ed. Psychology Foundation of Australia; 1995.
3.
Creamer MBell RFailla S. Psychometric properties of the Impact of Event Scale - Revised. Behav Res Ther. 2003;41:1489-96. [PMID: 14705607]
4.
Chan AOHuak CY. Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med (Lond). 2004;54:190-6. [PMID: 15133143]
5.
Li ZGe JYang Met al. Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control. Brain Behav Immun. 2020. [PMID: 32169498]  doi: 10.1016/j.bbi.2020.03.007

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Majorie Ann Mahusay9 June 2020
Questionnaire

Greetings, I have read the study and it is quite interesting for me. I am currently in my 2nd year of Residency Training in Pediatrics at Pasig City General Hospital. And I would like to have a copy of your questionnaire. This is to help me formulate a questionnaire suited for our demographics for our country. Hoping for your positive response.

Ema15 June 2020
Questionnaire
Greetings, I have read the study and i found it interesting . And I would like to have a copy of your questionnaire. Thank you
Janvil Meriales17 June 2020
Nursing Student
Hello, I found this research very relevant to a study I'm interested in doing a thesis on. Would it be possible for me to receive a copy of the full document?
.20 June 2020
questionnaire

have read the study and i found it interesting . And I would like to have a copy of your questionnaire. Thank you

Elitsa Gyokova24 June 2020
Request

Thank you for the interesting study! Can I receive a copy of the questionnaire?

Benjamin Y.Q. Tan, MD, Nicholas W.S. Chew, MD, et.al24 June 2020
Greetings

Hello Sir, I have read the journal and I am very much interested of having a same study here in my training institution. I am currently a 2nd year resident of Internal Medicine and one of the requirements to be promoted to 3rd year is to have a research. Is it possible if I could have a copy of your formulated questionnaire so I could somehow use and modify it according to our current system here in my institution. Hoping for a positive feedback. Thank You and Godspeed.

Vijay K Sharma, Nicholas WS Chew, Benjamin YQ Tan27 June 2020
Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore

We are happy to see the interest generated by our manuscript. We used Depression, Anxiety, and Stress Scales (DASS-21) and the Impact of Events Scale–Revised (IES-R) instrument (1,2).

In addition, we collected data about deographics, work role and symptoms, if any during the preceding one month. The primary outcome was the prevalence of depression, stress, anxiety, and posttraumatic stress disorder (PTSD) among all health care workers. Secondary outcomes were comparison of the prevalence of depression, anxiety, stress, and PTSD, and mean DASS-21 and IES-R scores between medical and non-medical health care workers.

The corresponding author would be happy to share the questionnaire upon request.

References-

1. Lovibond SH. Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2d ed. Sydney: Psychology Foundation of Australia; 1995.

2. Creamer M, Bell R, Failla S. Psychometric properties of the impact of event scale - revised. Behav Res Ther. 2003;41:1489-96.

Vijay K Sharma29 June 2020
Questionnaire
Dear sir, Greetings. I have read the journal and I am very much interested to know about your questionnaire. Is it possible if I could have a copy of your formulated questionnaire. Hoping for a positive feedback. Thank you for the interesting study, Can I receive a copy of the questionnaire?

Disclosures: I am currently working in epidemiology department of Bangladesh and also involved in covid case investigation in covid hospital. I am interested to read the questionnaire used in this study .

Johnson Olaniyi26 June 2020
Questionnaire
This is a wonderful work. I will appreciate if I can get the questionnaire to see the possibility of adopting it for a similar work I am doing
Nil23 June 2020
Request for questionnaire
Read through your study and was found to be very helpful, can I have access to the questionnaire, many thanks in anticipation of your quick response
LOMA R WAGHMARE26 June 2020
Share questionnaire
The study looks interesting. Would like to conduct similar study in my setup

Disclosures: would like to use your questionnaire

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 173Number 418 August 2020
Pages: 317 - 320

History

Published online: 6 April 2020
Published in issue: 18 August 2020

Keywords

Authors

Affiliations

Benjamin Y.Q. Tan, MD
National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore (B.Y.T., L.L.Y., V.K.S.)
Nicholas W.S. Chew, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Grace K.H. Lee, MD
Yong Loo Lin School of Medicine, National University of Singapore, Singapore (G.K.L.)
Mingxue Jing, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Yihui Goh, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Leonard L.L. Yeo, MD
National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore (B.Y.T., L.L.Y., V.K.S.)
Ka Zhang, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Howe-Keat Chin, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Aftab Ahmad, MD
Ng Teng Fong General Hospital, Singapore (A.A., F.A.K., G.N.S.)
Faheem Ahmed Khan, MD
Ng Teng Fong General Hospital, Singapore (A.A., F.A.K., G.N.S.)
Ganesh Napolean Shanmugam, MBBCh
Ng Teng Fong General Hospital, Singapore (A.A., F.A.K., G.N.S.)
Bernard P.L. Chan, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Sibi Sunny, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Bharatendu Chandra, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Jonathan J.Y. Ong, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Prakash R. Paliwal, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Lily Y.H. Wong, BN
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Renarebecca Sagayanathan, BSc
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Jin Tao Chen, BN
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Alison Ying Ying Ng, Dip
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Hock Luen Teoh, MD
National University Health System, Singapore (N.W.C., M.J., Y.G., K.Z., H.C., B.P.C., S.S., B.C., J.J.O., P.R.P., L.Y.W., R.S., J.T.C., A.Y.N., H.L.T.)
Cyrus S. Ho, MD
National University of Singapore, Singapore (C.S.H.)
Roger C. Ho, MD
Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore (R.C.H.)
Vijay K. Sharma, MD
National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore (B.Y.T., L.L.Y., V.K.S.)
Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Sharma (e-mail, [email protected]). Data set: Not available.
Corresponding Author: Vijay K. Sharma, MD, Division of Neurology, National University Health System, NUHS Tower Block, Level 10, 1 East Kent Ridge Road, Singapore 119228; e-mail, [email protected].
This article was published at Annals.org on 6 April 2020.
* Drs. Tan and Chew contributed equally to this work.

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Benjamin Y.Q. Tan, Nicholas W.S. Chew, Grace K.H. Lee, et al. Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore. Ann Intern Med.2020;173:317-320. [Epub 6 April 2020]. doi:10.7326/M20-1083

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