In this study, we examined depressive symptoms, anxiety levels, and psychosocial and occupational factors related to COVID-19 experienced by healthcare professionals in Sri Lanka, a middle-income country in South Asia.
In this sample of 512 healthcare professionals, 53.3% experienced elevated depressive symptoms, 42.2% mild anxiety, 6.6% moderate anxiety, and 2.5% severe anxiety. In line with our results, a similar study (n = 1257) conducted in China in early February 2020 found 50.3% cases of depression and 44.6% cases of anxiety [15]. However, in a study conducted in Singapore (n = 470), only 8.9% of participants were found to be positive for depression and 14.5% for anxiety [16]. The time of the survey, past experiences of working during infectious disease outbreaks, and characteristics of the healthcare systems would possibly explain the observed differences in the rates [7, 17, 18]. Nonetheless, our results showed a substantial worsening in the psychological health of all categories of healthcare professionals in Sri Lanka during this initial period of COVID-19 pandemic. Interestingly, we observed that the mere presence of the pandemic has elevated the fear and distress of all healthcare professionals irrespective of whether they work with COVID-19 positive or suspected cases or not. Thus, future psychological interventions of emergency outbreaks should focus on all categories of healthcare professionals working in healthcare facilities in Sri Lanka.
Women reported more severe symptoms of depression confirming the gendered impact of COVID-19 [15, 18, 19]. It should be noted that in this study, 78.9% were women (86.5% of whom were nurses who are closely working with patients) and most of them had not been received any training related to outbreak emergencies. Further, women in Sri Lanka are entrusted to do informal care within families and their dedication and psychological devotion to family well-being are somewhat exceptional. Such a bond could lead to compassion fatigue [20, 21]. Our results indicated that distress caused by the separation from family members is a strong predictor of depression and anxiety experienced by healthcare professionals. Staying out of their families for long work and quarantine periods would give them profound distress [20, 22, 23]. Further, nursing officers were more likely to work closely and more frequently with risky patients than others, which would result in more emotional exhaustion. Future infectious disease control training and psychological support programs should take into consideration these important factors which are related to the work efficiency of nurses during outbreaks [16]. In addition to gender, work experience was also found to be related to psychological pathologies observed among the participants of this study. Future psychological support services should especially target healthcare professionals who are in their early carrier. It is required to monitor those who confronted with distress and fear because they might be more likely to develop psychiatric morbidity in the future.
Research indicated that the shortage of personal protective equipment (PPE) and other medical equipment reduce the work efficiency of employees due to their increased frustration and insecure feelings that result [24, 25]. Shortage of safety equipment for low-grade healthcare workers was highlighted during COVID-19, and safety procedures and equipment across non-hospital quarantine centers and newly converted centers of COVID-19 are also inadequate [26]. It was observed that the availability of occupational safety measures at workplace would tend to reduce fear and stress among the participants. However, the lack of provision of PPE does not seem to be associated with the development of depressive symptoms or anxiety in healthcare professionals in Sri Lanka. The country has been ranked as one of the top countries in the world for voluntarism [27]. Healthcare professionals are mostly motivated by the nature of Sri Lankan culture to make their own PPE, buy from stores, and prepare their own sanitizers [26], and thereby lower the psychological burden on them. In addition to PPE, testing and containment are essential for preventing occupational health risks related to COVID-19. There have been failures in the social distance practices and screening in healthcare professionals in hospitals across many countries in the world including Sri Lanka [4, 26, 28, 29]. It is necessary to pay careful attention to these safety issues by health authorities in their future outbreak control programs.
In this study, only 14.1% of participants had received psychological support, and no significant differences in the development of depressive symptoms and anxiety were found between those who received and did not receive such psychological support. Material facilities such as transport and sanitation, emergency feeding and protecting, and supporting family members through neighbors in emergencies would provide more than psychological counseling for them to lessen the psychological burden as in the 2004 tsunami incidence [17]. Also, the proliferation of misinformation including sketchy remedies of COVID-19 in social media may have contributed to the increased tension and uncertainty among healthcare professionals [30]. Such perceived stresses must be discussed in psychological counseling sessions designed for healthcare workers. Challenges in regularly disseminating correct information on the spread of the virus and safety measures among healthcare professionals would leave many of them in uncertainty and indecision [31].
Stigmatization has been identified as a major factor associated with psychological pathologies in healthcare workers [32]. Stigmatization is one of the main predictors of elevated depressive symptoms in our sample of healthcare professionals. There were several incidences in Sri Lanka in which COVID -19 patients hid their illness and came to healthcare facilities for the treatment of other illnesses. Such information in social media has fueled fear among the general public and labeled healthcare professionals as asymptomatic carriers of COVID-19 in society. Fear of contamination has downgraded many healthcare professionals and in extreme cases, forced them to leave their rented houses [33]. These emerging issues have resulted in healthcare professionals being isolated and socially rejected [29, 33]. Stigmatization would increase absenteeism from work and lead to increased workloads for the remaining staff. Such a heavy workload makes serious repercussions to the psychological strengths of healthcare professionals, specifically to nurses. To minimize the possible consequences of stigmatization faced by healthcare professionals, it is necessary to recognize the distinctive features of COVID-19 in a social and cultural context [6]. Based on these evidences, those who are stigmatized should be supported through emotional interventions and social policies.
In this study, we found that poor self-confidence was associated with increased depressive symptoms and anxiety. Self-confidence about working abilities and safety conditions in the workplace contributes to increasing work performances in unprecedented events like COVID-19. Nearly 62% of participants in this study reported a moderate to high level of self-confidence, a good indicator of the character of resilience, a personality trait, found in Sri Lankan healthcare professionals. Exposure to civil wars and catastrophic natural events like a tsunami [34] may have cultivated strong psychological traits among healthcare professionals in Sri Lanka to be resilient when challenges occur.
Although there were a few failures, the Sri Lankan government’s preparedness and subsequent actions in controlling the pandemic since its inception should be praised. Precautionary measures practiced by the nurses in the country were highly effective. To date, none of the nurses working in healthcare facilities was infected with COVID -19 due to their work exposure, and there were only 13 deaths in the country due to COVID-19 as of 30 September 2020. This socio-political factor may have contributed to minimizing the psychological burden of healthcare professionals during COVID-19. Future research should explore relationships between these socio-political and ecological factors and psychological well-being in healthcare professionals during infectious disease outbreaks. One limitation of the study is the use of single-item indicators for the variables stigmatization and self-confidence. In addition, the participants who have had experiences of severe stigma due to COVID-19 may have decided not to fill the questionnaire even after they agreed to participate in the study.