Psychological impact of the COVID-19 pandemic on primary care workers: a cross-sectional study

Background The COVID-19 pandemic has had a major impact on the mental health of healthcare workers, yet studies in primary care workers are scarce. Aim To investigate the prevalence of and associated factors for psychological distress in primary care workers during the first COVID-19 outbreak. Design and setting This was a multicentre, cross-sectional, web-based survey conducted in primary healthcare workers in Spain, between May and September 2020. Method Healthcare workers were invited to complete a survey to evaluate sociodemographic and work-related characteristics, COVID-19 infection status, exposure to patients with COVID-19, and resilience (using the Connor–Davidson Resilience Scale), in addition to being screened for common mental disorders (depression, anxiety disorders, post-traumatic stress disorder, panic attacks, and substance use disorder). Positive screening for any of these disorders was analysed globally using the term ‘any current mental disorder’. Results A total of 2928 primary care professionals participated in the survey. Of them, 43.7% (95% confidence interval [CI] = 41.9 to 45.4) tested positive for a current mental disorder. Female sex (odds ratio [OR] 1.61, 95% CI = 1.25 to 2.06), having previous mental disorders (OR 2.58, 95% CI = 2.15 to 3.10), greater occupational exposure to patients with COVID-19 (OR 2.63, 95% CI = 1.98 to 3.51), having children or dependents (OR 1.35, 95% CI = 1.04 to 1.76 and OR 1.59, 95% CI = 1.20 to 2.11, respectively), or having an administrative job (OR 2.24, 95% CI = 1.66 to 3.03) were associated with a higher risk of any current mental disorder. Personal resilience was shown to be a protective factor. Conclusion Almost half of primary care workers showed significant psychological distress. Strategies to support the mental health of primary care workers are necessary, including designing psychological support and resilience-building interventions based on risk factors identified.


INTRODUCTION
The outbreak of the COVID-19 pandemic in March 2020 saturated the capacity of the Spanish healthcare system and forced organisational changes at all levels of care to adapt to the changing conditions. 1 There was an important and abrupt change in the working conditions of primary care staff to meet new requirements, with staff having to tolerate uncertainties, organisational shortcomings, and a shortage of protective equipment. 2 In Spain, primary care was responsible for the screening and diagnosis of patients with COVID-19, nonhospital treatment of most of the patients with COVID-19, and, in the initial moments of the collapse of the healthcare system, even complex home care for patients with COVID-19. Many primary care professionals took on occupational relocations and new tasks, such as working in nursing homes, COVID-19-specific field hospitals, and also relocations to hospital services. 3,4 Overload and changes in working conditions, facing new and unfamiliar situations, lack of resources, fear of contagion, or fear of infecting family members generated significant stress in healthcare professionals. An increase in the prevalence of depression, anxiety, post-traumatic stress, drugs use, burnout, and increased risk of suicide have been described. [5][6][7] Importantly, the psychological distress affecting healthcare workers not only has an impact on their wellbeing, but also their professional performance, quality of care, and patient safety. 8 On the other hand, a sense of professional and civic responsibility has emerged in healthcare professionals, 9,10

Abstract Background
The COVID-19 pandemic has had a major impact on the mental health of healthcare workers, yet studies in primary care workers are scarce.

Aim
To investigate the prevalence of and associated factors for psychological distress in primary care workers during the first COVID-19 outbreak.

Design and setting
This was a multicentre, cross-sectional, web-based survey conducted in primary healthcare workers in Spain, between May and September 2020.

Method
Healthcare workers were invited to complete a survey to evaluate sociodemographic and work-related characteristics, COVID-19 infection status, exposure to patients with COVID-19, and resilience (using the Connor-Davidson Resilience Scale), in addition to being screened for common mental disorders (depression, anxiety disorders, post-traumatic stress disorder, panic attacks, and substance use disorder). Positive screening for any of these disorders was analysed globally using the term 'any current mental disorder'.

Results
A total of 2928 primary care professionals participated in the survey. Of them, 43

Conclusion
Almost half of primary care workers showed significant psychological distress. Strategies to support the mental health of primary care workers are necessary, including designing psychological support and resilience-building interventions based on risk factors identified. and staff have shown resilience in the face of insecurity and difficulties.
Despite the abundant literature on this subject, few studies have specifically analysed the situation in primary care, [11][12][13][14][15] notwithstanding the repercussions for those working in these settings and the different characteristics and conditions compared with those reported in hospital settings. In addition, females constitute the largest group within healthcare professions and yet most studies on the psychological impact of the pandemic on healthcare workers rarely mention sex as a variable affecting the results and they have not provided disaggregated data. 16 This study therefore analysed the psychological distress experienced by primary care workers in the context of the COVID-19 pandemic, including a sex-disaggregated analysis.
The aim was to investigate psychological distress in Spanish primary care workers during the first COVID-19 outbreak period. Specifically, this study aimed to: • estimate the prevalence of psychological distress by sex; • evaluate the associations between psychological distress and sociodemographic, occupational, and health characteristics by sex; and • explore the role of resilience as a protective factor.

METHOD
Design, population, and sampling A multicentre, cross-sectional, web-based self-reported survey was conducted of Spanish healthcare workers between May and September of 2020 as part of the MINDCOVID-19 project. 17 All workers in each healthcare institution included were invited to participate using administrative email distribution lists (that is, census sampling) that generated invitations to participate in the study containing an anonymous link to access the survey. A detailed description of the methods and procedures can be found in a previous article. 6 The present study analysed the data obtained from professionals in the primary care settings of five autonomous communities in Spain 25 and substance use disorder, evaluated via the CAGE-AID questionnaire. 26,27 The main variable, the presence of psychological distress, was considered present when there was a current positive screening for any of the above-mentioned mental disorders.
Mental disorders before the onset of the COVID-19 outbreak were recorded using a self-reported checklist based on the Composite International Diagnostic Interview, including lifetime depressive disorder, bipolar disorder, anxiety disorder, panic attacks, alcohol and drug use disorders, and other mental disorders. 28,29 COVID-19 exposure and infection status. Participants were questioned about having been infected with SARS-CoV-2 and whether or not admission to hospital was necessary. Additionally, the responders were asked if their close ones (partner, children, parents, other relatives, or close friends) had contracted COVID-19. Occupational exposure to patients with

How this fits in
In the context of the COVID-19 pandemic, a psychological impact on healthcare workers has been described, although studies in non-hospital settings are scarce. This study found that a high proportion of primary care workers (43.7%) had a current mental disorder. Female sex, having a history of previous mental disorders, greater work exposure to patients with COVID-19, having children or dependents, and certain professional positions were associated with greater risk. Personal resilience was shown to be a protective factor. Preventive and support interventions for the mental health of primary care workers are required.
COVID-19 was assessed using a five-level Likert scale (ranging from none of the time to all of the time).
Resilience. The 10-item Connor-Davidson Resilience Scale (CD-RISC-10) 30,31 is a selfadministered questionnaire with items rated on a five-point Likert scale (from 0, completely disagree to 4, completely agree) so that higher total scores indicate greater resilience.

Ethical considerations
Before accessing the survey content, participants were informed about the objectives and procedures of the study, and their explicit consent for participation was obtained. The study was registered at ClinicalTrials.gov (reference: NCT04556565). As psychological distress could be revealed in the survey, participants were offered a list of local resources for mental health care.

Statistical analysis
Participants who completed all the mental health items were included in the analysis. Sociodemographic, occupational, and health characteristics were compared between responders with and without psychological distress (that is, participants with and without a positive screening for any current mental disorder). To explore resilience, these variables were compared between participants with a resilience score above and below the 25th percentile. Categorical variables were analysed using the χ 2 -test, and the Mann-Whitney U-test was used for continuous variables.
A multivariable logistic regression model was estimated to assess potential factors associated with any current mental disorder. As the psychological impact of the pandemic can vary over time, the analyses were adjusted by the month of the response to the survey. A sex-stratified analysis was also conducted.
Statistical analyses were conducted using Stata (version 14). Statistical significance was set at P<0.05.

Response
A total of 3089 primary care professionals participated in the survey. Of these, 155 were excluded because of missing data in the questionnaires regarding mental health and six because of a lack of information on sex. Finally, 2928 participants were included in the statistical analysis.

Prevalence of any current mental disorder
The global prevalence of a positive screening for any current mental disorder was 43.7% (95% confidence interval [CI] = 41.9 to 45.4). The prevalence was significantly lower for males (33.8%, 95% CI = 29.7 to 37.9) than for females (45.7%, 95% CI = 43.7 to 47.7) (data not shown). Table 2 shows the associations between the characteristics of participants and a positive screening for any current mental disorder, stratified by sex. Statistically significant differences in age and profession were found. Caring for people was associated with a higher prevalence of a current mental disorder in females, but these differences were not significant among males. The presence of a lifetime mental health disorder was associated with a positive screening for any current mental disorder.

Resilience
Resilience was associated with sex, profession, and lifetime mental health disorders (Table 3). Lower resilience was observed in females, administrative staff, responders with former mental health disorders, and those who declared being treated for such disorders. Table 4 shows the multivariate analyses of the associations between any current mental disorder and the characteristics of the responders. Being aged 30-49 years, having children aged >12 years, caring for an older person or someone with disablities, being a nurse or auxiliary nurse, or administrative staff, and being exposed to patients with COVID-19 were associated with a higher risk of mental disorder, both for the complete sample and in females alone. However, these associations were not present in males. Having a history of any lifetime mental disorder was associated with a higher risk of a current mental disorder. Resilience was shown to be a protective factor for any current mental disorder.

DISCUSSION Summary
The outcomes of the present study show that a high proportion (43.7%) of primary care workers screened positive for any current mental disorder; the proportion being significantly higher in females than in males. Female sex, having a previous history of mental disorders, greater occupational exposure to patients with COVID-19, caring for children or dependents, or certain occupations were factors that were independently associated with an increased risk of having a mental disorder, whereas resilience was shown to be a protective factor.

Strengths and limitations
This study is particularly relevant because it evaluated the impact of the pandemic on primary care professionals, whose work characteristics and pandemic-related experiences differ greatly from those of hospital workers, the latter being more widely studied in the scientific literature. 32 A strength of this study is that other professional profiles aside from doctors or nurses were included; previous studies have rarely included this data. This allowed confirmation of the significant psychological repercussions of the pandemic on administrative personnel. When interpreting these results, it should be kept in mind that females represent 83% of the participants, which, far from constituting a bias, is a reflection of the reality of the healthcare work setting, where females are the vast majority in all professional categories in European health systems and, in particular, in the Spanish health system. 33,34 One of the strengths of the present analysis lies in the reporting of sex-disaggregated data.
This study has several limitations. First, participation was voluntary, which may have introduced a difficult-to-predict bias because of self-selection of participants in the survey. 35 This is especially important when the non-response rate is high, although this limitation is inherent to the methodology employed and is similar to other studies based on telematic surveys. 36 Second, in a cross-sectional study, causality cannot be inferred from the factors associated with the assessed outcomes. Observing the evolution over time of psychological distress as a function of experience with the pandemic will be necessary to establish causal relationships. Indeed, this is precisely the objective of a prospective follow-up of this cohort currently underway. 6 Third, the presence of probable mental disorders has been assessed by a battery of screening instruments. Establishing genuine clinical diagnoses was not possible, but positive screenings can be a valid indicator of the presence of significant psychological distress. 37,38 Finally, when interpreting the data from this cross-sectional study, the time at which they were obtained, between the end of the first wave and the beginning of the second wave in the pandemic epidemiological curve in Spain, must be considered. 39 Comparison with existing literature Differences in the prevalence of psychological distress by sex are to be expected, as a higher prevalence of mental disorders in females is a consistent finding in epidemiological studies. 40,41 Greater vulnerability in females has also been reported among healthcare workers during the pandemic. [42][43][44] Various explanations for these differences have been proposed, including response bias (males would have greater difficulty recognising and communicating psychological distress), as well as biological, social, and demographic factors. 45,46 This study found that having children aged >12 years or caring for an older person or person with disabilities are important risk factors for psychological distress in females, whereas this association was not observed in males. This suggests that different family roles may be a key factor in sex-related differences in emotional distress. 16,47 In addition, differences in informal caregiving between sexes may have increased following the shutdown of or limited access to resources such as childcare centres, schools, daycare nursing centres, or residences for older people. 48 A qualitative study involving healthcare workers in England shows caring responsibilities as a factor that affects males and females differently in terms of their emotional state during the pandemic. 16 As expected, the greater the occupational exposure to patients with COVID-19, the greater the risk of psychological distress for the overall sample; an association that is stronger and more consistent in females than in males. 49,50 However, similar to findings from other research, 51-53 this study found the paradox that administrative personnel were at greater risk than professional groups with direct patient contact. Again, these associations are strong and statistically significant in females, but not in males. As a result of the pandemic, primary care administrative staff have been exposed to changes, uncertainty, and a heavy workload, perhaps without sufficient support to handle this type of situation and with less control over their job conditions than other professional categories. 54 In contrast, female doctors experienced less psychological distress than those in other occupations, possibly because of skills and experience in managing and coping with situations of complexity and uncertainty inherent to medical practice. 55 The association between the existence of previous mental disorders and the current presence of any mental disorder was particularly strong, being comparable in both sexes. This was to be expected given the tendency for recurrence and the often chronic nature of mental disorders, 56 and is consistent with other studies in healthcare workers in the pandemic setting. 44,57 The relevance of this risk factor is accentuated by the fact that 42% of the individuals in the present sample reported a history of previous mental disorders.
Resilience is an individual's ability to cope with and adapt to adverse situations while maintaining effective personal and professional functioning. 58 Concurring with a study on healthcare workers in Italy, 59 this work identified resilience as a protective factor against the psychological distress caused by the pandemic in healthcare professionals, both in males and females, although the level of resilience was higher among males. 60 This ability to cope with stress was shown to be significantly impaired in those individuals with a previous history of mental disorders.

Implications for research and practice
This study found that a high proportion of primary healthcare workers experienced psychological distress in the context of the COVID-19 pandemic and some particularly vulnerable profiles were identified. Given this situation, establishing strategies and interventions for psychological support and resilience building of healthcare workers is highly relevant, taking into account the risk factors identified and tailoring the interventions accordingly. Proactive systems should be established to assess and monitor the psychological wellbeing of different professional groups in primary care and facilitate their access to psychological

Discuss this article
Contribute and read comments about this article: bjgp.org/letters help. 61 Additionally, interventions should be conducted to promote resilience, as it is a modifiable factor, 62,63 implementing strategies focused on self-care and changes in the organisation and work environment. 64,65 Longitudinal studies are necessary to assess the evolution of the psychological impact of the pandemic over time and to identify the factors that determine or can predict this evolution. Evaluating the usefulness, feasibility, and effectiveness of any preventive or therapeutic interventions under real conditions will also be important, as well as determining the best way to implement them. 66