How did general practitioners protect themselves, their family, and staff during the SARS epidemic in Hong Kong?

Burnout, psychological wellbeing, and musculoskeletal complaints in UK GPs: an observational study

BACKGROUND

Healthcare systems are under unprecedented pressure. GPs are crucial to the health of the population, yet their own health and wellbeing is often overlooked.

AIM

To investigate feelings of burnout, psychological wellbeing, and musculoskeletal complaints in GPs across the UK and to examine whether these health outcomes vary according to the time GPs spent sitting, their participation in physical activity each day, and the time spent working per day or week.

DESIGN & SETTING

Observational study involving GPs located across the UK.

METHOD

An online survey was emailed to working members of the Royal College of General Practitioners and shared on social media between October and December 2020. The survey included questions on burnout, psychological wellbeing, musculoskeletal complaints, sitting time, physical activity, and time spent working. Mean differences were examined for burnout, psychological wellbeing, and musculoskeletal complaints.

RESULTS

Data from 406 GPs showed a high level of burnout (35.5%) and musculoskeletal complaints (neck, shoulder and back: 81.8%; arms: 28.3%; and legs: 49.8%). Psychological wellbeing was low in 22.9% of GPs. Burnout was lower in GPs who met current physical activity guidelines, while psychological wellbeing was higher in those with >2 breaks in sitting per hour. Musculoskeletal complaints were higher in those spending >50% of sitting time in prolonged bouts (≥30 minutes).

CONCLUSION

A high proportion of GPs reported experiencing burnout and musculoskeletal complaints, but these health concerns were less evident in GPs who spent less time in prolonged sitting, took more breaks in sitting, and who were more physically active.

The roles and challenges of the primary health care systems in epidemic management: a scoping review

BACKGROUND AND AIM

During the early stage of pandemics, primary health care (PHC) is the first point of contact with the health system for people. This study aimed to find the leading roles and challenges of the PHC system in dealing with the outbreak of infectious diseases.

METHODS

The current scoping review was conducted in 2022 using the Arkesy and O'Malley framework. A bibliographic search was conducted in PubMed, Web of Science, and Scopus databases. Following a Google Scholar search, a manual search in some journals, reference checks for articles, and a review of organizational reports, websites, and other sources of information were also conducted. Data were analyzed using the content-analysis method.

FINDINGS

Finally, 65 documents (42 articles and 23 reports, books, and news) were included in the study. Initially, 626 codes were extracted, and 132 final codes were categorized into eight main themes and 44 sub-themes. The main themes for the roles of PHC included: service provision, education and knowledge, surveillance, access, coordination and communication, management and leadership, infrastructure change and rapid preparation, and patient and community management. Regarding the challenges faced by PHC in the epidemic of infectious diseases, 24 key challenges were identified and categorized into four major areas.

CONCLUSIONS

Based on the results of the present study, there is a need for further studies to formulate and theorize the specific roles of PHC in managing infectious disease epidemics. The results of this study can be utilized by researchers and officials to inform their efforts in addressing this purpose.

The impact of psychological flexibility on family dynamics amidst the COVID-19 pandemic: A longitudinal perspective

Background

Health risks associated with contracting COVID-19, stay-at-home orders, and pandemic-related economic and social hardships created unique challenges for individuals throughout the pandemic, and in particular for families whose daily routines were disrupted at the start of the pandemic. This study applied a contextual behavioral science lens to Family Systems Theory to examine the impact of COVID-19 stressors on family and individual functioning.

Methods

A sample of 742 coparents (86% married/engaged; 84% Caucasian; 71% female; M = 40.7 years old, SD = 8.1; M _income = $82,435, SD _income = $27,604) of school-aged children (5-18 years old) completed a baseline survey from late March to late April 2020. Of the initial sample, 556 coparents completed weekly diaries for 8 weeks.

Results

Mediation models were tested within a multilevel path modeling framework to evaluate both the stable, between-family differences (i.e., at level 2) and the within-family changes from week to week (i.e., at level 1). Across both levels of the model, parent psychological inflexibility was robustly linked to poorer functioning across all levels of the family system, showing direct links to a majority of the processes assessed. The results further supported a top-down spillover cascade in which parent inflexibility was proximally linked to greater COVID-19 related stress and parent depressive symptoms, which were proximally linked to poorer romantic functioning (greater negative conflict, lower satisfaction), which were proximally linked to poorer family functioning (greater coparent discord and family chaos), which were proximally linked to poorer parenting (greater angry/reactive parenting), which was proximally linked to greater child distress. Multi-group models suggested that the results were largely stable across (1) parent race (white vs non-white), (2) family size (1 child vs 2 or more), (3) child age (less than 10 years old vs 10 or older), (4) parent age (under 40 vs. 40 or older), (5) perceived COVID-19 risk, (6) parent gender (mothers vs fathers), (7) household income groups (less than $100k vs $100k or more), and (8) perceived economic stress/uncertainty (low vs high). However, a handful of moderated effects emerged from those multi-group models suggesting that fathers might be slightly more prone to negative spillover effects across the family systems and that wealthier families might have experienced the stress of new demands (e.g., homeschooling, remote working) as more disruptive.

Conclusions

Results highlight the crucial role parental psychological flexibility and inflexibility play in families managing the stress of COVID-19, as well as key mechanisms for how those stressors may either reverberate or become dampened throughout the family system.

How South African Families Protected Themselves during the COVID-19 Pandemic: A Qualitative Study

The World Health Organization (WHO) reported a cluster of cases of ‘viral pneumonia’—‘Coronavirus Disease 2019’ (COVID-19)—in Wuhan City, the People’s Republic of China on 31 December 2019. To curb the spread of the virus, various containment measures were introduced. However, no study has explored how families protected themselves during the pandemic. Therefore, this study explored how families protected themselves during the COVID-19 pandemic using a qualitative exploratory design. Thirty-one adult participants, representing families in the Western Cape province of South Africa, were virtually interviewed. The sampling approach was both convenient and snowball. The data were analysed using thematic analysis. The results show that families followed and adapted to the mainstream protection measures as implemented by the South African government but in addition believed that adherence to non-pharmaceutical interventions would protect them from contracting the virus. Therefore, the government and other stakeholders should support families in making it easier to protect themselves during the current and future pandemic(s).

Psychological Distress Among Healthcare Professionals During the Early Stages of the COVID-19 Outbreak in Low Resource Settings: A Cross-Sectional Study in Bangladesh

The COVID-19 pandemic has been very destructive to and compromised the functioning of all nations' public health systems. In the absence of a vaccine, healthcare workers have been employed to relentlessly fight against COVID-19. The psychological status of healthcare workers during the pandemic in countries with limited resources, notably Bangladesh, remains unclear. The present study aimed to investigate the psychological states of frontline and non-frontline Bangladeshi healthcare workers during the early stages of the COVID-19 outbreak. An online cross-sectional study was conducted from May 5 to 31, 2020 with 203 respondents. Psychological states were measured with a self-reported numerical scale of fear, the Generalized Anxiety Disorder (GAD-7) scale, and the Patient Health Questionnaire (PHQ-9). The prevalence rates of fear, anxiety, and depression were 60.6, 71.9, and 55.2%, respectively. Compared to non-frontline workers, frontline workers reported higher rates of anxiety (79.0 vs. 67.2%) and depression (65.4 vs. 48.4%). Multivariate logistic regression models showed that working in a public institution, being employed for <5 years, and being over-worked were risk factors for developing psychological distress. Our findings emphasize the need for timely psychological interventions to support the mental well-being of healthcare professionals in Bangladesh.

Lessons for the global primary care response to COVID-19: a rapid review of evidence from past epidemics

BACKGROUND

COVID-19 is the fifth and most significant infectious disease epidemic this century. Primary health care providers, which include those working in primary care and public health roles, have critical responsibilities in the management of health emergencies.

OBJECTIVE

To synthesize accounts of primary care lessons learnt from past epidemics and their relevance to COVID-19.

METHODS

We conducted a review of lessons learnt from previous infectious disease epidemics for primary care, and their relevance to COVID-19. We searched PubMed/MEDLINE, PROQUEST and Google Scholar, hand-searched reference lists of included studies, and included research identified through professional contacts.

RESULTS

Of 173 publications identified, 31 publications describing experiences of four epidemics in 11 countries were included. Synthesis of findings identified six key lessons: (i) improve collaboration, communication and integration between public health and primary care; (ii) strengthen the primary health care system; (iii) provide consistent, coordinated and reliable information emanating from a trusted source; (iv) define the role of primary care during pandemics; (v) protect the primary care workforce and the community and (vi) evaluate the effectiveness of interventions.

CONCLUSIONS

Evidence highlights distinct challenges to integrating and supporting primary care in response to infectious disease epidemics that have persisted over time, emerging again during COVID-19. These insights provide an opportunity for strengthening, and improved preparedness, that cannot be ignored in a world where the frequency, virility and global reach of infectious disease outbreaks are increasing. It is not too soon to plan for the next pandemic, which may already be on the horizon.

Factors affecting healthcare workers' compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: rapid evidence review

OBJECTIVE

The 2019-2020 outbreak of novel coronavirus has raised concerns about nosocomial transmission. This review's aim was to explore the existing literature on emerging infectious disease outbreaks to identify factors associated with compliance with infection control measures among healthcare staff.

METHODS

A rapid evidence review for primary studies relevant to healthcare workers' compliance with infection control measures.

RESULTS

Fifty-six papers were reviewed. Staff working in emergency or intensive care settings or with contact with confirmed cases appeared more likely to comply with recommendations. There was some evidence that anxiety and concern about the risk of infection were more associated with compliance, and that monitoring from superiors could improve compliance. Observed non-compliance of colleagues could hinder compliance. Staff identified many barriers to compliance related to personal protective equipment, including availability, perceived difficulty and effectiveness, inconvenience, discomfort and a negative impact on patient care. There were many issues regarding the communication and ease of understanding of infection control guidance.

CONCLUSION

We recommend provision of training and education tailored for different occupational roles within the healthcare setting, managerial staff 'leading by example', ensuring adequate resources for infection control and timely provision of practical evidence-based infection control guidelines.

Factors influencing the willingness of primary care physicians to provide care during the coronavirus disease pandemic: a nationwide survey in Taiwan

OBJECTIVES

The COVID-19 pandemic continues to advance worldwide with tremendous impact on public health, economy and society. Primary healthcare is crucial in every country during the pandemic for an integrated and coordinated healthcare delivery system; hence, it is of paramount importance to maintain a sufficient frontline workforce. This study aimed to identify factors influencing the willingness of primary care physicians to provide care during the COVID-19 pandemic.

DESIGN

Cross sectional study.

SETTING

Nationwide survey PARTICIPANTS: Primary care physicians working in the community in Taiwan were selected using a cluster sampling method based on practice region from May to June 2020.

OUTCOME MEASURES

The willingness of primary care physicians to provide care during the COVID-19 pandemic.

RESULTS

This study surveyed 1000 primary care physicians nationwide, and 625 valid questionnaires were received and included in the final analysis, with an effective response rate of 62.5%. Factors significantly associated with physicians willingness to provide care during COVID-19 were 'joining the Community Healthcare Group (CHCG)' (p<0.001), 'perceived more overall benefits for providing care' (p<0.001) 'perceived less overall barriers to providing care' (p<0.001), 'higher knowledge scores about COVID-19' (p=0.049) and 'physician's major specialties' (p=0.009) in the multivariate logistic regression model.

CONCLUSIONS

Building a comprehensive primary care system such as Taiwan's CHCG, training of more family physicians or general practitioners, and protecting and supporting primary care physicians were important in response to infectious disease pandemics. The findings of this study inform the development of guidelines to support and maintain the primary healthcare workforces during the COVID-19 pandemic and for future events.

The Impact of Epidemics and Pandemics on the Mental Health of Healthcare Workers: A Systematic Review

BACKGROUND

There is increasing evidence that healthcare workers (HCWs) experience significant psychological distress during an epidemic or pandemic. Considering the increase in emerging infectious diseases and the ongoing COVID-19 pandemic, it is timely to review and synthesize the available evidence on the psychological impact of disease outbreaks on HCWs. Thus, we conducted a systematic review to examine the impact of epidemics and pandemics on the mental health of HCWs.

METHOD

PubMed, PsycInfo, and PsycArticles databases were systematically searched from inception to June-end 2020 for studies reporting the impact of a pandemic/epidemic on the mental health of HCWs.

RESULTS

Seventy-six studies were included in this review. Of these, 34 (45%) focused on SARS, 28 (37%) on COVID-19, seven (9%) on MERS, four (5%) on Ebola, two (3%) on H1N1, and one (1%) on H7N9. Most studies were cross-sectional (93%) and were conducted in a hospital setting (95%). Common mental health symptoms identified by this review were acute stress disorder, depression, anxiety, insomnia, burnout, and post-traumatic stress disorder. The associated risk factors were working in high-risk environments (frontline), being female, being a nurse, lack of adequate personal protective equipment, longer shifts, lack of knowledge of the virus, inadequate training, less years of experience in healthcare, lack of social support, and a history of quarantine.

CONCLUSION

HCWs working in the frontline during epidemics and pandemics experience a wide range of mental health symptoms. It is imperative that adequate psychological support be provided to HCWs during and after these extraordinary distressful events.

COVI-Prim survey: Challenges for Austrian and German general practitioners during initial phase of COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) represents a significant challenge to health care systems around the world. A well-functioning primary care system is crucial in epidemic situations as it plays an important role in the development of a system-wide response.

METHODS

2,187 Austrian and German GPs answered an internet survey on preparedness, testing, staff protection, perception of risk, self-confidence, a decrease in the number of patient contacts, and efforts to control the spread of the virus in the practice during the early phase of the COVID-pandemic (3rd to 30th April).

RESULTS

The completion rate of the questionnaire was high (90.9%). GPs gave low ratings to their preparedness for a pandemic, testing of suspected cases and efforts to protect staff. The provision of information to GPs and the perception of risk were rated as moderate. On the other hand, the participants rated their self-confidence, a decrease in patient contacts and their efforts to control the spread of the disease highly.

CONCLUSION

Primary care is an important resource for dealing with a pandemic like COVID-19. The workforce is confident and willing to take an active role, but needs to be provided with the appropriate surrounding conditions. This will require that certain conditions are met.

REGISTRATION

Trial registration at the German Clinical Trials Register: DRKS00021231.

Rapid Evidence Assessment of Mental Health Outcomes of Pandemics for Health Care Workers: Implications for the Covid-19 Pandemic

Background: Little is known about the long-term mental health (MH) impact of the Covid-19 pandemic on health care workers (HCWs). However, synthesizing knowledge from past pandemics can help to anticipate this, along with identifying interventions required, when, and target populations most in need. This paper provides a balanced evaluation of what is currently known about short- and long-term MH impacts of pandemics on HCWs and effect of methodological limitations on knowledge claims. Method: A rapid evidence assessment (REA) was conducted on 41 studies published in the past two decades that examined MH outcomes for HCWs in relation to pandemics. Results: Findings of literary synthesis highlight common MH outcomes across pandemics, including increased stress, distress, burnout, and anxiety in the short-term, and post-traumatic stress and depression in the long-term. Findings also show the key role that organizations and public health bodies play in promoting adaptive coping and reducing health worries and the emotional and psychological distress caused by this. Evidence highlights particular groups at risk of developing MH issues (contact with patients that are infected, having children), and time points where risk may increase (initial response phase, when quarantined). However, inconsistencies in measures, analysis, and reporting all create limitations for pooling data. Conclusions: Findings can be used by researchers to provide a knowledge framework to inform future research that will assist HCWs in responding to pandemics, and by policy makers and service planners to provide an evidence-led brief about direction and evidence base for related policy initiatives, interventions or service programmes.

Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review

BACKGROUND

Prior to the COVID-19 pandemic, physicians experienced unprecedented levels of burnout. The uncertainty of the ongoing COVID-19 pandemic along with increased workload and difficult medical triage decisions may lead to a further decline in physician psychological health.

METHODS

We searched Medline, EMBASE, and PsycINFO for primary research from database inception (Medline [1946], EMBASE [1974], PsycINFO [1806]) to November 17, 2020. Titles and abstracts were screened by one of three reviewers and full-text article screening and data abstraction were conducted independently, and in duplicate, by three reviewers.

RESULTS

From 6223 unique citations, 480 articles were reviewed in full-text, with 193 studies (of 90,499 physicians) included in the final review. Studies reported on physician psychological symptoms and management during seven infectious disease outbreaks (severe acute respiratory syndrome [SARS], three strains of Influenza A virus [H1N1, H5N1, H7N9], Ebola, Middle East respiratory syndrome [MERS], and COVID-19) in 57 countries. Psychological symptoms of anxiety (14.3-92.3%), stress (11.9-93.7%), depression (17-80.5%), post-traumatic stress disorder (13.2-75.2%) and burnout (14.7-76%) were commonly reported among physicians, regardless of infectious disease outbreak or country. Younger, female (vs. male), single (vs. married), early career physicians, and those providing direct care to infected patients were associated with worse psychological symptoms.

INTERPRETATION

Physicians should be aware that psychological symptoms of anxiety, depression, fear and distress are common, manifest differently and self-management strategies to improve psychological well-being exist. Health systems should implement short and long-term psychological supports for physicians caring for patients with COVID-19.

Prepared and highly committed despite the risk of COVID-19 infection: a cross-sectional survey of primary care physicians' concerns and coping strategies in Singapore

Background

Primary care physicians (PCPs) are first points-of-contact between suspected cases and the healthcare system in the current COVID-19 pandemic. This study examines PCPs’ concerns, impact on personal lives and work, and level of pandemic preparedness in the context of COVID-19 in Singapore. We also examine factors and coping strategies that PCPs have used to manage stress during the outbreak.

Methods

Two hundred and sixteen PCPs actively practicing in either a public or private clinic were cluster sampled via email invitation from three primary care organizations in Singapore from 6th to 29th March 2020. Participants completed a cross-sectional online questionnaire consisting of items on work- and non-work-related concerns, impact on personal and work life, perceived pandemic preparedness, stress-reduction factors, and personal coping strategies related to COVID-19.

Results

A total of 158 questionnaires were usable for analyses. PCPs perceived themselves to be at high risk of COVID-19 infection (89.9%), and a source of risk (74.7%) and concern (71.5%) to loved ones. PCPs reported acceptance of these risks (91.1%) and the need to care for COVID-19 patients (85.4%). Overall perceived pandemic preparedness was extremely high (75.9 to 89.9%). PCPs prioritized availability of personal protective equipment, strict infection prevention guidelines, accessible information about COVID-19, and well-being of their colleagues and family as the most effective stress management factors.

Conclusions

PCPs continue to serve willingly on the frontlines of this pandemic despite the high perception of risk to themselves and loved ones. Healthcare organizations should continue to support PCPs by managing both their psychosocial (e.g. stress management) and professional (e.g. pandemic preparedness) needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01370-7.

Mental health of clinical staff working in high-risk epidemic and pandemic health emergencies a rapid review of the evidence and living meta-analysis

PURPOSE

The SARS-CoV-2 / COVID-19 pandemic has raised concerns about the potential mental health impact on frontline clinical staff. However, given that poor mental health is common in acute medical staff, we aimed to estimate the additional burden of work involving high exposure to infected patients.

METHODS

We report a rapid review, meta-analysis, and living meta-analysis of studies using validated measures from outbreaks of COVID-19, Ebola, H1N1 influenza, Middle East respiratory syndrome (MERS), and severe acute respiratory syndrome (SARS).

RESULTS

A random effects meta-analysis found that high-exposure work is not associated with an increased prevalence of above cut-off scoring (anxiety: RR = 1.30, 95% CI 0.87-1.93, Total N = 12,473; PTSD symptoms: RR = 1.16, 95% CI 0.75-1.78, Total N = 6604; depression: RR = 1.50, 95% CI 0.57-3.95, Total N = 12,224). For continuous scoring, high-exposure work was associated with only a small additional burden of acute mental health problems compared to low-exposure work (anxiety: SMD = 0.16, 95% CI 0.02-0.31, Total N = 6493; PTSD symptoms: SMD = 0.20, 95% CI 0.01-0.40, Total N = 5122; depression: SMD = 0.13, 95% CI -0.04-0.31, Total N = 4022). There was no evidence of publication bias.

CONCLUSION

Although epidemic and pandemic response work may add only a small additional burden, improving mental health through service management and provision of mental health services should be a priority given that baseline rates of poor mental health are already very high. As new studies emerge, they are being added to a living meta-analysis where all analysis code and data have been made freely available: https://osf.io/zs7ne/ .

Immediate Psychological Responses, Stress Factors, and Coping Behaviors in Military Health-Care Professionals During the COVID-19 Pandemic in Tunisia

Objective: The COVID-19 epidemic began in Tunisia in March 2020; health-care workers (HCWs) were suddenly confronted with a particularly stressful situation. The aim of this study was to assess the psychological responses of HCWs during the epidemic, determine the stressors and identify ways to cope. Methods: This cross-sectional study used an online questionnaire that included 62 questions. ANOVAs and t-tests were used to compare the responses between professional groups, age groups, and genders. Results: Questionnaires were completed by 368 HCWs. HCWs believed they had a social and professional obligation to continue working long hours (95.3%). They were anxious regarding their safety (93.7%) and the safety of their families (97.8%). Youthful age (p = 0.044) and female gender (ps <0.046) were identified as stressors. The availability of personal protective equipment (PPE; 99.7%) and good communication between colleagues (98.1%) and managers (91.6%) were important protective factors. Family and friend support (95.9%), following strict protective measures (99.4%), knowing more about COVID-19 (94.8%), adopting a positive attitude (89.6%), and engaging in leisure activities (96.1%) helped in dealing with this epidemic. Conclusion: This study highlights the importance of providing HCWs with infection control guidelines and adequate PPE. Communication and support within the team and maintaining family support help in coping with this stressful situation.

Fighting against COVID-19: preparedness and implications on clinical practice in primary care in Shenzhen, China

Background

The new coronavirus pneumonia (NCP) caused by COVID-19 has affected more than 46 million people worldwide. In China, primary care has played a vital role during the COVID-19 outbreak, and it is important to examine the challenges faced by general practitioners (GPs). This study investigated the roles, preparedness and training needs of GPs in China in managing the NCP outbreak. Based on the outcomes of the study, we hope to take lessons and identify how GPs could be supported in delivering their gatekeeping roles and clinical duties in times of infectious disease outbreak.

Methods

An online survey on the official website of Shenzhen Continuing Education Center. It included questions on GPs’ demographics, their awareness of COVID-19 and their preparedness in managing suspected cases of NCP, as well as referrals and their training needs. Conditional multi-variate logistic models were used to investigate the relationships between GPs’ preparedness, situational confidence and anxiety.

Results

GPs’ clinical practice was significantly affected. GPs endeavoured to answer a flood of COVID-19-related enquiries, while undertaking community preventive tasks. In addition to in-person consultations, GP promoted COVID-19 awareness and education through telephone consultations, physical posters and social media. Overall GPs in Shenzhen felt well supported with adequate Personal Protective Equipment (PPE) and resources from secondary care services. Higher levels of self-perceived preparedness (OR = 2.19; 95%CI, 1.04–4.61), lower level of anxiety (OR = 0.56; 95%CI, 0.29–1.09) and fewer perceived family worries (OR = 0.37; 95%CI, 0.12–1.12) were associated with better confidence in coping at work.

Conclusions

Training and supporting GPs while reducing their (and their families’) anxiety increase their confidence in delivering the important roles of gatekeeping in face of major disease outbreaks.

The Mental Health of Frontline Health Care Providers During Pandemics: A Rapid Review of the Literature

OBJECTIVE

This rapid review addresses two key questions posed by the COVID-19 pandemic: What are the anticipated mental health sequelae for frontline health workers? and What are best practices during health emergencies to address the mental health needs of these workers?

METHODS

This review synthesized the literature on the mental health sequelae for health workers during major pandemics and epidemics that occurred in the 21st century (severe acute respiratory syndrome, Middle East respiratory syndrome, Ebola virus disease, and swine flu) and interventions used to address related mental health sequelae. PubMed, MEDLINE, and PsycINFO were searched with terms related to these epidemics/pandemics.

RESULTS

Of 3,876 articles retrieved, 94 were included in this review. Across these studies, most health workers exhibited some adverse psychological experiences during outbreaks, with stress and anxiety being most common. Psychological distress decreased over time. Some studies reported insomnia, burnout, and posttraumatic stress for a subset of individuals up to 3 years after the disease outbreak. Few interventions have been implemented to address providers' mental health needs, and these strategies have not been evaluated systematically.

CONCLUSIONS

Systems-level interventions may alleviate distress for most providers without the need for specialized mental health intervention. Psychotherapeutic support and referral to specialty care should be available to health workers with severe and intense adverse psychological outcomes during and beyond the COVID-19 pandemic. Evidence-based interventions are urgently needed to better serve health workers both during and following epidemics/pandemics.

COVID-19 infection outbreak increases anxiety level of general public in China: involved mechanisms and influencing factors

BACKGROUND

COVID-19 outbreak happened last December in China and is still continuing. Here, we reported effects of COVID-19 outbreak on the mood of general public and ascertained impacts of psychosocial factors on the plague-related emotional measures.

METHODS

During Feb. 4-6, 2020, a self-reported questionnaire Beck Anxiety Inventory (BAI) was disseminated to general public via Wechat, along with a sociodemographic information sheet. BAI score and incidences of moderate and severe anxiety in subgroups of respondents were compared. Multiple linear and logistic regressions were done for correlation analysis and to identify factors predictive of anxiety.

RESULTS

Averaged BAI score of all respondents is higher than those of general public in two previous studies. The people quarantined for probable COVID-19 infection presented higher BAI score and incidences of moderate and severe anxiety relative to non-quarantined respondents. People in high epidemic area showed higher BAI score and incidences of moderate and severe anxiety compared to those in low epidemic area. Significant associations existed between anxiety level of the respondents and each of the investigated factors, except for gender. Quarantine was the predictor with a highest OR, followed by divorced/widow. The other factors showed smaller but significant effects on the anxiety level of respondents.

LIMITATIONS

This cross-sectional study was unable to track the emotional changes in the respondents over time. It had a relatively small sample and involved some of emotional measures only.

CONCLUSION

These data are of help in planning psychological interventions for the different subpopulations in general public during and after COVID-19 outbreak.

The Role of Primary Care in a Pandemic: Reflections During the COVID-19 Pandemic in Canada

As COVID-19 cases began to rise in Ontario, Canada, in March 2020, increasing surge capacity in hospitals and intensive care units became a large focus of preparations. As part of these preparations, primary care physicians were ready to be redeployed to the hospitals. However, due to the effective implementation of community-wide public health measures, the hospital system was not overwhelmed. As Ontario prepares now for a potential second wave of COVID-19, primary care physicians have an opportunity to consider the full breadth and depth of scope for primary care during a pandemic. From planning to surveillance to vaccination, primary care physicians are positioned to play a unique and vital role in a pandemic. Nevertheless, there are specific barriers that will need to be overcome.

Psychological flexibility and inflexibility as sources of resiliency and risk during a pandemic: Modeling the cascade of COVID-19 stress on family systems with a contextual behavioral science lens

BACKGROUND

The coronavirus disease (COVID-19) pandemic and the historic economic shutdown and stay-at-home efforts to slow its spread have radically impacted the lives of families across the world, completely disrupting routines and challenging them to adjust to new health risks as well as to new work and family demands. The current study applied a contextual behavioral science lens to the spillover hypothesis of Family Systems Theory to develop a multi-stage mechanistic model for how COVID-19 stress could impact family and child functioning and how parents' psychological flexibility could shape those processes.

METHODS

A total of 742 coparents (71% female; 84% Caucasian, 85% married, M = 41 years old) of children (ages 5-18, M = 9.4 years old, 50% male) completed an online survey from March 27th to the end of April 2020.

RESULTS

Path analyses highlighted robust links from parent inflexibility to all components of the model, predicting: greater COVID-19 stress, greater coparenting discord and family discord, greater caustic parenting, and greater parent and child distress. Parent flexibility was associated with greater family cohesion, lower family discord and greater use of constructive parenting strategies (inductive, democratic/autonomy supportive, positive). Results further suggested that COVID-19 stressors predicted greater family and coparent discord, which in turn predicted greater use of caustic parenting (reactive, inconsistent, aggressive), which in turn predicted greater child and parent distress.

CONCLUSIONS

The current results highlight parental flexibility and inflexibility as key points of intervention for helping families navigate the current global health crisis, highlighting the crucial role they play in the lives of families.

Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis

OBJECTIVE

To examine the psychological effects on clinicians of working to manage novel viral outbreaks, and successful measures to manage stress and psychological distress.

DESIGN

Rapid review and meta-analysis.

DATA SOURCES

Cochrane Central Register of Controlled Trials, PubMed/Medline, PsycInfo, Scopus, Web of Science, Embase, and Google Scholar, searched up to late March 2020.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Any study that described the psychological reactions of healthcare staff working with patients in an outbreak of any emerging virus in any clinical setting, irrespective of any comparison with other clinicians or the general population.

RESULTS

59 papers met the inclusion criteria: 37 were of severe acute respiratory syndrome (SARS), eight of coronavirus disease 2019 (covid-19), seven of Middle East respiratory syndrome (MERS), three each of Ebola virus disease and influenza A virus subtype H1N1, and one of influenza A virus subtype H7N9. Of the 38 studies that compared psychological outcomes of healthcare workers in direct contact with affected patients, 25 contained data that could be combined in a pairwise meta-analysis comparing healthcare workers at high and low risk of exposure. Compared with lower risk controls, staff in contact with affected patients had greater levels of both acute or post-traumatic stress (odds ratio 1.71, 95% confidence interval 1.28 to 2.29) and psychological distress (1.74, 1.50 to 2.03), with similar results for continuous outcomes. These findings were the same as in the other studies not included in the meta-analysis. Risk factors for psychological distress included being younger, being more junior, being the parents of dependent children, or having an infected family member. Longer quarantine, lack of practical support, and stigma also contributed. Clear communication, access to adequate personal protection, adequate rest, and both practical and psychological support were associated with reduced morbidity.

CONCLUSIONS

Effective interventions are available to help mitigate the psychological distress experienced by staff caring for patients in an emerging disease outbreak. These interventions were similar despite the wide range of settings and types of outbreaks covered in this review, and thus could be applicable to the current covid-19 outbreak.

Perception and Barriers Regarding Infection Control Measures Among Healthcare Workers in Minia City, Egypt

Background:

This study aimed to assess perception of healthcare workers (HCWs) toward infection control measures and to identify the major barriers that may hinder the proper infection control practice and to compare perception of HCWs toward infection control measures between Minia University Hospital and Minia General Hospital. The study was a descriptive cross-sectional study.

Methods:

The study conducted on 350 HCWs (187 from Minia University Hospital, 163 from Minia General Hospital); data were collected using a structured questionnaire. The questionnaire was designed to assess perception toward infection control measures and to identify the major barriers that may hinder the proper infection control practice.

Statistical Analysis Used:

Data were gathered and entered into Statistical Package of Social Science (SPSS), version 22.

Results:

About 85% of HCWs in Minia University Hospital compared with 82% in Minia General Hospital had a positive perception toward Standard precautions (SPs). Knowledge score was the only significant predictors of perception of HCWs toward infection control. One-point increment in knowledge score is associated with significantly 13% lower odds to have negative perception; the multivariable-adjusted odds ratio (95% confidence intervals) was 0.87 (0.81–0.95). The most frequent barrier of practice of SPs was absence of enough gloves and gowns.

Conclusions:

HCWs demonstrated positive perception toward infection control and SPs measures. The most frequent reported barrier against practice of SPs was absence of enough gloves and gowns. The significant predictor that hindered the practice of SPs was that “Following SPs makes work harder.”

Occupational Stress and Mental Health: A Comparison Between Frontline Medical Staff and Non-frontline Medical Staff During the 2019 Novel Coronavirus Disease Outbreak

Background: During an epidemic, both frontline and non-frontline medical staff endure stressful work circumstances that render their mental health a major public health concern. This study aims at investigating and comparing the prevalence and severity of mental health symptoms (i.e., anxiety, depression and insomnia) between frontline medical staff and non-frontline medical staff during the coronavirus disease 2019 (COVID-19) outbreak. It also seeks to evaluate the association of their mental health with occupational stress. Methods: A cross-sectional study was conducted in Wenzhou, China from 2020 February 16th to 2020 March 2th. A total of 524 medical staff responded to the Generalized Anxiety Disorder Scale, the Patient Health Questionnaire, the Insomnia Severity Index, the Occupational stress Questionnaire, and a demographic data form. Data were principally analyzed with logistic regression. Results: Of the 524 participants, 31.3% reported depression, 41.2% reported anxiety, and 39.3% reported insomnia. Compared with the citizens during the COVID-19 epidemic, medical staff experienced higher level of anxiety, depression and insomnia, especially the frontline medical staff. Furthermore, male, married medical staff with poorer physical health reported lower mental health. Frontline medical staff endorsed higher self-reported occupational stress, especially higher occupational hazards, than non-frontline medical staff. In addition, four indicators on occupational stress (working intensity, working time, working difficulty and working risk) were correlated positively with mental health symptoms. Regression analyses found a significant association between occupational stress and mental health symptoms in both frontline and non-frontline medical staff during COVID-19 outbreak. Conclusion: The results indicated that during the COVID-19 epidemic, medical staff experienced higher levels of anxiety, depression and insomnia than citizens, and their occupational stress had positive effects on their psychological distress. These findings emphasize the importance of occupational stress management interventions to decrease the risk of developing mental health problems among the medical staff during a biological disaster.

A Systematic Review of the Impact of Viral Respiratory Epidemics on Mental Health: An Implication on the Coronavirus Disease 2019 Pandemic

Background: The twenty-first century viral respiratory epidemics have taught us valuable lessons. Our systematic review examined the impact of these epidemics, including coronavirus disease 2019 (COVID-19), on mental health among different population groups, drawing on their insights for recommendations for the current COVID-19 pandemic. Methods: Searches were performed on PubMed, Embase, PsycINFO, Web of Science, Scopus, CINAHL, and Cochrane on April 4, 2020. Studies that had undefined mental health outcomes or did not use a validated scale for measure were excluded. Quality assessment was carried out via the Newcastle-Ottawa Scale. Results: We included 95 studies, most of which were conducted in Hong Kong (31.6%) and China (21.4%). A total of 30 (30.9%) studies are on the general public, 41 (42.2%) on healthcare workers, and 26 (26.6%) on patients and quarantined individuals. Furthermore, 36 (37.1%) of the studies are of high quality, 48 (49.5%) are of moderate quality, and 13 (13.4%) are of low quality. The most significant mental health outcomes reported include anxiety, depression, and post-traumatic stress disorder symptoms. The subgroups identified to have a higher risk of psychiatric symptoms among the general public include females, the elderly, individuals with chronic illness, migrant workers, and students. Long-term mental health impact was reported in some healthcare workers and epidemic patients, even up to 3 years in the former. Interestingly, when compared to non-quarantined groups, quarantine was not significantly associated with worse mental health outcomes. Conclusion: Important implications for the COVID-19 pandemic were highlighted. Respiratory epidemics pose a significant psychological morbidity onto many population groups. Psychological support for vulnerable groups, including healthcare workers and patients, should be implemented to prevent them from spiraling into clinical psychiatric conditions.

Establishing research priorities to improve the One Health efficacy of Australian general practitioners and veterinarians with regard to zoonoses: A modified Delphi survey

While general medical practitioners (GPs) and veterinarians are often the first line responders in the face of a disease outbreak, pathways to improving the One Health efficacy of these clinicians remain unclear. A two-phase modified Delphi survey of professionals with known expertise in One Health (‘expert panel’) was used to 1) identify key knowledge, attitudes and practices (KAPs) of GPs and veterinarians that would be consistent with a One Health approach to zoonoses; and 2) determine priorities for future surveys with Australian GPs and veterinarians to identify important gaps that impede effective diagnosis and management of zoonoses. A list of 13 topics/sub-topics, as well as a list of 25 specific zoonotic diseases/agents emerged from the first phase of the survey. In the second phase the expert panel identified general knowledge of the clinical aspects and epidemiological aspects of zoonoses, as well as risk management practices, as the most important KAPs and research priorities for both GPs and veterinarians. In terms of diseases, the expert panel regarded knowledge of Hendra virus, Q fever, Australian bat lyssavirus (ABLV), anthrax and Brucella suis most important for veterinarians, whilst for GPs, Q fever, gastrointestinal/foodborne diseases, influenza, ABLV and local vector-borne diseases were found to be most important by the expert panel. Some differences were noted in terms of prioritization of topics/sub-topics and diseases/agents according to expert background (veterinary and non-veterinary). The Delphi survey technique enabled efficient collection of data from a diverse range of One Health ‘experts’/specialists and provided clear priorities for proposed future research, and potentially for educational interventions to improve One Health efficacy of clinicians.

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Delphi survey identified research priorities to improve One Health efficacy of clinicians.

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Top priority: GP and veterinarian knowledge of clinical aspects, epidemiology and risk management of zoonoses.

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Top 5 diseases for veterinarians: Hendra, ABLV, Q fever, anthrax and B. suis.

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Top 5 diseases for GPs: Q fever, GI/foodborne diseases, influenza, and local vectorborne diseases.

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Participants with veterinary background prioritised collaboration and referral.

Facing the threat of influenza pandemic - roles of and implications to general practitioners

The 2009 pandemic of H1N1 influenza, compounded with seasonal influenza, posed a global challenge. Despite the announcement of post-pandemic period on 10 August 2010 by theWHO, H1N1 (2009) virus would continue to circulate as a seasonal virus for some years and national health authorities should remain vigilant due to unpredictable behaviour of the virus. Majority of the world population is living in countries with inadequate resources to purchase vaccines and stockpile antiviral drugs. Basic hygienic measures such as wearing face masks and the hygienic practice of hand washing could reduce the spread of the respiratory viruses. However, the imminent issue is translating these measures into day-to-day practice. The experience from Severe Acute Respiratory Syndrome (SARS) in Hong Kong has shown that general practitioners (GPs) were willing to discharge their duties despite risks of getting infected themselves. SARS event has highlighted the inadequate interface between primary and secondary care and valuable health care resources were thus inappropriately matched to community needs.

There are various ways for GPs to contribute in combating the influenza pandemic. They are prompt in detecting and monitoring epidemics and mini-epidemics of viral illnesses in the community. They can empower and raise the health literacy of the community such as advocating personal hygiene and other precautious measures. GPs could also assist in the development of protocols for primary care management of patients with flu-like illnesses and conduct clinical audits on the standards of preventive and treatment measures. GPs with adequate liaison with public health agencies would facilitate early diagnosis of patients with influenza.

In this article, we summarise the primary care actions for phases 4-6 of the pandemic. We shall discuss the novel roles of GPs as alternative source of health care for patients who would otherwise be cared for in the secondary care level. The health care system would thus remain sustainable during the public health crisis.

What Australians know and believe about bird flu: results of a population telephone survey

The avian influenza A (A/H5N1) virus has attracted the attention of governments and health organizations throughout the world because of its pandemic potential. Despite the emerging nature of A/H5N1, there is limited research on public knowledge and perceptions of this disease. This study is based on a computer-assisted telephone interviewing survey conducted in May 2006 to determine the Australian public's knowledge of A/H5N1, their willingness to engage in preventive behaviors, and their acceptance of potential messages for communication campaigns. Awareness and concern about bird flu is low (lower than a recent survey of U.S. residents). There appears to be widespread support for bird flu control measures initiated by the federal government, although less agreement regarding personal protective behaviors. Our study and those examining the severe acute respiratory syndrome epidemic suggest that governments, including the Australian government, will encounter a number of significant communication challenges in the event of a bird flu outbreak.

The SARS (Severe Acute Respiratory Syndrome) pandemic in Hong Kong: effects on the subjective wellbeing of elderly and younger people

OBJECTIVES

This study examined the impact of the Severe Acute Respiratory Syndrome (SARS) outbreak in Hong Kong in 2003, on the subjective wellbeing (SWB) of elderly people and a younger comparative sample. The Personal Wellbeing Index (PWI), a contemporary instrument employed to measure SWB, was also examined for its psychometric performance to substantiate its use.

METHOD

A total of 302 older adults (age 65 + years) and 158 younger adults (age 35-46 years) were recruited from different districts. Data were collected by individual face-to-face interviews.

RESULT

While elderly people living in severely infected districts showed significantly lower levels of SWB, these levels and those of the younger sample were found to remain within the normative range. A major mitigating factor was an increased sense of community-connectedness. Other characteristics linked to low wellbeing levels included chronic illness, female gender, low education and unemployment. The living districts, characterized by varying extents of infection, had stronger associations with SWB than participants' age. The PWI demonstrated good psychometric performance and also more robustness with elderly people, including its sensitivity to the sense of population threat.

CONCLUSION

Psychological resilience was identified among both the elderly and younger age-groups in Hong Kong during the SARS pandemic. The PWI is verified as a suitable instrument for SWB measurements.

General practice: professional preparation for a pandemic

General practice will play a key role in both prevention and management of an influenza pandemic. Australian pandemic plans acknowledge a role for general practice, but there are few published data addressing the issues that general practitioners and their practices will face in dealing with such a crisis. The outcome will revolve around preparation in three key areas: Definition of the role of general practice within a broad primary care pandemic response, and adequate preparation within general practices so they can play that role well. Planning exercises and forums must include GPs, and rehearsals must include practical experience for general practices and their staff. Local Divisions of General Practice and GP practices can advocate for this, can define their role, and can prepare by using pandemic preparedness checklists; Definition and enactment of communication strategies to facilitate transfer of useful clinical and administrative data from practices and rapid dissemination of information into the community via general practice; Resource provision, which should be centrally funded but locally distributed, with personal protective equipment, vaccines and antivirals readily available for distribution. Resources must include support for human resource management to ensure appropriate health care professionals reach areas of workforce demand. Administrative, clinical and financial resources must be available to train GPs and practices in pandemic awareness and response.

Australian general practice and pandemic influenza: models of clinical practice in an established pandemic

To minimise the health impact of pandemic influenza, general practice will need to provide influenza-related and non-influenza primary health care, as well as contribute to the public health goal of disease control. Through interviews and workshops with general practitioners, nurses and policy leaders between March and July 2006, and literature analysis, we identified potential models of general practice in an established pandemic, and assessed their strengths and weaknesses. Three possible clinical models were identified: a default model of no change to service delivery; a streamed services model, where general practices reorganise themselves to take on either influenza-specific care or other clinical services; and a staff-determined mixed model, where staff move between different types of services. No single model or set of strategies meets the needs of all general practices to deliver and sustain the essential functions of primary health care during an established pandemic. Governments, general practice and the relevant peak professional bodies should decide before a pandemic on the suite of measures needed to support the models most suitable in their regions. Effective participation by general practice in a pandemic requires supplementary infrastructure support, changes to financial and staffing patterns, a review of legislation on medicolegal implications during an emergency, and intensive collaboration between general practices.

How to provide an effective primary health care in fighting against severe acute respiratory syndrome: the experiences of two cities

Objectives

This study was designed to compare the response and management of severe acute respiratory syndrome (SARS) by the family physicians of the Hong Kong and the Toronto health systems, and to provide evidence to improve health policy and practices in a newly emerging infectious disease.

Methods

A questionnaire was sent to family medicine tutors affiliated with either the Chinese University of Hong Kong or the University of Toronto in 2003. The survey questions covered training for SARS, the use of screening tools, an anxiety scale, clinical practices, and demographic data.

Results

137 (74.8%) and 51 (34%) doctors from Hong Kong and Toronto replied to the questionnaire, respectively. Most (80-84.6%) had no training in infectious disease control and were not confident in dealing with SARS (68.1-73.5%). In Hong Kong, the screening tools provided by international agencies did not meet the local needs. In Toronto, lack of a centralized hospital admission policy and fully public laboratory probably resulted in appointment cancellation and dissatisfaction. There may be a need for deployment of personnel between institutions but loss of income was not a major concern.

Conclusions

Sharing the “lessons learned” in different regions during a SARS outbreak will help prepare for the next epidemic.

Primary care physicians in Hong Kong and Canada--how did their practices differ during the SARS epidemic?

BACKGROUND

Hong Kong and Canada have very different primary health care systems. We thus hypothesized family physicians between the two places would be different in how they protected themselves, their staff and families during the epidemic.

OBJECTIVE

The purpose of this study was to explore and contrast the impact of SARS on family physicians in Hong Kong and Toronto.

METHODS

A postal questionnaire was designed and sent to 183 tutors affiliated with the Chinese University of Hong Kong with 137 replies (74.8%). In Toronto, 150 questionnaires were sent to academic family physicians affiliated with the University of Toronto with 51 replies (34%).

RESULTS

All agreed SARS had changed their clinical behaviour. For public health measures in the control of SARS, Hong Kong physicians were less likely to quarantined themselves (77.1% versus 19.4%, P < 0.01) or gave quarantine leave to staff (95% versus 59.7%, P < 0.01) after exposure to probable or suspected SARS. However, they were more likely to wear a mask (52.7% versus 97.7%, P = 0) during consultation, having support staff to wear masks (68.6% versus 97.8%, P = 0) and test patient's temperature (47.1% versus 68.1%, P < 0.01).

CONCLUSION

There were noticeable differences in how family physicians deal with SARS between the two cities. As SARS emerged as a global disease, better understanding of practice differences among physicians from different countries would facilitate globalization of public health.

Longitudinal assessment of community psychobehavioral responses during and after the 2003 outbreak of severe acute respiratory syndrome in Hong Kong

BACKGROUND

In previous literature, the stability and temporal evolution of psychobehavioral responses to an outbreak remained undefined, because of the exclusively cross-sectional nature of such study designs.

METHODS

Using random-digit dialing, we sampled 4481 Hong Kong residents in 6 population-based surveys that were conducted at different times during and after the 2003 outbreak of severe acute respiratory syndrome (SARS).

RESULTS

Respondents' State-Trait Anxiety Inventory score (range, 10-40) showed a decreasing temporal trend, from a high mean value of 24.8 during the peak of the Amoy Gardens outbreak to a postepidemic mean baseline value of 14.5. Those who perceived a higher likelihood of contracting or dying of SARS had significantly higher anxiety scores. Female respondents, individuals aged 30-49 years, and individuals with only a primary education or less were predisposed to greater anxiety. There was a positive dose-response gradient between anxiety level and uptake of personal protective measures. Males respondents, individuals at the extremes of age, and individuals with lower educational levels were less likely to engage in self-protective behavior. The presence of symptoms was the only consistent predictor for greater use of health services. There was remarkable stability in the magnitude and the direction of associations between predictors and outcomes over time.

CONCLUSIONS

Our findings can assist in modifying public service announcements in the future, which should be tailored to psychobehavioral surveillance intelligence to achieve the desired behavioral outcomes. Future research should explore the use of more-sophisticated techniques, including structural equation modeling and game-theoretical frameworks, to analyze population psychology and behavior, and it should integrate such findings with transmission dynamics modeling.

Post-SARS infection control in the hospital and clinic

The recent severe acute respiratory syndrome (SARS) outbreak has almost mandated a re-evaluation of infection control practices in hospitals, clinics, schools and domestic environments, especially for patients with respiratory tract symptoms. Triage, early case detection followed by prompt isolation and quarantine are major preventive measures. Respiratory tract infections are the most common childhood illnesses and paediatric SARS poses special problems in diagnosis because of its non-specific presentation. The main lessons learnt from the outbreak were: (1) despite well established guidelines on infection control precautions, poor understanding of underlying principles and deficiencies in compliance are common among healthcare professionals, especially during emergencies; (2) even a slight lapse can be fatal; and (3) over-protection can be counterproductive. Hence it is important to: (1) be protected to protect others; (2) be vigilant and prepared for emerging infections; (3) be proficient and scrupulous in infection control measures; (4) be apposite and practical on personal protective equipments to ensure sustainability; and (5) be dutiful and prompt in informing of potential threats and work closely with others.

Emotional and behavioral consequences of bioterrorism: planning a public health response

Millions of dollars have been spent improving the public health system's bioterrorism response capabilities. Yet relatively little attention has been paid to precisely how the public will respond to bioterrorism and how emotional and behavioral responses might complicate an otherwise successful response. This article synthesizes the available evidence about the likely emotional and behavioral consequences of bioterrorism to suggest what decision makers can do now to improve that response. It examines the emotional and behavioral impact of previous "bioterrorism-like" events and summarizes interviews with experts who have responded to such events or conducted research on the effects of community-wide disasters. The article concludes by reflecting on the evidence and experts' perspectives to suggest actions to be taken now and future policy and research priorities.