Stress, Depression, Anxiety and Willingness to Seek Help of Healthcare Workers in the COVID-19 Pandemic
Article information
Abstract
Background and objective
Although the serious stage of the COVID-19 pandemic has passed, the consequences are not only socio-economic but also affect the mental health of many people, in which healthcare workers tolerate the fiercest and longest-lasting consequences compared to other social groups in the community. This study aims to explore the status of healthcare workers’ mental health and evaluate their capacity to effectively manage mental health issues in the context of the COVID-19 pandemic. Particularly, it explores the relationship between depression, anxiety, and stress (DASS) scale and seeking help from healthcare workers.
Methods
The study was conducted from April 2022 to August 2022, using an online survey of 638 healthcare workers working at two frontline hospitals in Ho Chi Minh City, Vietnam. It was undertaken at two hospitals in Ho Chi Minh City (i.e., Cho Ray Hospital and the COVID-19 Resuscitation Hospital), facilitated through the social work departments of these hospitals.
Results
The result shows that the majority of medical staff faces various mental health problems from mild to severe, with different degrees of severity, depending on the individual’s psychological characteristics, gender, education level, and work position. The study also revealed a correlation between help-seeking attitudes and symptoms of depression, anxiety, and stress. It shows that only a minority of healthcare workers have the attitude demonstrated a willingness to seek help and request assistance from psychologists when experiencing mental health issues.
Conclusion
Policymakers should prioritize regular awareness campaigns during the initial phases of a pandemic to enhance motivation, knowledge, and preventative measures among healthcare workers. This approach can help identify mental health issues early and reduce the stigma of seeking support. Encouraging group psychotherapy and addressing cultural barriers in the medical field can increase trust in therapists and psychiatrists, improving overall mental well-being.
Introduction
In December 2019, the Chinese city of Wuhan experienced the start of the COVID-19 epidemic, which quickly spread throughout the world. Although vaccines have been developed, outbreaks continue to occur on a global scale. Since the fifth epidemic in May 2021, the number of infections has significantly increased in Vietnam, along with the highest death rate, especially in Ho Chi Minh City and its neighboring provinces (i.e., Binh Duong Province, Dong Nai Province). Many provinces and localities have implemented social distancing and medical isolation measures due to the on-going rise of COVID-19 cases. From May 2021 until November 2021, Ho Chi Minh City had citywide social distancing measure in place. Social exclusion, the closing of businesses and schools, and the increase in patient numbers have all contributed to severe effects and crises in all facets of socioeconomic life, including noticeably the mental health issues experienced by the citizens of the City.
The COVID-19 outbreaks have been demonstrated to pose a significant threat to the well-being of healthcare workers. These individuals are not only at an elevated risk of COVID-19 exposure but also endure adverse consequences for their mental health, such as depression, stress, and insomnia (Shaukat & Razzak, 2020). Previous research has shown that the detrimental influence of COVID-19 on the mental health of healthcare workers exposes them to substantial physical and psychological distress, leading to a decline in work motivation (Chirico et al. et al., 2021). Over the long term, these negative impacts can put pressure on the healthcare system’s capacity to deliver services to the community, both during the pandemic and post-pandemic periods.
Healthcare professionals consider social support, including support from family, friends, and colleagues, as a significant protective element in their efforts to manage mental health challenges (Muller et al., 2020; Nguyen et al., 2021). More specifically, workers in the healthcare sector frequently employ methods like engaging in conversations and telecommunication with their colleagues, friends, and family members to garner motivation and resilience in the face of mental health difficulties caused by the COVID-19 pandemic (Cai et al., 2020; Cao et al., 2020; Louie et al., 2020; Mohindra et al., 2020; Sun et al., 2021). Additionally, the pursuit of informal professional assistance is a strategy commonly considered by healthcare workers to address mental health issues. In particular, they may turn to professional psychologists for aid, seeking services such as counseling and psychotherapy, or they may explore available resources and psychological support through other online communication channels, such as: Wechat and Tiktok (Cai et al., 2020; Kang et al., 2020; Liu et al., 2020; Zhang et al., 2020). Applying self-care strategies is another effective approach to overcoming mental health problems. During the COVID-19 pandemic, healthcare workers actively engage in psychological protective mechanisms, such as meditation, and adjusting life habits to sleep, exercise, and follow a nutrition diet to enhance their overall well-being and better manage mental health issues (Muller et al., 2020). Furthermore, they actively searched for personal protective equipment for their therapeutic and patient care practices, deeming it highly significant in minimizing workplace exposure and, consequently, reducing the risk of mental health complications (Chen et al., 2020; Chung and Yeung, 2020). Healthcare workers also actively pursue training courses to enhance their knowledge of COVID-19 (Kisely et al., 2020). The research mentioned above findings emphasize the urgent need for a comprehensive formulation of strategies to address mental health concerns within the context of the COVID-19 pandemic. However, current research has predominantly focused on the therapeutic approaches embraced by healthcare professionals for addressing their mental health challenges.
The study of Menwell et al (2015) explored the core concept of mental health. The study drew on discussions of 58 clinical experts (with all their working experiences) from 8 countries around the world. 46% of experts agree with the concept of mental health of Public Health Agency Canada (PHAC) published in 2006; 20% agree with the WHO concept and the remaining 34% agree with 4 other mental health concepts. It becomes apparent that the term “mental health” presents a challenge in achieving a universally agreed-upon and precise definition, as Dang et al (2022) stated that: “Mental health is the successful performance of mental and emotional functions, resulting in productive activities, successful interpersonal relationships, and the ability to adapt to changes and cope with adversity.” In alignment with the theory proposed by the author group led by Dang et al ( 2022), the American Mental Health Government Organization (Mental Health GOV), operating under the United States Department of Health and Human Services, defines: “Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we manage stress, relate to others, and make healthy choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood”. Simultaneously, the criteria for mental disorders in the study conducted by Pastel (2003) include somatic symptoms, emotional symptoms, (typically characterized by feelings of sadness or fear) as well as cognitive, behavioral and perceptual symptoms.
Stress can be defined as a state of worry or mental tension caused by a difficult demanding situation (WHO, 2023). It is a natural human response that prompts us to address challenges and threats in our lives to a certain degree. The way we respond to stress, however, largely affects our overall well-being. Stressors can cause cognitive, attitudinal and behavioral disturbances that consequently affect one’s life organization (Dang et al., 2022; Pham, 2020; Nguyen et al, 2019). The categorization of stress types varies based on several factors, including duration (acute stress and chronic stress), nature (positive stress, negative stress, and neutral stress), and stages (the alarm stage, the resistance stage, and the exhaustion stage) (Dang et al., 2022; Pham,T., 2020). In this study, we will adopt the WTO’s definition of stress and pay particular emphasis on Dang et al.’s (2022) delineation of the exhaustion stage. This stage refers to a scenario where an individual is challenged with an overwhelming stressor, making them incapable of an immediate response, leading to a physical or mental breakdown.
According to the American Psychology Association (APA) (2013), depression refers to an adverse emotional state that ranges from general unhappiness and dissatisfaction to the experience of profound sadness, pessimism, and hopelessness, significantly disrupting daily life. Many physical, cognitive, and social changes also tend to occur simultaneously, including alternations in sleep and dietary patterns changes in eating and sleeping patterns, a decrease in energy and motivation, impairments in cognitive functions difficulties in (concentration and decision-making), and a withdrawal from social engagement. Symptoms of depression are specified according to the diagnostic criteria of the DSM IV TR as: persistent sadness, loss of interest, appetite changes, sleep disturbances, lack of energy and activity, feelings of worthlessness and guilt, cognitive impairments, suicidal thoughts, and self-harm tendencies.
According to the definition of APA (2013), anxiety is considered as one of the fundamental human emotions. Typically, it occurs when there is a perception of impending danger or the anticipation of a highly unpleasant and challenging situation. Anxiety is an emotional stage characterized by stress, anxious thoughts, and physiological changes like elevated blood pressure. Generalized Anxiety Disorder (GAD) often involves persistent and overwhelming feelings of anxiety or fear that can disrupt daily life. It goes beyond occasional worries, or the anxiety associated with stressful life occasions. Individuals diagnosed with GAD commonly experience prolonged periods of anxiety, spanning months, if not years (APA, 2013; DSM IV-TR). The symptoms of GAD may include restlessness, agitation, or irritability, easily fatigued, difficulty maintaining focus or concentration, heightened irritability, negative physical symptoms like headaches, muscle aches, abdominal discomfort, or unexplained pains, difficulty managing anxiety, sleep disturbances, encompassing difficulties falling asleep or staying asleep.
The Health Protection Surveillance Center (2023) in Ireland defines: “A health and care worker is anyone who works in a healthcare or social care setting, including healthcare and care students on clinical placement, frontline healthcare & care workers, and other healthcare or care workers not in direct patient contact.” Likewise, Joseph & Joseph (2016) also provide the following definition: “A healthcare worker delivers care and services to the sick and ailing either directly as doctors and nurses or indirectly as aides, helpers, laboratory technicians, or even medical waste handlers.”. This can be explained as reinforced in a study on the mental health of healthcare professionals conducted by the American Mental Health Organization (MHA) in 2020. Among the 1,119 healthcare workers who took part in the survey, merely 7.24% were physicians, while the remaining participants comprised various healthcare personnel, including medical staff, nurses, physiotherapists, X-ray technicians, office staff, and even caregivers involved in food service.
According to the document “Supporting the Mental Health of the Health Workforce and Other Essential Workers” (2021) by the European Union (EU) risk factors and protection in response to the mental health of healthcare workers is one of the complex concepts. Specifically, risk factors refer to elements that increase the vulnerability to healthcare worker’s mental health in the context of COVID-19. In contrast, protective factors are those that protect and aid in recovery from stressors, safeguarding the mental well-being of healthcare workers against the adverse effects brought about by the global COVID-19 crisis, including stress, anxiety, depression, and PTSD. Both risk and protective factors in the mental health response of healthcare workers can be categorized into key factors such as demographic characteristics, role, occupation, intrinsic work factors, control factors, relationships, and career environment.
This study aims to find the self-evaluated mental status of mental of healthcare workers and how they cope with depression, anxiety, and stress during and after the pandemic. The study firstly figures out the scale of depression, anxiety, and stress (DASS). Then the study explores the attitude of healthcare workers towards seeking psychological assistance. Finally, it discovers the relationship between the level of DASS and willingness to seek help from mental health professionals.
Research Methods
This research was conducted from April 2022 to August 2022 with the aim of providing a detailed overview of the mental health status of healthcare workers and evaluating their capacity to effectively manage mental health issues under the extraordinary conditions of the Covid-19 pandemic.
This research was undertaken at two hospitals in Ho Chi Minh City (i.e., Cho Ray Hospital and the COVID-19 Resuscitation Hospital), facilitated through the social work departments of these hospitals. The selection of participants for the study was conducted using a convenience sampling method at the aforementioned two hospitals. The official survey sample consisted of 638 medical staff members who are employed full-time at the hospital, ranging in age from 21 to 63 years of service, with tenure in their current positions from 1 to 42 years. Survey questionnaires were distributed to healthcare workers through the assistance of the hospital’s social workers, allowing participants to complete them during their breaks. Additionally, in-depth interviews and group discussions were and used as supplementary data collection methods based on the actual circumstances (Table 1).
Demographic attributes of the study participants
This study uses several research methods including secondary data analysis, online questionnaire, and psychological tests and statistical analysis. The questionnaire in the study consists of 3 main parts. Part 1 is the demographic information. Part 2 is Livibond’s scale of depression, anxiety and stress (DASS-21) scale (1995) shortened from DASS-42. DASS-21 has been translated into Vietnamese and evaluated for validity and validity on 221 women, applied in many studies in adolescents and adults according to research by Tran et al. (2013). Part 3 is the scale “Attitudes Toward Seeking Professional Psychological Help Scale” used according to the Vietnamese version of Nguyen (2020), to find out and clarify whether healthcare workers seek help from psychologists as one of the ways to cope with mental health problems health such as stress, anxiety, depression. This scale is based on 4 four factors including awareness of the need for psychotherapeutic help, ability to withstand prejudice related to mental health, openness to people about mental health issues, spirit, and faith in mental health professionals.
The Depression, Anxiety and Stress Scale-21 Items (DASS-21) is questionnaire consisting of 21 items to assess the level of depression, anxiety and stress. Survey participants will rate their own emotional level through 21 items on a scale of 0 to 3 with a score of 0 = Did not apply to me at all; 1= Applied to me to some degree; 2 = Applied to me to a considerable degree or a good part of the time; 3 = Applied to me very much or most of the time. The scoring method on this scale is calculated by adding the scores of the component items, and then multiplying the factor by 2 for the final score.
Attitude scale for seeking help from psychologists used according to the Vietnamese version of Lena Nguyen (2020) is divided into 4 factors. All questions are rated on 4-point Likert-type scale: 0 = Strongly Disagree; 1 = Disagree; 2 = Agree; 3 = Strongly Agree.
1) Factor I: Ability to recognize the need for psychotherapeutic help ( items 4, 5, 6, 9, 18, 24, 25, 26). The higher the total score, the more obvious the need and vice versa, in which there a re 3 inverse items of 4, 6, 9 will be exchanged points when calculating reliability, validity and average score of the scale.
2) Factor II: Ability to tolerate prejudice related to mental health (3, 14, 20, 27, 28). The higher the total score, the lower the ability to accept the prejudice (of which there are 2 inverse points of 27, 28 will be changed points when calculating the reliability, validity and average score of the scale).
3) Factor III: Willingness to share about mental health issues (7, 10, 13, 17, 21, 22, 29). The higher the total score, the lower the willingness (in which an inverse item of 7 will be exchanged for reliability, validity, and scale mean).
4) Factor IV: Trust in mental health professionals (1, 2, 8, 11, 12, 15, 16, 19, 23). The higher the total score, the greater the trust in the doctors (in which there are 5 inverse items of 2, 11, 12, 16, 23 that will be changed when calculating the reliability, validity and average score of the scale).
Results and Discussion
Stress, anxiety and depression scale of healthcare workers
Based on the findings presented in Table 2, which employs the DASS-21 scale for evaluating the degrees of depression, anxiety, and stress experienced by healthcare workers during the COVID-19 pandemic, the majority of healthcare personnel self-reported their mental health status to be within the ‘normal’ level. Specifically, the proportions of healthcare workers reporting ‘normal’ levels of depression, anxiety, and stress were 55.5%, 48.3%, and 69.7%, respectively. This proves that the mental resilience of a majority of healthcare workers remains intact within the ‘normal’ range, enabling them to effectively function under elevated levels of stress, particularly in the challenging context of the pandemic.
Current status of stress, anxiety, and depression among healthcare workers
Overall, healthcare workers reported “Mild” to “Extremely severe” depression is 44.6%, of which 13% of medical staff experienced mild depression while moderate, severe and extremely severe levels were reported by 21.2 %, 4.1% and 6.3%, respectively Healthcare workers experienced symptoms of anxiety is 51.7%, includes at mild (8.6 %), moderate (22.9%), severe (8.9%), and extremely severe levels (11.3%). In addition, the rate of stress among medical staff at mild level accounted for 30.2%, including 12.1%, moderate level accounted for 7.5%, severe level accounted for 7.8%, and extremely severe level accounted for 2.8%.
The above survey results show the similarity of mental health problems reported by healthcare workers in Ho Chi Minh City with the mental health status of healthcare workers around the world in the context of COVID-19 pandemic. For example, in the meta-analysis of Salazar de Pablo et al (2020) with 115 articles published globally, there are surprising data. The results show that 62.5% of healthcare workers worldwide have common health problems. In particular, in terms of mental health, the results also show that 43.7% (n=584) related to fear, 37.8% (n=24346) were associated with stress, 37.9% (n= 5067) with insomnia, 29% (n=9191) with anxiety, 26.3% (n=9893) with depression; 27% with PTSD (n=3826). A multinational study was conducted by Nicolaou et al (2021) with 1,556 healthcare workers from 78 countries/territories with 18 different languages. The results of this study indicate that almost half (51.8%) of healthcare workers have sleep problems (sleeping less than 4 hours) and suffer from stress, depression or anxiety.
Current situation of the attitude of healthcare workers towards seeking psychological assistance
The results of the survey on the willingness of medical staff to seek help from psychologists in the context of the Covid-19 in Ho Chi Minh City (Table 3) showed that the majority of healthcare workers spontaneously self-rated ““disagree” with all four components representing an attitude to seek help from a psychologist (the component “Ability to recognize the need for psychotherapeutic help” with M = 1.33 and SD = 0.77; the component “Trust in psychiatrists” with M = 1.33 and SD = 0.75). This shows that the awareness of the need for help of the medical staff and the trust in the mental health doctors are equivalent. That is, the two factors above tend to be proportional to each other, the higher the awareness of the need for help, the higher the trust in professional support (psychiatrist) and vice versa.
The mean scores and deviations of the factors representing willingness to seek help from psychologists
In addition, the healthcare workers self-rated “disagree” about the “Ability to tolerate prejudices related to mental health” with M = 1.20 and SD = 0.80. The same goes for “Willingness to share about mental health issues” with M = 1.16 and SD = 0.79. Research results of She et al. (2021) also found that only 12.7% healthcare workers found professional psychiatric help during the COVID-19 outbreak. Among healthcare professionals, the tendency to seek psychiatric assistance was more pronounced among individuals of advanced age, those with a higher frequency of overnight shifts, individuals with a background in psychological training, those who perceived greater levels of social support, as well as those who exhibited symptoms of depression and anxiety. Conversely, healthcare workers working at the Centers for Disease Control and Prevention displayed a reduced likelihood of seeking psychiatric support. Mental health problems are not a priority (64.4%), Lack of time (56.4%), and Lack of psychologists (32.7%) were the most commonly advocated reasons for not seeking help.
Relationship between symptoms of stress, depression, anxiety and the willingness of medical staff to seek help from psychologists
To examine the close linear correlation between healthcare workers’ attitudes towards seeking help from experts and their mental health, Pearson correlation analysis using SPSS 20.0 was conducted with a significance level of 95% confidence interval for the estimated correlation coefficient. The study’s results evaluated the strength/weakness of the correlation between “attitudes towards seeking help from healthcare professionals” and “mental health” through the absolute value of r. According to Andy Field (2009), the interpretation is as follows: |r| < 0.1: very weak/insignificant correlation; |r| < 0.3: weak correlation; |r| < 0.5: moderate correlation; |r| ≥ 0.5 indicates a strong correlation.
The results from Table 4 indicate a strong correlation between general help-seeking attitudes and mental health with r = .597**. Specifically, factors such as “The trust in psychiatrists,” “The ability to tolerate prejudices related to mental health,” “The willingness to share about mental health issues,” and “The ability to recognize the need for psychotherapeutic help” exhibit correlation coefficients (r) ranging from r = .409** to r = .503**, indicating a moderate level of correlation.
Pearson correlation coefficient (r) between symptoms of mental health (stress, depression, anxiety) and attitude to seek help from psychologists of healthcare workers
However, in considering each specific mental health symptoms, the results indicated weak positive correlations between the general attitude of seeking assistance from psychologists and stress (r = .230**), depression (r = .323**), and anxiety (r = .330**). In terms of stress, there is no correlation with ‘The ability to recognize the need for psychotherapeutic help’ and ‘The willingness to share about mental health issues’ (r = .124; r = .119) or an insignificant correlation with ‘The trust in psychiatrists’ (r = .143*). Regarding depression, the results also indicate that the correlation between depression and ‘The ability to recognize the need for psychotherapeutic help’ is insignificant (r = .190**).
This indicates that as mental health issues escalate, healthcare professionals seem to demonstrate a more proactive attitude in seeking help from mental health experts, wherein they prioritize recognizing the need for psychotherapeutic assistance and also seem willing to share about their mental health concerns. The impact of mental health concerns varies for each individual, influenced by some factors such as gender, educational attainment, and professional position. Consequently, each healthcare worker tends to develop their own coping strategies. With certain individuals demonstrating “normal” levels of stress, anxiety, or depression, they can manage the stress through mechanisms like taking time off, engaging in physical exercise, or dedicating personal time for relaxation. Simultaneously, when resolving mental health issues, aside from the individual’s personal coping strategies, the willingness to seek assistance from healthcare professionals plays a significant role in helping medical staff regain balance during the on-going complexity of a pandemic.
Conclusion
In conclusion, within 638 healthcare workers, who willingly participated in the survey, reported that “Mild” to “Extremely severe” of depression is 44.6%, anxiety is 51.7%, and stress is 30.2%. The attitude of healthcare workers towards seeking psychological assistance shows that The higher the awareness of the need for help, the higher the trust in professional support (psychiatrist) and vice versa. There are positive correlations between depression – anxiety – stress and the ability to recognize the need for psychotherapeutic help, the ability to tolerate prejudices related to mental health, the willingness to share about mental health issues, the trust in psychiatrists, and general attitudes.
This proves that the mental resilience and fortitude of healthcare workers largely remain within an acceptable threshold. Nonetheless, the research outcomes show that a significant proportion of healthcare workers are facing a spectrum of mental health issues, ranging from mild to severe, with varying degrees of severity.
The study’s findings also demonstrate a positive correlation between factors such as awareness, tolerance, receptivity, and trust in mental health practitioners and the anxiety and stress symptoms. In other words, as stress symptoms develop, the attitude to request assistance from a psychologist tends to increase. However, it is worth noting that the symptoms of depression among health care workers were not correlated with the desire of seeking help from psychologists. It implies that in addition to their willingness to consult professionals, these healthcare workers demand the support of qualified and skilled therapists to avoid self-destructive tendencies, particularly in cases of mild to extremely severe depression.
To date, studies have primarily relied on cross-sectional surveys which investigated the scope and repercussions of the pandemic on the mental well-being of healthcare professionals. Regrettably, there has been a lack of longitudinal or multi-temporal assessments of psychotic symptoms and the factors affecting healthcare workers, especially in HCMC. Moreover, studies have not systematically investigated the attitude of seeking help from psychologists with the mental health of healthcare workers. The cause-and-effect relationship between these two factors has also remained unexplored. Hence, there is a pressing need for systematic, multi-temporal assessments and an exploration of the causal relationship between levels of DASS and the willingness of healthcare personnel to seek help from mental health professionals. This vital research is not only valuable within the Vietnamese research landscape but also holds significance in the current global research context.
Furthermore, in the future policymakers should prioritize the implementation of regular awareness campaigns during the initial phases of a pandemic. These campaigns could enhance motivation and knowledge, subsequently improving preventative measures and encouraging healthcare workers to seek assistance when needed. This approach can contribute to the early identification of mental health issues among healthcare workers, then reducing the stigma attached to themselves when seeking support for their mental well-being. Health professionals are encouraged to consider group psychotherapy rather than individual therapy sessions. Notably, a reduced inclination to seek individual assistance is correlated with a decreased inclination to make referrals. Addressing cultural and practice barriers in the medical field are necessary to increase trust in therapists and psychiatrists among healthcare workers.