An exploration of psychological distress and stigma in frontline workers amidst COVID-19 from Andhra Pradesh, India

the of various pandemics on the human with association to psychological distress.


INTRODUCTION
Across the globe, mankind has been battling an existential crisis with the coronavirus disease 2019 (COVID-19) pandemic, the first of its kind in the 21st Century. e last century has borne witness to the Spanish flu, severe acute respiratory syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Ebola which proved equally challenging from healthcare standpoint. Scientific literature notes that the impact of a pandemic is not only among afflicted patients but among frontline workers who face unprecedented circumstances whilst performing their duties. [1] Reports of a significant prevalence of mental health issues among the frontline workers have abounded amidst the booming literature during this pandemic, namely distress, burnout, insomnia, anxiety, depression, illness anxiety, posttraumatic stress disorder (PTSD) which is mediated by various biopsychosocial factors. [2] India began facing the full force of the pandemic from March 2021, with medico-socio-economic challenges. Apart from government measures to curtail the spread of the illness with nationwide lockdowns which in itself causes isolation and distress, rapid conversion of general hospitals to COVID-19 care centres occurred. Additionally, frontline workers were faced with reports of shortage of personal protective equipment (PPE) across the world while dealing with a highly contagious nature of illness, diverse clinical presentation, unrecognised asymptomatic and pre-symptomatic carriers, rapid spread, non-availability of specific antiviral treatment, high mortality rate, and possible sequelae. [3] e frontline healthcare workers (FHCWs) who work in active COVID-19 areas, with exposure to the confirmed and suspected COVID-19 cases are vulnerable to both high risks of infection and mental health issues. e most common psychiatric issues experienced by FHCWs include anxiety, posttraumatic stress symptoms, depressive symptoms, sleep disturbances, concern regarding contagion exposure to their friends and family, and stigma was additionally reported. [ OR OR OR OR OR OR OR OR OR ORIG IG IG IGIN IN IN INAL AL AL AL P P P PAP AP AP APER ER ER ER: RE RE RE RESE SE SE SEAR AR AR ARCH CH CH CH A A A ART RT RT RTIC IC IC ICLE LE LE LE  OR OR OR OR ORIG IG IG IGIN IN IN INAL AL AL AL P P P PAP AP AP APER ER ER ER: RE RE RE RESE SE SE SEAR AR AR ARCH CH CH CH A A A ART RT RT RTIC IC IC ICLE LE

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We aimed to study the psychological distress experienced among frontline workers in active COVID-19 duties in our state of Andhra Pradesh, India and also assess for stigma as a consequence of the job.

MATERIALS AND METHODS
e study is a cross-sectional, observational study designed at the PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India. Doctors, interns, and nurses involved in COVID-19 duties across the state of Andhra Pradesh who consented for the study and aged above 18 years were included in the study.
Acquisition of data occurred through online platform, namely a semi-structured questionnaire fashioned on Google forms, having attached to it an informed consent to be given electronically. e consent form explains the study to be anonymous, voluntary, the participant being allowed to drop out at any point, and that the data will not be used commercially and is meant only for scientific publication. Additionally, three other mandatory questions were: Are you a doctor/intern/nurse? Do you work in Andhra Pradesh? Are you involved in active COVID-19 duties? Only if the above along with consent being marked "yes" mandatorily, did the form proceed to subsequent pages or would stop recording, ensuring exclusion criteria. A semi-structured questionnaire with five close-ended questions, with "yes/no" response was used to explore stigma. Questions included were: anxiety/ fear to get COVID-19 evaluation, days taken to get tested a er onset of symptoms, fear to reveal COVID-19 symptoms, discrimination/shame at working in COVID-19 centre, displeasure faced from family/friends/neighbours when living among them. Tool used to measure psychological distress was the General Health Questionnaire (GHQ)-12. GHQ-12 scale is a free scale used worldwide in different segments of practice and research -clinical, epidemiological, and psychological;[4] GHQ-12 showed high internal reliability (Cronbach's alpha of 0.82) and acceptable criterion validity. GHQ-12 score cut-off was taken as 15 as statistically 15 was the mean and median value obtained.
Sample collection occurred by online means, specifically through Facebook and WhatsApp groups. Outreach to universal groups involving specialist doctors, postgraduates, interns, nursing staff posted in active COVID-19 duties across Andhra Pradesh and their participation formed the data.
e data was collected from the Google forms and method of sample collection was purposive. Data collection began on August 15th 2020 and ended on September 15th 2020. e study received clearance by the institutional ethics research board. A total of 321 FHCWs have filled the forms completely; 18 forms were incomplete and excluded.

Statistical analysis
e data was entered into Microso Excel 2007 version and further analysed using Statistical Package for the Social Sciences (SPSS) version 20. Descriptive statistics involved the categorical data being analysed using percentages. e continuous data was analysed using mean and standard deviation. Inferential statistics analysed included chi-square test and Fischer's exact test. A probability value of <0.05 was considered as statistically significant. Table 1 shows that out of 321 frontline workers, the significant majority of 86% was younger than 30 years, predominantly male (52.3%), and marital status being unmarried for Interestingly, the majority of the sample frontline workers revealed having suffered COVID-19-like symptoms following their COVID-19 duties (57.3%).

RESULTS
GHQ-12 scores measuring psychological distress were statistically significantly associated with age in our study at p=0.028 (Table 2). Interestingly, 87% of the respondents (148 out of 170) were found in younger age group of 21 to 30 years to have higher levels of distress (GHQ scores ≥15).
GHQ-12 scores measuring psychological distress were very significantly associated with marital status in this study at p=0.008 (Table 3). Here, elevated distress was found more in the unmarried (68% [115 out of 170]).
GHQ-12 scores were found significantly associated with development of COVID-19-like symptoms in this study at p=0.017 (Table 4). Majority of respondents (63.5% [108 out of 170]) who had experienced COVID-19-like symptoms also reported higher distress levels. Table 5 shows that among 321 frontline workers, majority (53%) reported being anxious about getting a COVID-19 evaluation done. 68.8% of the workers did not go for the COVID-19 test despite suffering COVID-19-like symptoms, followed by 15.5% presenting for testing only a er seven days of symptoms. Interestingly, 82.6% reported no shame in having worked in a COVID-19 centre, 72.3% reported never having felt afraid to report upper respiratory tract infection (URTI) symptoms in fear of negative reaction of others, and 82.2% reported no experience of family/friends/neighbours disliking them living among them post-completion of self-quarantine.
GHQ-12 scores were found highly significantly associated with the fear/anxiety about going for COVID-19 evaluation at p=0.0001 (Table 6). 68.8% of the respondents (117 out of 170) revealed elevated distress and reported positively for being anxious/fearful about going for COVID-19 evaluation.    Our study found GHQ-12 scores to be highly significantly associated with feeling discriminated/shameful while working in a COVID-19 centre at p=0.0001 (Table 7). e majority of the sample, 82.5% (265 out of 321) of the total respondents did not feel shameful/discriminated for working in a COVID-19 centre but among those reporting discrimination, majority 76.8% (43 out of 56) had higher distress levels.
Our study found GHQ-12 scores to be highly significantly associated with feeling afraid to reveal URTI symptoms fearing a negative reaction of others at p=0.0001 (Table 8). 27.7% (n=89) of 321 frontline workers felt afraid to reveal URTI symptoms fearing a negative reaction of others. Majority of those having elevated psychological distress were 53% (170 out of 321), of which 36.4% (n=62) felt afraid to reveal URTI symptoms fearing a negative reaction of others.
Our study found GHQ-12 scores to be very significantly associated with being disliked by family/friends/neighbours for living among them a er having completed self-quarantine period at p=0.001 (Table 9). 24.7% (42 out of 170) of respondents with higher GHQ-12 scores were disliked by the family/friends/neighbours for living among them although they have finished self-quarantine period post-COVID-19 duties.

DISCUSSION
is cross-sectional survey enrolled 321 respondents and our sample when compared to a study by Bennaoui et al. [5] had a similar profile of having more residents and interns than nurses and specialists, a similar age spectrum with our study including age less than 30 years predominantly and their study having average age of 29 years, but differed in terms of most being females and married as against our study having majority males and most being unmarried.
Our study revealed a high prevalence of psychological distress among healthcare workers exposed to COVID-19.   We found psychological distress was higher in 53% of the respondents in which 51.2% were females. is could be attributed to females being more susceptible to psychological distress when compared to males. Similarly, recent studies in China and Italy that assessed psychological distress post-COVID-19 outbreak found that females were more likely to develop psychological distress when compared to males. [6,7] is could be attributed to the gender differences in the hormonal response to stress. Young and Korszun [8] substantiated this evidence that female hormones amplify the magnitude of stress responses. is was in concordance with earlier study by Lai et al. [1] in China, on factors associated with mental health outcomes among healthcare workers exposed to coronavirus disease.
Working in the frontline was found to be an independent risk factor for poor mental health outcomes across spectrums of interest. e perceived stress levels were higher in nursing staff recording 77.7%, as compared to 70.6% of the postgraduates, 70.1% of the interns, 60% of the senior residents, and 65% of the consultants showing higher stress levels. Frontline nurses treating patients with COVID-19 are likely exposed to the highest risk of infection because of their close, frequent contact with patients and working longer hours than usual which lead to increased stress levels. Our results are in concordance with the study done by Khanam et al. [3] in India showing that when compared to doctors, the nurses experienced more stress in terms of feeling sad and pessimistic, the burden of change in the quality of work, stress due to colleagues testing positive, and worrying whether the family will be cared for in case anything untoward happens to them.
Bennaoui et al. [5] reported healthcare workers perceived lack of support from the hospital in 42%, fear of contaminating near and dear ones in 80%, being isolated, feelings of uncertainty and social stigmatisation in 43%. Bhattacharjee et al. [9] pointed out that in the Indian context, stigma was experienced by not just COVID-19 recoverees, nor only those afflicted by it, or presumptive cases or who have succumbed to it or their families. e brunt of social stigma was additionally faced by frontline workers, medical practitioners, nurses, police personnel, etc. Reports of being forced to leave the neighbourhood and denied access to their houses and the families were seen. ese aspects of societal backlash against the serving warriors amidst the war against the virus is o en ignored. Instead, social stigma has overpowered the goodwill of those for whom they are fighting. [10]  Mostafa et al. [11] found in their study on physicians in Egypt, significant stigma. Among 509 physician participants, 138 (27.1%) participants had direct involvement in the care of COVID-19 patients. One hundred and fi y nine (31.2%) participants reported severe level of COVID-19-related stigma. Participants' mean overall COVID-19-related stigma score was 40.6±8.0. e variety of stigma encountered by healthcare personnel was further elucidated in viewpoints by Singh and Subedi. [12] Several frontline healthcare providers serving in laboratories and hospitals were discriminated by staffs at hotels and encountered difficulty finding food and shelter. [13] Additionally, discrimination within healthcare workers fraternity was also reported wherein those involved in non-COVID-19 responses were reported to exhibit discrimination towards the frontline healthcare providers via behaviours such as refusal to talk to them and depicting disapproval to eat in the same cafeterias. Among residential areas, community members showed a kind of displeasure to allow the frontline healthcare providers reside in their home despite the fact that healthcare workers were working with all necessary precautions. [14] Some of the above findings resonated with the findings of our study. Similarities included significant association of psychological distress with those reporting discrimination for working in a COVID-19 centre and discomfort from family/ friends/neighbours when frontline workers lived among them.

Limitations
is study was a cross-sectional, online survey type with a purposive sampling method; hence, the results may not be generalisable. Being an online survey, we were unable to delineate the attrition rate in sample owing to those who dropped out in the midst of completing survey, or refused consent. Additionally, the survey being online could not account for those frontline workers without internet facilities. A longitudinal study, with detailed in-person psychiatric evaluation would be more conclusive measure of distress in the healthcare workforce.

Conclusion
Our study found high prevalence of psychological distress among frontline workers working in COVID-19 centres across Andhra Pradesh. Younger age, unmarried status, females, and suffering COVID-like symptoms among frontline workers was associated with psychological distress. Stigma was revealed in the form that majority were anxious about going for COVID-19 evaluation a er duty, majority did not get tested despite suffering COVID-19-like symptoms and around 15% presented for COVID-19 testing only a er seven days of symptom onset. High significant association was found between psychological distress and feeling discriminated for working in COVID-19 centres, being afraid to reveal URTI symptoms for fear of negative reaction of others, and family/ friends and neighbours disliking frontline workers living among them a er having completed quarantine period.

AUTHOR CONTRIBUTIONS
KD: Primary conception and design of study, acquisition of data, analysis, dra ing, final approval; BSR: Assisted design, acquisition of data, analysis, interpretation of data, revision work, final approval; MSC: Assisted design, acquisition of data, interpretation of data, dra ing, revision work, final approval.