Introduction

Coronavirus disease-19 (Covid-19) has been defined as a coronavirus disease that has been declared as a pandemic by the World Health Organization (WHO) and develops due to the newly defined severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) (1). Covid belongs to a large family of viruses and it is known to cause diseases such as common cold, pneumonia and SARS-CoV (2). According to WHO, published on March 3, 2020, the fatality rate of coronavirus is 2.4% worldwide (3).  Covid-19 is spread through droplets from symptomatic or asymptomatic patients (4). The first patient in our country was detected on March 10, 2020 (5).  Measures such as social distancing, hand washing and using masks have been taken to prevent rapid spread (6). In addition to these measures, curfew restrictions started in our country, as in many countries (7). In addition, a 14-day quarantine rule was applied to suspicious patients and people from abroad. By these measures, the spread rate of the virus was reduced and a plateau effect in the case-time curve was achieved (8). On June 1, 2020, a step in the normalization process was taken in our country with a decrease in the number of patients. However, as the number of patients increased again in our country with the end of the summer season, curfew restrictions restarted in the last period of November (9).

Healthcare professionals have spent a lot of effort in this difficult process in which dynamic and continuous rapid decisions have been made.  With the establishment of pandemic hospitals, many healthcare professionals in different positions have switched to a new working order (10). Reasons such as intense work pace, variable working hours and constant use of personal protective equipment have caused fatigue and wear out in healthcare professionals over time. The fact that 601 (3.8%) of the patients diagnosed at the beginning of April were medical personnel increased the concern (11). In the ongoing process, the rights of all healthcare professionals to leave and quit were restricted starting in mid-March (12). This restriction, which was temporarily lifted during the summer period, was re-applied during the second peak period (13). Along with all these, the continuous updating of diagnostic/follow-up/treatment algorithms related to Covid-19 has caused instability and then anxiety and despair in healthcare professionals. Although the success of some pharmaceutical companies in Vaccination Studies against Covid-19 in the last quarter of 2020 has raised hopes, it can be said that the Covid-19 pandemic will not end in the short term (14,15).

The purpose of this study was to determine the level of anxiety in healthcare professionals who were infected and who were not infected with coronavirus, to reveal the presence of emotional stress caused by coronavirus and to identify other triggers underlying this anxiety.

Method

It is a cross-sectional descriptive study. While 76 healthcare workers with positive Covid-19 polymerase chain reaction tests were used as the study group, 112 healthcare workers who were not diagnosed as having Covid-19 constituted the control group. The necessary approval for the study was obtained from The University of Health Sciences Turkey İzmir Tepecik Training and Research Hospital Clinical Research Ethics Committee (decision no: 2020-7-15/date: 08.06.2020).

Participants and Procedure: Our study was conducted with 188 healthcare professionals active in our hospital between 1-30 July 2020, which coincided with the first (1) peak period of coronavirus in our country. The data were collected on a purely voluntary basis with the consent and permission of the individuals. The questionnaire was prepared on the internet in accordance with the social distance rule. The internet address associated with the questionnaire was delivered via text message to the mobile phones of healthcare professionals. In the questionnaire developed by the researchers, questions were examining sociodemographic characteristics (age, gender, marital status, etc.), the working order of healthcare professionals in the Covid-19 pandemic period and whether they received mental support during this period. The Turkish version of the “Covid anxiety scale” and the short form of the “perceived stress scale (PSS)” were also applied in the questionnaire.

Coronavirus Anxiety Scale: The Coronavirus anxiety scale is a 5-question scale with robust reliability (a=.93) based on a study with n=775 people (16). In our study, it was determined as (a=0.95). Cronbach is often used in Alpha Likert-type scales. Cronbach is defined as unreliable if Alpha is 0I felt dizzy, dazed or unconscious when I read or listened to the news about the coronavirus, I had trouble falling asleep or staying asleep because I thought about the coronavirus, I felt paralyzed or frozen when I thought about the coronavirus or was exposed to information, I lost interest in eating when I thought about the coronavirus or was exposed to information, I felt nauseous or had stomach problems when I thought about the coronavirus or was exposed to information”. The answers to these questions and the score equivalent are: “None=0, Rare, Less than one or two days=1, More than a few days=2, More than seven days=3, Almost every day in the last two weeks=4”.

Perceived Stress Scale: The PSS was developed by Cohen, Kamarck and Mermelstein (1983) and  designed to measure the degree of several situations which were perceived as stressful in an individual’s life. In addition to the long-form with 14 items, it has two other forms with 10 and 4 items (19). In this study, a 4-question short form was used. Two questions are with straight statements and 2 questions are with reverse expressions. These questions are: “How often did you feel that you couldn’t control the important things in your life last month? How often have you relied on your ability to address your personal problems in the past month? How often did you feel that everything was going well in the last month? In the last month, how often did you feel that problems had accumulated so much that you couldn’t overcome them?”  The answers to these questions and the score equivalent are: “Very often =4, Quite often =3, Sometimes =2, Almost never =1, Never =0”. It is known that PSS scores have a significant and positive relationship with life events and depression, and a negative and significant relationship with life satisfaction, self-esteem and social support (19). A high total score means that the perceived stress level is high (20). Considering that the predicted reliability levels for the scales planned to be used in the studies were 0.60 and 0.80, the Cronbach’s alpha score of the scale for this study was 0.61 and showed internal consistency (20-22).

Measures

While determining the sample, it was aimed to reach all healthcare workers infected with Covid-19. The study was terminated due to the presence of health workers who did not accept to participate in the study and the end of the first peak period in the pandemic.

Statistical Analysis

Statistical evaluation was made with SPSS 18.0 program. Validity and reliability analysis of applied Likert-type questionnaires were performed. The compliance of continuous variables to normal distribution was tested. Comparisons of independent groups were made using the “Student's t-test for variables conforming to the normal distribution, and the “Mann-Whitney U” test for those not conforming to the normal distribution. Categorical variables were presented as frequencies and percentages with cross-tables and their distributions were compared with “chi-square” test methods. In all statistical comparison tests, the margin of error of the first type was determined as a:0.05, and the difference between groups was considered statistically significant if the value of “p” was less than 0.05.

Results

One hundred eighty eight health workers, including the control group, participated in our study. Of participants 40.43% (n=76) tested positive for Covid-19. Of them, 59.57% (n=112) were not diagnosed as having Covid-19, and this group constituted the control group (Table 1).

Of the health workers who tested positive for Covid-19, 76.31% (n=58)  were in the 20-39 age range. Of the control group 54.48% (n=61) were in the 20-39 age range. Of healthcare professionals who tested positive for Covid-19 36.8% (n=28) were male and 63.2% (n=48) were female, while 34.8% (n=39) of the control group were male and 65.2% (n=73) were female (Table 1).

There was a significant association between Covid-19 negative status and age increase (p=0.002). While there was no significant relation between Covid-19 negative status and gender and marital status, a significant relationship was found between Covid-19 negative status and high educational level (p=0.049). It was significant that the physician group was less Covid-19 positive than the nurses/obstetricians and other assistant healthcare personnel (p=0.001). In addition, there was a statistically significant relation between the increase in years of work and a lower rate of Covid-19 positivity (p=0.008) (Table 1).

The percentage of health workers who considered themselves at risk, including the control group, was 84.04% (n=158), while the percentage of health workers who said they had anxiety during this process was 88.30% (n=166). Although there were numerically many anxious health workers, the rate of those who said they needed psychological support during the pandemic period was 38.83% (n=73). However, the percentage of those receiving psychological support was 21.80% (n=41). Of those who received support, only 29.27% (n=12) received professional support. The percentage of those who thought their job was always stressful was 44.68% (n=84) (Table 2).  

The health workers were more likely to be infected with Covid-19 when there was at least one of the family member diagnosed as having Covid-19 (p=0.000). The health workers were less likely to be infected with Covid-19 if they were assigned in another unit by leaving the current unit of work (p=0.000) (Table 3).

There was a significant relationship between the status of getting infected with Covid-19 and serving only on the day shift (08:00-17:00) (p=0.015). The higher levels of Covid-19 negative status were significant in those who served in pandemic services or outpatient clinics than those who did not (p=0.014). It was statistically significant that those whose working time did not change during the pandemic had a higher level of Covid-19 positivity than those whose working time did (p=0.003) (Table 3).

The average Coronavirus anxiety scale score of all participants was 3.03, while the average value of the total score of the PSS short form, another important scale, was 8.04 (Table 4).

No statistical significance was observed in terms of the total score of the Coronavirus anxiety Scale between those who tested positive for Covid-19 and the control group (p=0.349). Similarly, no statistical significance was observed in terms of the total score of the PSS (short form) between those with positive Covid-19 test and the control group (p=0.290) (Table 4).

Compared to the educational level of all participants and the total score of the Covid anxiety scale; it was statistically significant that the anxiety level decreased as the educational level increased (p=0.006). When the total score of Covid anxiety scale was compared with working in pandemic outpatient clinics or services, it was found that the anxiety level did not increase statistically (p=0.504). The Covid anxiety scale score of those receiving mental support was high, and it was statistically significant that those with high anxiety levels also needed mental support (p=0.001) (Table 5).

Considering the answers given in the Covid anxiety scale, the sample size and the statistical significance value, when we accepted the cut off value as “1”, no statistically significant difference was observed in terms of the scale value between Covid-19 positive group and the control group (p=0.556). Also, no statistically significant difference was observed in terms of the scale value between participants who worked for 16 years or over and who worked for 0-15 years, and between those who worked in outpatient clinic or service and who did not (p=381 and p=474, respectively) (Table 6).

Discussion

Healthcare professionals, who have to work 24 hours a day without interruption under the stress of being primarily responsible for health, experience psychological and physiological disorders due to the increased workload (23). These can occur in the form of health problems such as chronic insomnia, fatigue, fear of causing malpractice, burnout syndrome, concentration disorders, chronic diseases, and some types of cancer (24). Furthermore, trying to fight an pandemic that they did not know about before has affected medical personnel too much (25,26). In our study, no relation was found between coronavirus infection status and both the Covid anxiety scale and the PSS scores. It can be said that those who fully carry out infection protocols/procedures have both avoided being infected with coronavirus and that their stress level has not changed. Although the presence of a continuous infection creates a persistent level of anxiety, it can be said that being infected with Covid-19 does not cause much variability on the anxiety.

In our study, it was observed that anxiety levels decreased as education levels increased, and stress increased in the presence of infected or suspected patient contact with Covid-19. Some studies showing that anxiety and insomnia are more common in doctors and nurses who come into contact with possible or diagnosed patients (27,28). We can say that those with a high level of education can access sufficient data in the light of evidence-based medicine, and accordingly, the level of anxiety decreases. On the other hand, we believe that when it comes to contact with a suspicious patient, it creates an exacerbation of the anxiety level again.

Chan and Huak (29). found that doctors were 1.6 times more likely to experience psychiatric symptoms than nurses. Another study showed high levels of sleep problems, anxiety, and depression symptoms in healthcare professionals (30). In addition, Ataç et al. (31) stated in the study that while anxiety symptoms in nurses/obstetricians and dentists were higher than other professions, doctors constituted the occupational group with the least anxiety symptoms. In our study, it was found that the physician group was less likely to be infected with coronavirus than the nurse/obstetrician and other auxiliary medical personnel. As the years of working in the profession increased, the rate of Covid-19 positivity decreased. It can be concluded that a doctor with high experience in the profession has a low level of being infected with Covid-19, while other healthcare professionals have a higher level of being infected with Covid-19 and a higher level of anxiety than doctors.

In a study on the anxiety levels of individuals, Tutku et al. (2) found that women’s health anxiety perception levels were high. Moreover, another study found that levels of anxiety and depression in women were significantly associated with the Covid-19 pandemic (32). Our study is similar to this aspect. We believe that being a woman, as well as being a medical staff, deepens the level of anxiety in this process.

Looking at the researches on Covid-19, some studies are showing that lower levels of psychological impact, depression and anxiety are detected with more preventive measures (33). Ataç  et al. (31) found that there was no significant difference in anxiety and insomnia both according to the current task unit and according to the new tasks carried out during the pandemic period. Polat and Coşkun (34) found that healthcare professionals who used their personal protective equipment appropriately when necessary had low depression, anxiety and stress scores. Likewise, in a study conducted in China, it was reported that individuals with high mask-wearing rate who took part in this process had lower DASS depression and anxiety subscales scores (35). In our study, similarly, working in Covid-19 outpatient clinics or services did not increase the level of anxiety. Those who did not work in Covid-19 outpatient clinics or services had a higher rate of Covid-19 than those who worked. Based on this, strict measures taken at the first point of close contact can be considered to have reduced the level of anxiety. On the other hand, it can be interpreted that those who do not work in Covid-19 departments are more easily infected by assuming that they are away from the danger zone.

Anxiety disorders are known to become more pronounced with a decrease in interpersonal communication and with the cessation of social support (36). It should be noted that all kinds of psychological events disrupt the general functioning of the body with prolonged stress, laying the ground for not only Covid-19 but many infections or exacerbating psychosomatic diseases (26). In a multicenter study in Turkey; the perception of stigma score in those who received psychological support during the Covid-19 pandemic and who had psychological disorders during or before the Covid-19 pandemic outbreak were found to be significantly higher (37). In our study, those who said they needed mental support had a higher score in the Covid anxiety scale, while those who had high anxiety levels also needed mental support. We believe that the morale and motivation of health workers should be increased throughout the pandemic and that institutions should provide all kinds of support in terms of psychological support.

No cut-off value was detected for the Covid anxiety scale in studies (16,18). In the score table, when the cut off  value “9” was taken as a basis, 90% sensitivity and 85% specificity were found, and 71% sensitivity and 74% specificity were found when “5” was taken as a basis (16,18). In our study, we considered the cut-off as “1”. Accordingly, no significant difference was found between those with “1 and above” and those with a “0” in terms of the frequency of Covid-19. It can be concluded that there is no change in the individual’s current level of anxiety, whether the person is infected with coronavirus or not.

Study Limitations

The limitations of our study were that the Covid anxiety scale used in our study did not have a certain cut-off value and the sample size did not include primary health care institutions.

Conclusion

Those fighting on the front lines against the pandemic are healthcare professionals. A staff with a high level of anxiety does not have any change in the anxiety level after being infected, indicating that the individual is now hopeless and bored. The fact that the healthcare professionals’ anxiety level does not decrease indicates that their concerns about Covid-19 persist. The service of a disenchanted healthcare professional will reduce the quality of health, as well as lead to dangerous consequences such as medical malpractice, burnout or suicide.

At this point, we believe that institutions should be as committed to protective equipment as they are to social or psychological support. A widespread, effective and sustainable psychosocial support will lead to efficient service in the health system.

Acknowledgements: Thanks to all the healthcare professionals who participated in our study.

Ethics

Ethics Committee Approval: University of Health Sciences Turkey İzmir Tepecik Training and Research Hospital Clinical Research Ethics Committee (decision no: 2020-7-15/date: 08.06.2020).

Informed Consent: Informed consent was obtained from the patients for this study.

Peer-review: Externally peer reviewed.

Authorship Contributions

Concept: M.M.U., N.Y., D.S., Design: M.M.U., H.P., N.T., Data Collection or Processing: M.M.U., N.Y., Analysis or Interpretation: M.M.U., H.P., N.Y., D.S., N.T., Literature Search: M.M.U., H.P., N.T., Writing: M.M.U., H.P., D.S., N.T.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.