Abstract
This study analyzed the frequency and intensity of acute stress among health professionals caring for COVID-19 patients in four Latin American Spanish-speaking countries during the outbreak. A cross-sectional study involved a non-probability sample of healthcare professionals in four Latin American countries. Participants from each country were invited using a platform and mobile application designed for this study. Hospital and primary care workers from different services caring for COVID-19 patients were included. The EASE Scale (SARS-CoV-2 Emotional Overload Scale, in Spanish named Escala Auto-aplicada de Sobrecarga Emocional) was a previously validated measure of acute stress. EASE scores were described overall by age, sex, work area, and experience of being ill with COVID-19. Using the Mann–Whitney U test, the EASE scores were compared according to the most critical moments of the pandemic. Univariate and multivariate analysis was performed to investigate associations between these factors and the outcome ‘acute stress’. Finally, the Kruskal–Wallis was used to compare EASE scores and the experience of being ill. A total of 1372 professionals responded to all the items in the EASE scale: 375 (27.3%) Argentines, 365 (26.6%) Colombians, 345 (25.1%) Chileans, 209 (15.2%) Ecuadorians, and 78 (5.7%) from other countries. 27% of providers suffered middle-higher acute stress due to the outbreak. Worse results were observed in moments of peak incidence of cases (14.3 ± 5.3 vs. 6.9 ± 1.7, p < 0.05). Higher scores were found in professionals in COVID-19 critical care (13 ± 1.2) than those in non-COVID-19 areas (10.7 ± 1.9) (p = 0.03). Distress was higher among professionals who were COVID-19 patients (11.7 ± 1) or had doubts about their potential infection (12 ± 1.2) compared to those not infected (9.5 ± 0.7) (p = 0.001). Around one-third of the professionals experienced acute stress, increasing in intensity as the incidence of COVID-19 increased and as they became infected or in doubt whether they were infected. EASE scale could be a valuable asset for monitoring acute stress levels among health professionals in Latin America.
ClinicalTrials: NCT04486404.
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Introduction
The front line of care professionals for COVID-19 patients has to experience extreme emotional overload that causes acute stress reactions, compassion fatigue, and other affective pathologies and adaptative responses1,27.
EASE has been adapted to the linguistic and cultural context of Argentina, Colombia, Chile, and Ecuador. This tool combines reliability and construct validity suitable for screening acute stress reactions of healthcare professionals who care for COVID-19 patients who speak Latin American Spanish.
The scale includes a set of situations identified as the primary sources of stress and facilitates awareness of the impact of the pandemic on professionals, the second victims of SARS-CoV-2. Unlike other instruments that measure general anxiety or depression, the EASE focuses its content on distress in the care of COVID-19 patients. Furthermore, its length (10 elements) and the fact that it is linked to support mechanisms for professionals and teams, depending on the case, are provided through a web page and mobile app13,16, which prove to be other advantages. These data suggest that it can be used in the recovery phase of professionals and health systems to monitor professionals' responses after the impact of the pandemic. In this case, it can be expected that professionals' resilience will be more significant in the event of new outbreaks28. However, the reaction may differ depending on the support received during the first wave and the public response. Finally, if the health system is concerned about the welfare of its professionals29.
Through EASE, it has been possible to interpret that being in critical situations that do not allow them to disconnect from work and the fear of infecting your family when they get home are health professionals' main concerns and sources of stress. As reported in other studies, professionals in the direct care of COVID-19 patients showed higher emotional overload and distress levels11. Caring for the professional caregiver is a prerequisite for optimal care. The World Health Organization has identified the importance of the well-being of the healthcare providers and has announced new objectives for all healthcare systems in this direction. Studies like this reinforce this decision and show how the outbreak accelerates the need to implement measures that promote the welfare and work morale of the healthcare workforce for patients' benefit.
The levels of acute stress were also higher, coinciding with the moments of greatest incidence of COVID-19 cases, unlike what was observed in Spain. As predicted by the Community disaster response model30, acute stress was more significant during the restoration phase4. These differences could be because the pandemic's impact was not expected in Europe despite the data from Asian countries arriving, particularly China and Korea, in Latin American countries, it was intuited, and the lack of individual protection measures and fear of contagion was anticipated.
Monitoring stress seems advisable as interventions to strengthen the resilience of the health workforce have, so far, not achieved their goal. The reasons for this may vary, including resistance to participating in these techniques. Tools are needed to enable health professionals, especially men, to recognize the effect of the pandemic on their mental health. Almost 70% of the participants in this study were women, and this may be due to different reasons, including the fact that most health professionals are women, they tend to be more open to asking for help than men, and they participate more in this type of interventions. EASE can help monitor levels of acute stress and determine the degree of effectiveness of programmed interventions to reduce this stress, including those tested in other extreme situations31.
Limitations. The sample was not randomized, so a selection bias cannot be ruled out. Furthermore, convenience sampling was used, and participants were invited thru institutional mailings, instant messaging applications, and discussion forums. Individuals who chose to participate might systematically differ from those who did not, affecting generalizability. The survey used an online platform designed for this study or by downloading an application and was sent out to healthcare networks and hospitals in the participating countries; due to this, data on its reach is not known to establish an uptake percentage. There may be turns or grammatical expressions in Bolivia, Mexico, Peru, or other regional countries that are not covered by this adaptation. The availability of resources, mental health support, PPE provision, and the pandemic incidence between countries, territories of the same country, or between health centers can modify the responses and relationship of acute stress situations contemplated in the EASE scale. Approximately half of the respondents did not answer whether they had been infected. When interpreting these data, it is important to consider the diagnostic limitations that may exist in the region and how they may affect the rate of confirmed cases case fatality rate. If we compare the testing rate per million population in the United Kingdom (482,040) or the United States (505,045), the rate in Latin American countries is much lower (Chile 251,862; Colombia 89,101; Argentina 66,017; Ecuador 30,555)24.
In conclusion, this multinational study in Latin America shows that the infection affected healthcare workers' mental health. Twenty-seven percent of health care workers in Argentina, Colombia, Chile, and Ecuador experienced a medium to high level of acute stress following the outbreak. A higher intensity was observed among those working in COVID-19 critical care units and those who became infected or doubted whether they were infected with SARS-CoV-2. Acute stress increased as the incidence of COVID-19 cases increased. In future potential pandemics, this aspect should not surprise us, and from the very beginning, it is necessary to activate support measures to prevent this situation from negatively affecting patients.
Data availability
Data are available upon reasonable request.
Change history
07 June 2022
A Correction to this paper has been published: https://doi.org/10.1038/s41598-022-13900-z
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Acknowledgements
The authors would like to thank all the participants who voluntarily participated in the study. To Angel Mari Albert and Alejandro Gimenez Buitrago for their assistance in the statistical analysis.
Funding
This study was supported by Generalitat Valenciana, 2021. CONV. UMH-GVA REF. SOLCIF 2020/0005. (Cód. Sub. 11-134-4-2021-0068). J.M.D., R.P., P.S., I.C., E.G.E., M.G., and J.J.M. were supported by The European Cooperation in Science and Technology, COST [Grant Number CA19113].
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J.J.M. and J.M.D. conceived and designed the work. C.F. and M.A.V. designed the online platform. J.J.M., I.C. and M.G. R.P., P.S., C.L., F.J., and E.G.E. were responsible for the recruitment of participants. A.M. and J.M.D. performed the statistical analysis. J.M.D., I.C. and M.G. wrote the first draft of the manuscript, critically reviewed for important intellectual content by J.J.M. and all of the authors. All authors reviewed the draft and approved the final version of the manuscript.
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The original online version of this Article was revised: The Funding section in the original version of this Article was incomplete. Now reads: "This study was supported by Generalitat Valenciana, 2021. CONV. UMH-GVA REF. SOLCIF 2020/0005. (Cód. Sub. 11-134-4-2021-0068). J.M.D., R.P., P.S., I.C., E.G.E., M.G., and J.J.M. were supported by The European Cooperation in Science and Technology, COST [Grant Number CA19113]."
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Martin-Delgado, J., Poblete, R., Serpa, P. et al. Contributing factors for acute stress in healthcare workers caring for COVID-19 patients in Argentina, Chile, Colombia, and Ecuador. Sci Rep 12, 8496 (2022). https://doi.org/10.1038/s41598-022-12626-2
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DOI: https://doi.org/10.1038/s41598-022-12626-2
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