Impact of overburden due COVID-19 pandemic on psychological health and work efficacy of doctors in Mangalore city, Dakshina Kannada district -A cross-sectional study

Introduction and Aim: One of the greatest pandemics faced by the world was COVID-19 which has added increased strain and psychological impacts on healthcare workers. This study was conducted to find out the impact of overburden due to COVID-19 on the psychological health of doctors and further to know whether it has affected the services provided by them. Materials and Methods: An information sheet which contained the details regarding purpose and nature of the study, questionnaire and consent form were given to each participant. Data was collected through email, WhatsApp, and physical forms. Depression, anxiety, stress, self-efficacy, and perceived social support were assessed using standard questionnaires. Results: Out of the 205 participants, 9 (4%) had a mild depression, 6(3%) had mild anxiety and 6(3%) had mild stress. Female doctors, those involved in fever clinics and inpatient care of COVID patients had significantly higher scores for depression, anxiety and stress when compared to others. Those involved in ICU care of COVID patients had higher General Self Efficacy (GSE) scores. General Self Efficacy (GSE) and Multidimensional Scale of Perceived Social Support (MSPSS) scores showed a positive correlation. Conclusion: Doctors involved in care of COVID-19 patients at fever clinic and inpatient care had several mental health problems. Hence, they along with female doctors need to be periodically screened for these conditions periodically.


INTRODUCTION
OVID-19 has been the one of the greatest pandemics faced by the world so far and it has added increased strain on the healthcare resources worldwide (1).The district of Dakshina Kannada in Karnataka has accounted for 1,37,221 positive cases as on 22/11/2023 (2).There has been immense work done on the impact of COVID-19 on healthcare workers.Studies have found that the pandemic has had a psychological impact like anxiety, depression, stress and burnout among frontline workers (3).The main challenges faced have been fear of infection, social isolation, stigma, guilt, financial hardships, and uncertainty (4,5).The long working hours and excessive workload may lead to negative and detached feelings towards patients (6).
This study was done to find out the impact of the current COVID-19 pandemic on psychological health and work-efficiency of doctors and its association with perceived social support among them.This will in turn help to address these issues to have better well-being among the doctors which is the need of the hour.The primary objectives were to assess the impact of COVID-19 pandemic on the psychological health of doctors and on the work-efficacy of doctors.The secondary objectives were to assess the association between psychological health and perceived social support among doctors, and to assess the association between efficacy and perceived social support among doctors.

MATERIALS AND METHODS
A cross sectional study was conducted in Mangalore city of Dakshina Kannada in the month of year.All doctors who were registered with the Indian Medical Association, Mangalore Branch were invited to participate.Those giving written informed consent for participation were included in this study.Study was conducted for a period of 3 months from June to August 2021 Sample size was calculated based on the findings of a previous study where 50.4% of the doctors were having anxiety and stress Hence, sample size (n) was calculated using the formula n = 4pq/d 2 , considering 13% as p, with 95% confidence interval, an absolute error (d) of 5% the sample size estimated for the study was 180.Adding10% to make up for non-responses the final sample size was calculated as 200 (7).

C
The list of medical practitioners who were enrolled in Indian Medical Association, Mangalore was obtained.Members, whose email IDs, or phone numbers were available, were included in the study population.300 participants were randomly selected among them using a random number.The information sheet which contained the details regarding purpose and nature of the study, questionnaire and consent form was created through Google forms, following which it was sent by email to all the selected 300 participants.The same was shared via WhatsApp also.The recipients of the information sheet were requested to share the survey among their network of doctors.Physical copies of the information sheet were also given to consenting doctors to be filled.Reminders were sent to those who did not reply.A total of 205 participants giving a response rate of 68.3%.To maintain confidentiality, potential identifiers of doctors were not collected.A pretested semistructured validated questionnaire was used to collect the data on background characteristics.Psychological well-being was measured by the Depression, Anxiety, and Stress Scale-21 (DASS-21), Efficacy was assessed using general self-efficacy scale (GSE) and perceived social support using Multidimensional Scale of Perceived Social Support (MSPSS).
The data was analyzed using SPSS (Statistical Package for Social Sciences) version 16.Descriptive statistics was applied, and data were presented proportions, median scores, and percentages.Mann Whitney U test was used to find the association of psychological health with demographic factors type of work, self-efficacy, and perceived social support.Spearman's correlation was used to assess the correlation between DASS, MPSS and GSE scores Statistical significance was set at 0.05% level of significance (p < 0.05).

RESULTS
The mean age of the study participants was 35.6 years (SD 9.5).Majority of the participants were female 112(56%).Most of the study participants worked in urban areas 179 (87%) Majority of the participants were working in fever clinic 70 (34%) followed by providing inpatient care to COVID 19 patients 64 (31%) (Table 1).Majority of the participants 92 (45%) agreed that they were afraid of getting infected and it used to freak them out.Majority of the participants 90 (44%) strongly agreed that they had the fear of infecting their family members in case they tested positive (Table 1).Most of the study patients were normal, 9(4%)of the study participants had mild depression, 6(3%) had moderate anxiety and 6(3%) had mild stress.On an average 1% suffered from severe depression (Table 2).Those involved in fever clinic and inpatient care of COVID patients had higher scores for depression, anxiety and stress and it was found to be statistically significant (Table 3).Higher scores of stresses were also seen in those involved in ICU care and were found to be statistically significant.Female health care workers had higher scores for anxiety which was found to be statistically significant (Table 3).
Females and those involved in providing ICU care for COVID patients had higher MSPSS scores and it was found to be statistically significant.Those involved in providing ICU care for COVID patients had higher GSE scores it was found to be statistically significant (Table 4).

DISCUSSION
In the current study 4% of the study participants had mild depression, 3% had moderate anxiety and 3% had mild stress.According to Zhu et al., who surveyed HCWs to measure psychological impact of COVID-19 13.5% were found to have depression, 24.1% had anxiety and 29.8% of respondents were found to have stress (7).Zhan et al., (8) reported 27.3% of moderate to severe depression, and 9.4% of moderate to severe anxiety among the participants in their study.
In the current study it was highlighted that majority of the participants (45%) agreed that they were afraid of getting infected and it used to freak them out.Cao et al., (9) also highlighted fear of infection in their qualitative study, and the same theme was also brought up in a cross-sectional survey by Chung and Yeung (10) in a free-text feedback.
Majority of the participants in the current study (41%) strongly agreed that they were afraid of exposing their family members in case they tested positive while another study reported that 79.7% of the participants feared of infecting their family members (11).A qualitative study done by Sun et al., highlighted the same theme (12).Being aware that their family was safe had the highest impact in reducing stress as reported by Cai et al., (13).
In the present study female doctors had higher scores for depression anxiety and stress, anxiety was found to be statistically significant.The study by Wang et al., also reported females experience a higher degree of the psychological impact of the outbreak (14).
Another nationwide study done in China, was also reported this to be an independent risk factor for anxiety (15).
Those involved in fever clinic and inpatient care of COVID patients had higher scores for depression, anxiety and stress and it was found to be statistically significant.Similar findings were by Lin et al., also reported that working in high-risk areas like emergency departments, intensive care units, and isolation wards have been found to have a greater risk for developing adverse psychological morbidities following outbreak (16).
In our study we found that depression, anxiety and stress was negatively correlated with social support, this emphasizes the importance of social support as a protective factor for mental health similar findings were reported by other studies (8,17,18).We also found positive correlation between self-efficacy and social support.Higher social support scores among people indicates that they receive adequate understanding and support from their family, friends, and colleagues.People with better social support have lower levels of loneliness and this helps to building higher self-efficacy, thus they have more respect, courage and do better professionally (19).
There has been immense work done on the impact of COVID-19 on healthcare workers.Previous studies have found that the pandemic has had a psychological impact like anxiety, depression, stress, and burnout among frontline workers.This study helps to understand the impact of the current COVID-19 pandemic on psychological health and efficiency of doctors in an urban area in Dakshina Kannada district and its association with perceived social support.
Limitations: Since the data was mainly collected using online based portals, it may not be representative of all the doctors in Mangalore city.

CONCLUSION
This study aimed to find out the extent of impact due to COVID-19 on doctors and whether it has affected the service provided by them.Most of the study patients were normal, 4% of the study participants had mild depression, 3% had mild anxiety and 3 % had mild stress.We found that 90% of the participants were afraid of infecting their family members with COVID-19.We also found that those involved in fever clinic and inpatient care of COVID patients had higher scores for depression, anxiety and stress when compared to those involved in triage, contact tracing and ICU care of COVID patients.General Self Efficacy (GSE) and Multidimensional Scale of Perceived Social Support (MSPSS) scores showed a positive correlation.This study helps us to identify the factors like type of work, fear for the well-being of their family and themselves and perceived social support which interplay to affect the psychological health and efficiency of doctors during a pandemic.This will in turn help to address these issues to have better well-being among our doctors which is the need of the hour.

Table 1 :
Characteristics of the study participants

Table 2 :
Distribution of study participants with depression, anxiety, and stress according to DASS-21 scores

Table 3 :
Association of DASS-21 scores with certain factors

Table 4 :
Association of GSE and MSPSS with certain factors

Table 5 :
Correlation between DASS, MPSS and GSE