Analysis on mental health status and needs of health care workers in designated medical institutions of tuberculosis during the epidemic period of COVID-19

Background Coronavirus disease 2019 (COVID-19) has spread rapidly in China and other overseas areas, which has aroused widespread concern. The sharp increase in the number of patients has led to great psychological pressure on health care workers. The purpose of this study is to understand their mental health status and needs, so as to provide a scienti�c basis for alleviating the psychological pressure of health care workers. Methods Using a cross-sectional study design, 511 health care workers were randomly selected from two designated tuberculosis medical institutions in Anhui Province. The basic situation, perceived social support, depression level, loneliness and COVID-19 related knowledge were collected and analyzed by questionnaire. Results There were 139 people in epidemic prevention and control positions (27.20%). Depression level: female was higher than male; nurse was higher than doctor; middle and junior job titles were higher than senior titles; junior college degree or below were higher than bachelor's degree, master's degree and above; isolation ward, fever clinic and pre-check triage were signi�cantly higher than those of non-prevention and control positions (P < 0.05). Loneliness scores: doctors were higher than that of medical technicians, and isolation ward, fever clinic and pre-check triage were higher than those of non-prevention and control positions (P < 0.05). Social support: doctors were lower than that of medical technicians, and isolation ward, fever clinic and pre-check triage were signi�cantly lower than those of non-prevention and control positions (P < 0.05). The score of social support was negatively correlated with depression and loneliness (P < 0.001), while depression was positively correlated with loneliness (P < 0.001). Health care workers most want to receive one-to-one psychological counseling (29.75%), and provide crisis management (24.07%). The awareness rate of health care workers on COVID-19's knowledge was relatively high. Conclusions The psychological problems of health care workers, especially women, nurses with low educational background, low professional title, and staff in the epidemic prevention and control positions are relatively serious. We should focus on this population, and take targeted intervention measures.


Introduction
The Coronavirus Disease 2019 (COVID- 19), formerly referred to as 2019 Novel Coronavirus (2019-nCoV) is a new respiratory virus that was rst identi ed in Wuhan of Hubei Province, China in December, 2019.COVID-19 can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome [1] .It is similar to Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) virus in its pathogenicity, clinical spectrum, and epidemiology [2] .The COVID-19 epidemic spreads very quickly.It took only 30 days to expand from Hubei province to the rest geographical locations of China Mainland.With many people returning from a long holiday, China needs to prepare for the possible rebound of the epidemic [3] .At present, COVID-19 cases have also appeared in many overseas countries and regions, the spread of COVID-19 in the United States, Spain, Russia, Britain and Italy has become the greatest concern.
Worldwide, more than 4 million cases of COVID-19, and close to 30 0000 deaths have been reported.COVID-19 is thought to have higher mortality than seasonal in uenza, even as wide variation is reported [4] .
Health care workers are at high risk of COVID-19 infection, a study by Wu et al [5] showed that a total of 72314 cases have been reported nationwide by February 11, 2020, of which 44,672 cases have been con rmed.Of all the con rmed cases, there were 1716 health workers (3.8%), of which 14.8% of the con rmed cases were diagnosed as severe or critical cases, and 5 cases died.Another study showed that [6] front-line health care workers are prone to psychological problems in public health emergencies.COVID-19 is a new type of infectious disease.At present, there is a lack of effective drugs for this disease, as the main force in the ght against the epidemic, health care workers are prone to all kinds of psychological problems in the face of high-intensity and high-risk work.Two recent studies in China both revealed that the incidence of anxiety and stress disorder is high among health care workers who were treating patients with COVID-19 infection during the epidemic period [7][8] .The National Health Commission issued a public document requiring [9] that all localities should strengthen the psychological crisis intervention and guidance of health care workers.But at present, there are few studies on the mental health of health care workers in both epidemic prevention and control positions and non-epidemic prevention and control positions.Therefore, in order to know the mental health level of health care workers in time, and take targeted intervention measures, this study investigated the mental health status and needs of health care workers in two provincial tuberculosis designated hospitals (designated medical institutions to combat the epidemic situation of COVID-19) in Anhui Province, which is of great signi cance to improve the mental health level of health care workers and better carry out the work of ghting against the epidemic situation.

Objects
The method of random sampling was applied to select health care workers from different positions from two provincial tuberculosis designated medical institutions in Anhui province, and a questionnaire survey was conducted.A total of 540 questionnaires were distributed and 511 valid questionnaires were collected, with an effective rate of 94.63%.

Questionnaire investigation
A questionnaire survey was conducted among the selected health care workers, including: (1) Basic demographic characteristics, including gender, age, occupation, job title, education level, marital status and positions during epidemic prevention and control, etc. (2) COVID-19 related knowledge: including the source of infection, the route of transmission, the susceptible population and the main clinical symptoms, etc. (3) Perceived Social support scale (PSSS): The scale was compiled in 1987 [10] , revised by Chinese scholars and widely applied in China, Cronbach's α = 0.88 [11] .It consists of 12 items, each of which is rated on a scale ranging from 1 to 7, and each item is randomly arranged, which is divided into three dimensions: family support, friend support and other support.The total support is the sum of the three dimensions, the higher the score, the higher the perceived social support [12] .(4) Self-rating Depression scale (SDS): the scale includes 4 groups: psycho-emotional symptoms, somatic disorders, psychomotor disorders and psychological disorders of depression.The speci c scoring method is as follows: each item is scored according to grades 1, 2, 3 and 4. The higher the score is, the more serious the degree of depression is, and the cumulative score was more than 40 points, which was judged as depression [13] .(5)   ULCA loneliness scale: The scale was compiled and revised by Russell et al [14] , including 11 "lonely" positive order items and nine "non-lonely" reverse order items, the items with asterisks should be in reverse order, and then each item should be added.The higher the score, the higher the degree of loneliness [15] .

Statistic analysis
The quantitative data were expressed as Mean ± Standard Deviation (Mean ± SD), t-test was used to compare the quantitative data between the two groups, one-way ANOVA was used to compare the quantitative data among different groups, Pearson correlation analysis was used when the variables were in accordance with bivariate normal distribution.The test level was α = 0.05.The investigation and experimental data were double input by EpiData 3.1 and analyzed by SPSS 23.0.

Basic situation of health care workers in designated medical institutions for tuberculosis
A total of 540 questionnaires were distributed and 511 valid questionnaires were retrieved, with an effective rate of 94.63%.The average age of 511 respondents was 31.19 ± 6.62, including 88 males (17.22%), 423 females (82.78%), the proportion of nurses was the highest (57.34%), and the proportion of bachelor degree was the highest (70.65%).Also, there were 139 people in epidemic prevention and control posts, accounting for 27.20%, of which fever clinic and pre-check triage accounted for the highest proportion (9.59%), and 186 health care workers had depression, accounting for 36.40%(Table 1).There was no signi cant difference in the score of social support and loneliness among health care workers of different genders.The depression score of female was higher than that of male (P < 0.05).
One-way ANOVA showed that there were statistically signi cant differences in social support, loneliness and depression among different occupations.The scores of family support, friend support, other support and total support of doctors were signi cantly lower than those of medical technicians (P < 0.05), the score of loneliness was higher than that of medical technicians (P < 0.05), and the depression score of nurses was higher than that of doctors (P < 0.05).The difference in the level of depression was statistically signi cant in terms of professional titles, the depression scores of intermediate and junior health care workers were signi cantly higher than those of senior titles (P < 0.05).The depression scores of health care workers in junior college and below were higher than those with bachelor's degree or master's degree or above (P < 0.05) (Table 2).There was signi cant difference in the score of total social support between the health care workers in COVID-19 prevention and control posts and those in non-prevention and control posts, but the scores of loneliness and depression of health care workers in prevention and control posts were signi cantly higher than those in non-prevention and control posts (P < 0.05).One-way ANOVA showed that there were statistically signi cant differences in the scores of social support, loneliness and depression in speci c prevention and control posts.Among them, the score of social support of health care workers in isolation ward, fever clinic and pre-check triage were lower than those in non-prevention and control posts (P < 0.05), while the scores of loneliness and depression were signi cantly higher than those in nonprevention and control posts (P < 0.05), and the scores of depression even reached the diagnostic criteria.The social support of health care workers in imaging and laboratory diagnosis positions was higher than that of non-prevention and control posts (P < 0.05).There was no statistically signi cant difference between Medicament and non-prevention and control posts in terms of social support, loneliness and depression (Table 3).

Correlation analysis social support with depression and
Family support, support, other support and total social support of health care workers were negatively correlated with the scores of depression and loneliness (P < 0.001).Also, there was a signi cant positive correlation between the score of depression and the score of loneliness (P < 0.001) (Table 4).The top three psychological needs that health care workers were willing to accept were one-to-one psychological counseling (29.75%), psychological lectures (27.20%) and participating in interactive groups (18.59%).The top three psychological services needed were crisis event management (24.07%),emotional management (21.33%) and stress and frustration coping (21.13%).Most health care workers were willing to have psychological counseling during normal working hours (61.84%).The awareness rate of COVID-19 related knowledge was relatively high, the highest was the source of infection (100%), and the lowest was the clinical manifestation (93.54%).It shows that the understanding of COVID-19 related clinical manifestations among health care workers remains to be deepened (Table 5).4.
COVID-19 has been listed as Class B infectious disease under the Law of Prevention and treatment of Infectious Diseases in China, and it is managed according to Class A infectious diseases.As an emerging infectious disease, much is still unknown about how the COVID-19 spreads, so it is easy to cause panic and psychological problems.A population-based cross-sectional study [16] explored the psychological reaction of people in China in the early stages of the COVID-19 outbreak, and found that the rates of moderate and severe anxiety among volunteers ghting the epidemic in were 32.7% and 20.4% in Wuhan and Shanghai, respectively, suggesting that during the rising stage of the outbreak, the physical and mental reactions of the masses were signi cant.In order to win this battle, the health care workers in China have made great efforts.As front-line personnel in the ght against the COVID-19 epidemic, they not only undertake heavy prevention and control tasks, but also bear tremendous psychological pressure.
Studies have shown that there is a signi cant positive correlation between depression and loneliness, 36.4% of health care workers had depression, which was higher than that reported in a previous study by Qi et al [17] , and the depression scores of health care workers with lower job title and educational background were higher.The score of loneliness of doctors was higher than that of medical technicians, the scores of depression and loneliness of health care workers in isolation ward, fever clinic and pre-check triage were higher than those of non-prevention and control posts, It shows that the psychological problems of doctors, especially doctors with low job titles and academic quali cations, as well as those in epidemic prevention and control positions are relatively serious.Shao et al [18] found that during the period of ghting against SARS, the mental health level of health care workers was lower than the domestic norm, and there were mental health problems such as anxiety, fear, etc.And doctors, especially health care workers in prevention and control posts such as isolation wards and fever clinics, rushed to the front of the epidemic.Due to the high infectivity and unknown nature of the new coronavirus, problems encountered in clinical work could not be solved in time, and there is no one to talk to in the face of the pressure of the epidemic, and there is no psychological comfort.In particular, some doctors are directly engaged in the diagnosis and treatment of COVID-19 in the isolation ward, and they are in a state of isolation for a long time and cannot be reunited with their families, but also worried about the risk of family infection, making them feel lonely and helpless, extremely prone to psychological problems.
In addition, this study found that depression had statistically signi cant differences in gender, occupation, professional title, education level and different positions.Among them, the depression score of nurses was higher than that of doctors.Qi et al [17] found that clinical nurses have psychological problems in the special period of facing COVID-19, another study by Jiao et al [19] shows that in the ght against the epidemic, nurses have a high intensity of tasks, as well as greater physical and mental pressure.There are several reasons that might cause this situation, rst of all, during the ght against the COVID-19 epidemic, nurses work intensively, have heavy tasks, and are in a state of physical and mental exhaustion.Secondly, some nurses work at front line in COVID-19 ght, thus they have a high probability of contact with infected patients, and face the risk of being isolated at any time.Moreover, COVID-19 is highly contagious and has various clinical manifestations, so there is no speci c drug at present, and the drugs previously used to treat other coronaviruses may be effective, but they need to be veri ed by further clinical trials [20] .Therefore, in the face of many uncertainties, clinical nurses are prone to varying degrees of psychological problems, such as depression, anxiety, etc.At the same time, the lack of in-depth understanding of COVID-19 aggravates the fear of nurses.
This study suggests that the social support of health care workers was negatively correlated with the scores of depression and loneliness.Further analysis of the social support of health care workers is particularly important for a comprehensive understanding of mental health status.Among them, the scores of social support of health care workers in prevention and control positions were lower.The reason is that doctors in prevention and control positions, are more likely to come into contact with COVID-19 patients, and there is a risk of infection.Their family and friends may be worried about being infected and have low support for them.In the absence of social support, health care workers tend to choose negative coping styles, such as self-attack and retreat, thus affecting their mental health [21] .Therefore, close attention should be paid to improving the psychological coping ability of health care workers under stress [22] , in order to enhance their mental health level, and then carry out epidemic prevention and control work more effectively.
In the face of the psychological problems that need to be solved urgently, this study continues to investigate the psychological needs of health caregivers, in order to provide a better solution for hospital management and improve mental health.The following reference improvement measures are obtained from the study, such as mental health lectures, psychological counseling and psychological guidance for them, because healthy psychological counseling can maintain a positive and stable state of mind to deal with unexpected situations and reduce the risk of mental disorders such as anxiety and depression [23] .In addition, it is also very important to actively care for the families of health care workers and make them feel at ease with their work.It is suggested that managers should communicate more, understand their di culties encountered in work and life, give timely help, improve their family conditions and reduce their life stress [24] .
Mental health is not only related to individual health, but also affects social function and professional ability [25] .During the ght against COVID-19, health care workers, as front-line personnel in the ght against the epidemic, face both physical and mental pressure.The quality of their work is not only related to the life safety of patients, but also related to whether the epidemic can be effectively controlled and social stability.Therefore, we should actively take mental health intervention measures for health care workers according to the psychological needs of them.This study points out that the health care workers who need to pay attention to during the epidemic can provide reference for the prevention and management of public health emergencies.

Study Limitations
This study also has some limitations.First of all, despite the widespread spread of COVID-19, this study only investigates the mental health status of health care workers in two designated tuberculosis medical institutions during the epidemic period.The conclusions are limited, so multicenter studies should be considered.Secondly, the mental health status is dynamic, and the results of cross-sectional survey can only re ect the psychological information at a certain point in time.The design method of longitudinal study will make the research results more rigorous.Finally, this study only analyzes the mental health status of health care workers from the aspects of depression, perceived social support and loneliness, which needs to be studied more comprehensively.

Conclusion
During the period of COVID-19, the psychological problems of health care workers, especially women, nurses with low educational background, low professional title, and staff in the epidemic prevention and control positions are relatively serious, and targeted intervention measures could be taken according to their psychological needs to improve their mental health.

Declarations
Ethics approval and consent to participate Since this was an observational study without any interventions, which had no any adverse effects on the study subjects, thus only oral informed consent was obtained, the procedure had been approved by the Medical Ethics Committee of Anhui Chest Hospital (K2020-004).

Consent for publication
Not applicable.

Table 1
Basic situation of health care workers [n(%)] Comparison of social support, loneliness and depression scores among medical workers of different genders, occupations, job titles and educational levels.

Table 3
Comparison among health care workers of different positions (Mean ± SD) * : Compared with non-prevention and control positions, P < 0.05, ** : The result of t-test, P < 0.05.

Table 4
Correlation analysis of social support with depression and loneliness

Table 5
The need for mental health and awareness rate of COVID-19 [n(%)]