Psychological Responses to Coronavirus Disease 2019 amongst Healthcare Workers in South Africa during the Pandemic

: Background: It is important to understand HCWs’ (healthcare workers ) psychological responses to the Coronavirus disease 2019 (COVID-19) pandemic as they are exposed to the virus on a daily basis. This study helps identify some of the challenges they face. Aim: The overall aim of the study was to investigate psychological responses to COVID-19, including vaccinations and stressors, amongst healthcare HCWs in South Africa during the pandemic. Setting: HCWs who worked in private and state hospitals and private practice in Tshwane, South Africa. Methods: A quantitative approach using a cross-sectional survey design was used. Several standardised and validated questionnaires were used in the survey including the Coronavirus-19 Fear Scale, the COVID-19-related stigma scale and the COVID-19 stress scale. A purposive sample (N=103) was analysed using descriptive statistics and chi-square. Results: There were 103 completed questionnaires. Many (76% and 54%) either


INTRODUCTION
Since the start of the COVID-19 pandemic, mental health globally has worsened, both for those with existing disorders [1] and those who have not previously been diagnosed with a psychiatric disorder. Globally, public health officials have expressed concern that fear, related to the pandemic and the COVID-19 vaccines, could make this challenging situation worse [2]. Psychological illnesses associated with social isolation, anxiety, and fear, are on the rise amongst all age groups [3], which is detrimental to individuals' overall health and well-being [2]. This is underpinned by Gan et al. [4] who report that exposure to the pandemic and associated stressors have resulted in increasing mental illnesses related to social isolation, such as depression and anxiety [5]. This has been found in all population groups globally and puts vulnerable populations at a high risk of suicidality [6 -8]. Healthcare workers are one of these populations because, as a group, they have ongoing exposure to COVID-19 and all its variants [9]. However, there is a dearth of research on HCW's responses to the COVID-19 pandemic.
De Kock et al. [10] report that amongst HCWs female nurses are likely to have the most negative mental health responses to the COVID-19 pandemic, however, it has a significant impact on all workers in the sector particularly women and older HCWs [11,12]. Robertson et al. [13] concur and noted that depression, anxiety, Post Traumatic Stress Disorder [PTSD] were found in HCWs exposed to the COVID-19 pandemic when they reviewed 19 studies. This is problematic as HCWs were stressed and suffered burnout before the pandemic. Moreover, it was estimated that 40% or more now experience burnout, 50% suffer from anxiety and many had some form of depression [14]. Tomlin et al. [15] report that the mental health of HCWs can be enhanced by the organisations they work for in terms of proper provisions being made for them in terms of specific models and interventions. This is supported by the Department of Health in South Africa [16], which reports that managing stress, anxiety, and the mental health of HCWs during the COVID-19 pandemic is of critical importance.
Although vaccines can reduce the likelihood of morbidity and mortality associated with COVID-19, according to the World Health Organisation (WHO) [17], it was estimated that in 2021 only 1 in 4 HCWs in Africa had been vaccinated against COVID-19, it is unlikely that this has changed substantially. Wiysonge [18] reports that vaccine hesitancy is high among HCWs in Cape Town, South Africa and that older individuals were more likely to show vaccine acceptance. This is supported by Daniel [19] who indicated that up to 47% of South Africans would not get vaccinated because of its perceived lack of efficacy, not liking vaccines and possible side effects. At the time of this research, it was estimated that over 60% of public HCWs in SA have been vaccinated [20]; however, it seems a sizeable proportion are hesitant to vaccinate (there are no statistics available for HCWS in the private sector).
Vaccine hesitancy exists worldwide, for instance, Callaghan et al. [21] report that in the United States of America (USA) nearly a third of adults in the country, particularly women, conservative persons, and people of colour, did not want to have the COVID-19 vaccination because it was not [in their opinion] safe or effective. In support of this Jolley and Cookson [22] report that 1 in 6 British adults are likely to refuse the COVID-19 vaccine. This is important because to develop resistance to COVID-19, or so-called 'herd immunity,' around 70% of any country's population needs to be vaccinated against it. In South Africa, there are many negative opinions related to the COVID-19 vaccines, which suggests there is a rise in the anti-vax movement [23]. A survey carried out by Daniel [19] suggested that in December 2020 up to 47% of South Africans would not get vaccinated because of their perceived lack of efficacy, not liking vaccines and possible side effects. Schmidt et al. [24] support these findings as they found that false information, or conspiracy theories, that were accessed via social media instilled 'confusion, fear and panic' into the populace and heightened 'stigmatising' responses. Cooper et al. [25] report that disinformation and conspiracy theories drive concerns people have about vaccine safety and efficacy in South Africa.
The pandemic was in a stable or chronic phase in South Africa at the time this article was written, however, it is certainly putting a strain on both private and public hospitals and their staff as it was in the acute phase [26]. As all restrictions have been lifted it will only be in several months' time South Africa may see any rise in infections. It is thus important that psychological responses to the COVID-19 pandemic are documented so as to respond appropriately to the HCWs mental health needs before another wave of infection. To do this, it is necessary to find out the levels of fear, stress, and anxiety among HCWs, as well as levels of vaccine acceptance.
The conceptual framework of this research is linked to factors that are associated with the COVID-19 pandemic, for instance, socio-demographic determinants with variables such as chronic illness, race, and age [27].
The study aimed to investigate psychological responses to COVID-19 amongst HCWs in South Africa during the COVID-19 pandemic. Its objectives were to: explore the differences in demographics and social indicators in the sample associated with the COVID-19 pandemic; examine the psychological responses to COVID-19 and consider HCWs' acceptance of the COVID-19 vaccination.

Study Design
The study utilised a quantitative approach and a crosssectional survey design.

Setting
HCWs approach included medical practitioners and allied healthcare professionals such as psychologists and nurses.

Study Population and Sampling Strategy
As it was not possible to hand out survey questionnaires owing to COVID-19 pandemic health protocols a purposive sample of 20 HCWs were identified by the researchers and emailed surveys. Snowball sampling was then used as the identified HCWs were asked to send the protocol on to colleagues. One hundred and three (103) questionnaires were returned that were properly completed and constituted the final sample.

Data Collection
English was the medium for the survey as the healthcare professionals were all trained in that medium. The protocol consisted of several instruments. Demographic questions provided information such as gender, age, any underlying risk factors, family structure and if respondents knew of someone who had died or recovered from COVID-19. The Coronavirus-19 Fear Scale. This instrument measured fear of COVID-19 using a five-point Likert type scale from 'strongly disagree to strongly agree'. Internal consistency or Cronbach Alpha of the overall scale was, α = .82 [28]. In this study it was α = .80. The COVID-19-related stigma scale [29] was used. It is a 12-item COVID -19 related stigma scale which measures self-reported perceptions of stigma to COVID-19. It uses Likert scale type measurements from 'strongly agree to strongly disagree'. The scale has an overall internal reliability of Cronbach Alpha, α = .74, which was found to be the same in this research. The COVID-19 Stress Scale was used to measure stress and anxiety [30]. The instrument has a Likert scale response format from 'never to 4 almost always'. Cronbach Alpha was estimated at α = .93 in American and Canadian samples and α = 0.90 in this research. Various items of the vaccine acceptance survey developed by WHO, UNICEF (United Nations Children's Fund) and NITAG (National Advisory Committee on Vaccinations, 2020) were also used which had a Cronbach Alpha, α = .78. Lastly, the Perceived Mental Healthcare Needs of Participants during the COVID-19 Pandemic was adapted from Roy et al. (2020) [31]. This 4item questionnaire was used as a self-report mechanism for HCWs to report their mental health needs. In our adapted version it used a 'Yes' and 'No' scoring format.

Data Analysis
Data were uploaded into the spreadsheet by one of the researchers. Another researcher analysed the data which was checked by another member of the research team. Data were cleaned and checked for any outliers however, none were found. Missing data in the spreadsheet was checked against the protocols and errors were corrected.
Descriptive statistics were used to give a broad overview of the data that is, percentages, frequencies, and correlations. Correlation analysis was used to see if there were any associations between COVID-19 fear, anxiety, stress, and mental healthcare needs. An independent t-test was used to see if there were any significant differences between male and female HCWS who participated in the study, stress, and overall mental health healthcare needs as well as acceptance of the COVID-19 vaccination.

Ethical Considerations
Ethical clearance was given from the University of Limpopo's Research Ethics Committee (TREC) number TREC/459/2020: IR. We have followed all the guidelines of the Helsinki Declarations.

Demographic Characteristics of the Participants
Thirty-nine percent (39%) of the sample of HCWs were male and 69% were female. Twenty-nine percent (29%) of the sample were in the age range 20 -29 years, 36% were aged 30 -39 years, 19% were aged 40 -49 years, 11% were aged 50 to 59 years of age, 4% were aged 60 to 69 years and 1% were age 70 to 79 years of age. In terms of ethnicity, 89% of the sample were black, 9% coloured, 1% Indian/Asian and 1% white. Educational achievements by the sample were 47% had a matriculation certificate, 31% had a degree, 12% had postgraduate degrees and 1% noted 'other' academic achievements. Forty-four percent (44%) of the HCWs were single, 17% were single with a child, 4% were married with one child, 32% were married with more than one child and 3% stated 'other.' In terms of socio-economic status, 57% identified as working class and 43% identified as middle class.
The response rate was 51.5%, and the majority of the respondents were Black and female. Males were underrepresented as this was a purposive sample and gender was not stratified. The sample was diverse in terms of age, educational attainment, and family status ( Table 1). Sex differences in HCWs' personal knowledge of death and illness related to COVID-19 were analyzed with t-tests and are presented in Table 2. As seen in Table 2, most variables related to personal knowledge of death and illness related to COVID-19 did not differ across males and females. The exception was that males were more likely than females to know someone who had contracted the COVID-19 virus.
These results do not include any persons who the HCWs have treated in a hospital or clinic setting (which is made clear in the protocol).
Over a third (37%) of the sample agreed that they were very afraid of COVID-19 as shown in Table 3. Overall, 42% felt uncomfortable when thinking about the virus. Additionally, 15% indicated that their hands started to sweat when they thought about COVID-19. In total, 35% of the sample thought they might lose their lives to the virus. Twenty-nine percent of respondents noted feeling nervous or anxious when listening to stories about the virus on social media. Nine percent reported not sleeping because of worry and 15% indicated that they suffered palpitations when thinking about COVID-19. There were no sex differences in these outcomes.  Overall, 12% of the sample reported thinking about the virus when they did not want to and 24% noted that disturbing mental images about the virus popped into their minds against their will, refer to Table 4. Seventeen percent had trouble concentrating because of the virus while 19% noted having physical symptoms (pounding heart and/or sweating) when they were reminded about COVID-19.

HCWs Vaccine Readiness and Vulnerability to COVID-19 Infection
The majority of HCWs responded that they were likely or very likely to become infected with COVID-19 (79.61%). An independent t-test was undertaken to ascertain any differences between the male and female groups in regard to their perceptions of the likelihood of contracting COVID -19.
The majority of HCWs responded that they were likely or very likely to become infected with COVID-19 (79.61%). An independent t-test was undertaken to ascertain any differences between the male and female groups in regard to their perceptions of the likelihood of contracting COVID -19.
The majority of HCWs (80.5%) reported that they were likely or very likely to have the vaccination and booster for COVID-19. An independent t-test was undertaken to ascertain any differences between the male and female groups in regard to their likelihood of having the COVID-19 vaccination and boosters. Males were more likely than females to indicate they were likely to take the COVID-19 vaccine, t (101) = 2.41, p = .02. Table 5 looks at the relationship between the age of the HCW and their family structure, fear of COVID-19 and any chronic disease such as hypertension and diabetes.
The majority of the sample were single or single with a child and aged between 20 to 30 years. Younger persons 20 -30 years were less likely to be afraid or show symptomology associated with fear and stress, in terms of COVID-19, than those in older age groups. Age groups from 40 -79 years of age were also more likely to have chronic disorders such as high blood pressure and diabetes.

DISCUSSION
The COVID-19 pandemic has been a major stressor for HCWs worldwide particularly women [11]. Results in this research, to some degree, support this finding as female HCWs are more likely to have bad dreams about the virus and reported knowing more people who had contracted the virus. Age appears as a protective factor against the fear of the disease with younger HCWs being less likely to show fear and anxiety in relation to COVID-19 than older ones [12]. This finding is supported by research results in this research which indicate an association between fear of COVID-19 and age, with younger persons being less prone to fear and anxiety related to the virus. It is likely that psychological illnesses such as depression and anxiety are more likely to be found in older HCWs [11]. Older HCWs also reported more chronic disorders such as high blood pressure and diabetes. Proper support for HCWs who have chronic illnesses, and are thus at high-risk of contracting the virus, must be provided to ensure they have minimal exposure to . Wiysonge [18] reported that vaccine hesitancy is high in Cape Town, South Africa amongst HCWs. The results in this study do not support that finding, albeit with a smaller sample. Most of the HCWs in the present study would be likely to have the vaccination (80.5%). Although this is a high proportion of the sample it still means that 19.5% would not be likely to be vaccinated which infers there is still vaccine hesitancy amongst some HCWs as reported by Daniel [19] and the rise of the anti-vax movement in the country [23]. Moreover, 79.61% of the sample responded that they were likely to become infected with COVID-19 which indicates they may not have adequate protection against the virus [9]. The findings of the present study suggest that mental healthcare intervention for HCW's during a pandemic should be a priority in order to protect the psychological wellbeing of the healthcare community. It is further advocated that healthcare managers be involved in the development of guidelines and policies aimed at maintaining mental health and the overall well-being of HCWs.

LIMITATIONS
On the other hand, the study has limitations; it had a purposive sample thus results cannot be generalised. It was also a cross-sectional survey that measured responses at one moment in time thus correlational data could only be measured. Additionally, the data looked at HCWs generally and did not consider differences in groups [medical professionals, nurses, etcetera]. The length of service of the HCWs was not asked in the questionnaire which, on reflection, should have been asked.

IMPLICATIONS
The results of this study indicated that older HCWs are more likely to suffer fear, which will likely result in psychological distress. Female HCWs were also more likely than males to be fearful about COVID-19. It is apparent that the psychological well-being of HCWs needs to protect during pandemics as, although the majority may not be fearful or overly stressed, those that may suffer burnout or depression. As the majority of HCWs have direct contact with patients with the virus support for them should be made readily available and easily accessible, more so for the older HCWs who are more vulnerable to the disease.

RECOMMENDATIONS FOR FUTURE RESEARCH
A larger sample of HCWs should be recruited to validate the results of this study. Furthermore, much more research should be conducted to explore the long-term effects of 1) treating and nursing COVID-19 patients and 2) the effects of long COVID on HCWS. Additionally, a larger, randomised mixed-methods study exploring vaccine hesitancy and stigmatisation of COVID-19 amongst HCWs should be conducted.

CONCLUSION
Healthcare professionals across all categories have, arguably, suffered more anxiety and psychological stressors than any other part of the community. The present research found that fear, anxiety, and stress exist amongst a portion of HCWs although the majority appear to be coping with stressors. It appears that being female and older is more likely to be associated with psychological distress. Older HCWs were more likely to have a chronic illness and thus be more vulnerable to COVID-19. Those over 40 years of age are likely to have more experience in a clinical setting and are thus more aware of the risks of contracting an infectious disease, and the consequences thereof. This group, especially females and those with comorbid disorders should be prioritised in terms of both medical and psychological interventions. However, all HCWs require ongoing support. Continuing information sessions and briefings about the virus and efficacy of vaccinations against COVID-19 should take place. These timely psychological counselling and intervention sessions should be implemented for HCW's to alleviate and mitigate their anxiety and stress in a crisis as well as improve their mental health.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
Ethical clearance was given from the University of Limpopo's Research Ethics Committee (TREC) number TREC/459/2020: IR

HUMAN AND ANIMAL RIGHTS
No animals were used for studies that are the basis of this research. All the humans were used in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration.

CONSENT FOR PUBLICATION
The written informed consent form was taken from the participants.

STANDARDS OF REPORTING
STROBE guidelines were followed.

AVAILABILITY OF DATA AND MATERIALS
The data supporting the findings is available with in the article.

FUNDING
The study was not externally funded.