The psychological impact of the COVID-19 pandemic on physiotherapists in Sri Lanka: a cross-sectional online-based study

INTRODUCTION

Corona virus disease-2019 (COVID-19) is a global health concern which was declared as a pandemic in March 2020. The majority of countries proclaimed public health emergencies.

When considered up to date situation of COVID-19 in Sri Lanka, the patient count and deaths have been increased in considerably higher amounts.¹

This pandemic has caused unprecedented psychological distress among healthcare workers throughout the world.² Physiotherapists are a group of healthcare professionals on the frontline of managing this pandemic and have direct exposure to the virus.

Physiotherapists are usually considered as first contact practitioners in managing COVID patients.³ They have to work with patients' secretions/respiratory droplets, which is the most common form of virus transmission.⁴ It is difficult to maintain the recommended level of physical distance when offering adequate physiotherapy treatment.

The physiotherapists are affected badly in their psychological status due to many reasons during this pandemic, such as disruption in smooth functioning of personal life due to avoiding physical contact with family and society, inability to fulfil family responsibilities due to tight work schedules and self-isolation strategies, inability to give necessary parental support for children, fear of infecting themselves, fear of infecting family members, highly vulnerable family members, difficulty in fulfilling the needs like transport, daily needs, society discrimination of healthcare workers as vectors of the virus, workplace situations such as tight work schedules, limited number of staff, excess working hours and workload, work related fatigue, wearing Personal protective equipment (PPE) in hot humid climatic situations, shortage of PPEs and adaptation to telehealth strategies which are new to them.^5-12 The above-mentioned factors can act as stressors for physiotherapists, and they may be going through a stage full of work-related stress.

Physiotherapists’ health, efficiency and productivity at work, and occupational well-being may be negatively impacted by stress, anxiety and depression.^13-16 Patient dissatisfaction, burnout, post-traumatic stress disorder, depression, and a rise in undesirable personal behaviors such as anger, anxiety, and irritability are all long-term impacts of stress.^17-19 There is a lack of evidence on the psychological status of Sri Lankan physiotherapists during COVID-19 pandemic, and studies are needed to assess the impact of COVID-19 on physiotherapists’ psychological health.²⁰

The aim of the study was to determine the prevalence of stress, anxiety and depression among physiotherapists during COVID-19 pandemic in Sri Lanka. Also, we assessed the associations between these psychological components with each other, the factors associated with stress, anxiety and depression, and the relationship between these psychological components with age and gender among physiotherapists. The findings will be helpful to enhance the physiotherapists’ mental health during the pandemic and in other ways it will help to increase their involvement to control the pandemic actively and efficiently.

METHODS

This was a hospital-based, descriptive cross-sectional study conducted among physiotherapists in Sri Lanka to assess the psychological status of physiotherapists in Sri Lanka during the COVID-19 pandemic. The data were collected from July to September 2021. Forty-eight physiotherapists (regardless of age and gender were recruited from government and private hospitals all around the country via purposive sampling. Physiotherapists who did not consent and who were on leave for special reasons such as medical leave, study leave, or maternity leave, and returned from abroad less than 6 months ago were excluded from the study to ensure that all participants have been adequately exposed to the pandemic situation in the country.

The questionnaire consisted of three sections: sociodemographic data, factors related to stress and the Depression-anxiety-stress scale (DASS-21) to assess psychological components. The socio-demographic questionnaire was designed to collect participants’ information on age, gender, marital status and facts regarding current working place. They were given a list of factors which can cause stress in the part II of the questionnaire and asked to identify the factors which induced stress on them. The factors which can cause stress in healthcare workers were identified by reviewing previously published literature and carefully selected relevant and possible factors to be included in the questionnaire. They were also given the opportunity to state other factors which caused stress on them in addition to the list of factors given in the questionnaire.

The short form of the DASS questionnaire consisted of 21 items, which was used to identify the psychological issues among physiotherapists. This scale consisted of three subscales: stress, anxiety and depression. Each subscale consisted of 7 questions. The scores were given as 0-3 based on responses ranging from never to almost always. The maximum score for each item was 42.

Ethical approval for this study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka (ERC: EC-21-027). The responses of the Google form were only accessible to the principal investigator and secured confidentially with passwords. Only the investigators had access to the data for analysis and storage. The Google form link was sent along with the informed consent form and participants were supposed to respond to the consent form prior to participate in the study. Informed consent form was consisted of all the necessary information, including the purpose of the study, rights of the participants, and a brief introduction to the study. All the participants were given the right to independently decide their participation and were asked to respond to the questionnaire at a convenient time.

The study was carried out for a period of two months starting from July 2021. The self-administered online questionnaire was distributed via email and social media among physiotherapists in Sri Lanka. The participants had to spend 20-30 minutes to complete the questionnaire.

Analyses were conducted using SPSS for windows (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) at a significance level of 0.05. Descriptive statistics were used to define the prevalence rates of stress, anxiety, depression, factors causing psychological distress and sociodemographic factors. Pearson correlation was used to find out the association of stress, anxiety and depression components with each other. One-way ANOVA test was used to assess the association of each psychological component with age and the chi-square test was used to find the association of psychological components with gender.

RESULTS

Stress, anxiety and depression were assessed using the validated DASS-21 questionnaire.

General demographic data, work experience and family related data of the study participants are given in Table 1. The mean age±SD of the participants was 30.19±3.8 years. A majority of the sample was female (76.2%).

Table 2 shows the prevalence rates of stress, anxiety and depression among the physiotherapists.

Stress scores calculated from DASS were categorized into 5 levels as normal, mild, moderate, severe and extremely severe. The scores relevant to the above stress levels are 0-14, 15-18, 19-25, 26-33 and 34+ respectively. The mean score of stress in the sample was 23.19±5.894. 9.5% of the physiotherapists perceived no stress and a majority of the sample (35.7%) had a moderate level of stress.

Anxiety scores received from DASS were categorized into five levels: normal (0-7), mild (8-9), moderate (10-14), severe (15-19) and extremely severe (20+). The mean anxiety score of the sample was 22±6.492. A majority (61.9%) of the participants had extremely severe level of anxiety. No participants were identified without anxiety or mild levels of anxiety.

Depression scores were also categorized into five levels as normal (0-9), mild (10-13), moderate (14-20), severe (21-27) and extremely severe 28+. The mean depression score of the sample was 22.43±7.477.

No participants were found without depression and with mild depression. A majority of the sample (52.4%) had moderate levels of depression.

The association of main psychological components (stress, anxiety and depression) with each other was assessed using Pearson correlation test. There were statistically significant association and a strong positive correlation between each component. Table 3 summarizes the results of Pearson correlation tests.

Majority of the participants (81%) have identified ‘risk of infection of family members because of them’ as the main stressor followed by ‘risk of infection of themselves’ (61.9%). ‘Adaptations to new technology like telehealth’ causes minimum stress (9.5%) to physiotherapists in the sample. Table 4 summarizes the factors causing psychological distress among physiotherapists. In addition to the factors in Table 4, participants reported other factors including family responsibilities, lack of personal protective equipment, seeing lots of deaths per day and negative attitudes of the society as healthcare workers are a host of the virus are other factors causing psychological distress.

Pearson correlation test was used to find out the association of stress, anxiety and depression levels with age separately, whereas they did not show a statistically significant association and the correlation was negative while not strong. The results indicated p=0.487, r=-0.110 for stress with age, p=0.240, r=-0.185 for anxiety with age and p=0.365, r=-0.143 for depression with age.

Independent sample t test was used to find out the association of stress, anxiety and depression levels with gender separately. The p values for the associations of stress, anxiety and depression with gender were p=0.142, p=0.074 and p=0.417 respectively, and they were not statistically significant.

Note: *-r value was calculated to assess the correlation for the associations. Pearson correlation test (bivariate) was used; **-p value was calculated to test the significance of the associations.

Note: Frequency and percentages were calculated by descriptive statistics.

DISCUSSION

This study was conducted to assess the psychological status of physiotherapists working in hospitals, and to identify the factors causing psychological distress during the COVID-19 pandemic. To our knowledge, this is the only study conducted among physiotherapists in Sri Lanka to assess their psychological status during the pandemic.

According to the results of the current study, it is clear that the physiotherapists working in Sri Lanka perceive considerable level of psychological distress. We identified 90.5% physiotherapists with stress, while anxiety and depression were present among all the participants with varying degrees. The percentages of normal, mild, moderate, severe and extremely severe stress categories were 9.5%, 16.7%, 35.7%. 33.3% and 4.8% respectively. When considering anxiety levels, the rates of moderate, severe and extremely severe categories were 9.5%, 28.6% and 61.9% respectively. Moderate, severe and extremely severe levels of depression were prevalent among 52.4%, 19.0% and 28.6% of the population respectively. No one was found with normal and mild categories of anxiety and depression. Stress, anxiety and depression were associated with each other and positively correlated, implying that the exaggeration of any component of these three can lead to the same in the other components. These psychological factors were not dependent on the sociodemographic factors such as age and gender.

The findings of the current study were consistent with those of similar studies conducted in other countries. Fear of infecting COVID-19, anxious about being shifted to the ward for COVID-19 (18.4%), concern about being quarantined or isolated, risky nature of the job which makes them infected (48.3%), the possibility of infecting close relatives by them (48.7%), staying away from others due to their job, being stigmatized by others due to their job, wearing PPEs, insufficient PPEs and tight work schedules were revealed as causes for psychological distress.^21-28

A cross sectional study was conducted among 262 healthcare workers including physiotherapists in Egypt during the COVID-19 pandemic has revealed that 98.5% had moderate to severe stress, 90.5% had different levels of anxiety, whereas a majority (40%) showed mild anxiety. Further, 94% of the population suffered from mild to severe depression.²¹ The situation among physiotherapists in Sri Lanka appears to be more complicated than in Egypt, as prevalence rates for all the above components are higher in Sri Lanka, with the majority falling into the severe and extremely severe categories. The increase in COVID -19 positivity rate and death rate in a very high degree in Sri Lanka compared to Egypt during the time of conducting these studies should be the reason behind the increase in levels of psychological distress.²⁹ A study conducted among different categories of healthcare workers in Sri Lanka during the COVID-19 pandemic showed 53.3% with depressive symptoms and 51.3% with anxiety symptoms, which is still lower than the prevalence rates in the current study.³⁰ This can be attributed to the fact that the study periods of these studies are different as the average patient counts at the time of conducting this previous study ranged from 0.88-1.79 cases per million people, while those in the current study ranged from 85.87-92.78 cases per million. Also, the psychological impact of the pandemic may differently perceive among healthcare workers depending on the nature of the duty with the COVID-19 patients. Death rates were also progressing in the same way, and the gradients of patient and death counts were continuously increasing during this time.³¹

Moreover, the number of HCWs who were verified positive for COVID-19 grew over the study's duration. Mean age of the study population in the current study (30.19±3.8 years) is less compared to this study (37.5±9.4 years) and it is also supposed to be a cause to increase in mental distress in current study supporting the evidence that work experience and age are negatively correlated with occupational stress.³² The risk of infecting family members was the main stressor in both studies as Sri Lankan culture is centralized around family compared to other countries.³⁹ Even when physiotherapists are given specific attention in the current study, their psychological state is still poor when all healthcare workers are addressed as a group, underscoring the need for special emphasis on the psychological status of physiotherapists.³³ However, a study conducted in Singapore has shown that 8.9% of the HCWs were with depression, 14.5% were with anxiety and 6.6% were with stress which are small rates compared to the current study and other studies.²² The timeframe of conducting this study should be the ground for this contrast, as it has been done in the first wave of COVID-19 and only 200 confirmed positive cases without any deaths were recorded, which is a total controversy for the condition in Sri Lanka during the period when this study was conducted.²³ The results of these two studies clearly reflect how the positive case count is associated with psychological distress.

Published evidence to assess the psychological status of physiotherapists is scarce. A study conducted in South Korea among 65 physiotherapists revealed the percentages of anxiety and depression were 32.3% and 18.5% respectively, which is definitely lower than in the current study. Conduction of the study in the first wave of the pandemic and lesser exposure to the virus should be the reason behind the lower prevalence rates of this South Korean study.²⁶ Exposure to COVID-19 patients and maintaining close contacts with patients is highly correlated with stress, anxiety and depression and it is obvious that increase in patient count leads increase in persisting psychological distress. Hence, their psychological level must have worsened at the time of writing than to the time conducted this study.³⁴ Moreover, a prediction of daily death count over 200 and a total death toll of 20000 by September was published by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington may also have led to induce stress, anxiety and depression in the targeted population.³⁵

As the psychological components were not associated significantly with the age and gender implying that physiotherapists are affected mentally by this pandemic regardless of the sociodemographic characteristics which is strengthened by the same evidence in the above-mentioned Egyptian study and Sri Lankan study.^21,30

The psychological status among physiotherapists in Sri Lanka is considerably retarded when compared with the evidence throughout the world among other healthcare workers as well as among physiotherapists. As the study population in this study were from different types of hospital settings which have different exposure levels to COVID-19 patients, distributed throughout the country and the sample represents both government and private sectors it shows how the physiotherapists’ psychology have been affected all over the country.

Limitations

Small sample size was the main limitation of the study. The low response rate might be due to physiotherapists’ tight work schedules and the fact that they were preoccupied with household duties in their spare time. Furthermore, in light of their difficult condition, forcing them to answer to Google forms was unethical. Due to the inability to conduct face-to-face interviews due to the current pandemic crisis and the hectic schedules of physiotherapists, the study was conducted online via a Google form. As a result, some physiotherapists might have missed to respond due to the unavailability of internet facilities at hospitals and not interested in cutting-edge technologies.

CONCLUSION

The physiotherapists in Sri Lanka experienced higher levels of stress, anxiety, and depression during the COVID-19 pandemic, which requires specific attention. It's essential to monitor physiotherapists' mental health on a regular basis and take the necessary actions to improve their mental health.

ACKNOWLEDGEMENTS

The authors would like to thank the respondents who participated in the online survey.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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