Occupational Health Conditions Among Healthcare Workers During the COVID-19 Pandemic

Introduction

In 2019, the COVID-19 pandemic originated in Wuhan, China, when deaths due to pneumonia of unknown etiology were reported. Subsequently, the coronavirus responsible for severe acute respiratory syndrome, named SARS-CoV-2, was identified [1]. The first case of COVID-19 in Mexico was detected in March 2020. Hence, the Mexican government implemented control phases to prevent the spread of this virus, including lockdowns on the public, private, and social sectors [2]. States were encouraged to define hospital reconversion plans to ensure timely health care for COVID-19 cases, considering health system activities as essential [3].

In this context, occupational accidents and work-related diseases have posed a concern for health systems, as they cause economic, social, and mental impacts and result in economic losses due to disabilities and/or loss of working life years. Occupational health, as defined by the World Health Organization (WHO), the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations through the prevention of health deviations, risk control and the adaptation of work to people, and people to their jobs [4]. Moreover, health organizations must deal with psychosocial impacts, which directly exert influence on the quality of health care delivery [5]. The Job Demands-Resources Model states that maintaining a balance between the work environment and available resources is a determinant that affects occupational health. This model seeks to explain how multiple risks at work affect in terms of economic losses, mental health and even the quality of care provided to patients [6].

In Mexico, healthcare workers are in occupational settings with a high potential for exposure to COVID-19, classified as an occupational disease [7]. 283,122 cumulative COVID-19 cases were reported nationwide, with nursing staff accounting for 38.9%, physicians 25.3% and other health professionals 32%. Of the 4,517 confirmed deaths, 45% occurred among medical personnel, 19% among nursing staff, and 31% among other professionals [8].

Healthcare workers in close contact with infected patients were reported to experience symptoms of distress, depression, anxiety, and insomnia, attributable to the risk of contagion, feelings of vulnerability or loss of control, concerns about personal and family health, the spread of the virus, work changes, and isolation [9]. From a psychosocial perspective, the Demand-Control Model and the Effort-Reward Imbalance Model highlight that in work environments with high demands, limited control, or insufficient rewards, stress and anxiety levels tend to increase. This is particularly evident during crises such as the COVID-19 pandemic, where work overload and a shortage of personal protective equipment (PPE) exacerbated stress and anxiety [10,11]. In addition, we identified that the front-line nursing staff experienced the highest levels of anxiety, stress, and depression, which were mainly related to the shortage of PPE, followed by a lack of technological equipment and human resources [12].

Additionally, ergonomic occupational risks were identified, with more than 70% of workers experiencing muscle pain or sprains and 56% reporting posture problems. Among physical hazards, the most common were slips and falls, forced postures, and repetitive activities [13-15].

The interaction between workers and their activities during contingency affected their performance and quality of working life. Several studies have shown that the lack of PPE during the COVID-19 pandemic resulted in increased fear [12,16]. On the other hand, Wauters et al. reported that institutional support, proper implementation of safety protocols, work organization, and training are protective factors that contribute to maintaining a favorable work environment and satisfactory quality of life [16].

However, it has been observed that healthcare workers in healthy work environments show high levels of work engagement, strive for excellent patient care and improve care quality techniques, even in difficult situations [17,18]. This study focused on the secondary level of care, as it experienced a higher demand for medical services. Patients with complications from the disease required hospitalization and specialized management, which extended their hospital stays and increased the workload and altered occupational health. Therefore, the objective of this research was to analyze the occupational health conditions of healthcare workers in a secondary care hospital during the first year of the COVID-19 pandemic to explore their working conditions to improve and promote safe and healthy work environments. The hypothesis that guided the research is that during the first year of the COVID-19 pandemic, healthcare workers in a secondary care hospital experienced poor occupational health conditions, including physical and mental health problems, high musculoskeletal risks, low quality of work life, and unsatisfactory perceptions of workplace safety.

Method

Design and Context

We conducted a quantitative, observational, and retrospective study. The target population included healthcare personnel from medical, paramedical, and general services departments who worked during the first year of the COVID-19 pandemic (2020) at a secondary care hospital clinic that delivers health services to government workers and is located in the state of Veracruz, Mexico.

Participants

The population size consisted of 673 workers; the sample was determined using the formula for finite populations with a 95% confidence interval and a 7% margin of error. This margin was chosen due to continuing restrictions, as the hospital had been converted to care for COVID-19 patients and the data collection period was limited. A total of 159 workers were included in the sample, selected through random sampling. Inclusion criteria required participants to have worked during the first year of the COVID-19 pandemic for more than six months.

Tools and Variables

Healthcare workers participated in a survey for data collection using a 103-item questionnaire, which included an informed consent section and five domains:

1) Sociodemographic characteristics: Health (diseases or risk conditions, occupational accidents, and work-related diseases) and work (job role, type of personnel, employment history, etc.). 2) Job satisfaction and quality of working life: A 31-item questionnaire with seven domains assessed satisfaction levels as low (≤ 40th percentile) or high (≥ 60th percentile) for variable analysis. Validation was conducted through expert consultation and Exploratory Factor Analysis (EFA), complemented by relevant validity using the average square root of communality (0.68). Reliability was measured with Cronbach’s Alpha (α = 0.95) [19]. 3) Occupational safety climate: A 29-item Nordic Occupational Safety Climate Questionnaire assessing safety perception on a low-to-high scale. Validation through EFA explained 84.6% of total variance, with reliability measured as α = 0.88 [20]. 4) Mental health: The Depression, Anxiety, and Stress Scale (DASS), including seven items per subscale, was quantitatively assessed by average scores for each domain. EFA with varimax rotation explained 46.6% of total variance, and reliability was α = 0.86 [21]. 5) Musculoskeletal symptoms: The Standardized Nordic Questionnaire explored pain in 11 body areas using "yes" or "no" responses. EFA explained 72.5% of total variance, and reliability was α = 0.86 [22]. All questionnaires were standardized and validated for the Mexican population.

Data Processing and Analysis

Microsoft Excel for Mac (version 16.69.1) was used for data cleaning and coding. The normality assumption was tested using the Kolmogorov-Smirnov test, as the sample size exceeded 30 participants. Since the continuous variables did not meet the normality assumptions, nonparametric tests were used to compare the continuous occupational health variable. Univariate analyses were conducted for descriptive statistics (frequencies and proportions) and measures of central tendency. Bivariate analyses were conducted for group comparisons, using the chi-square test for categorical variables. For comparisons of the continuous variable across more than two independent groups, the nonparametric Kruskal-Wallis test was applied. Finally, a multivariate analysis was conducted to reduce the dimensions of analysis and generate the new occupational health variable. The categorical principal components technique was employed, as it was suitable for the nominal and ordinal measurement scales of the instruments. The instruments mentioned above were selected based on a literature review, and the decision to include them in this study was based on a review by expert researchers in occupational health. No adjustments were made for complementary variables during the creation of the new variable. This new variable was elaborated considering tools 2 to 5 and measured from 1 to 100, with the higher score, the better occupational health. The open-source R Studio software (version 4.0.3) was used for analysis and graphical representation. No missing values were identified in the statistical analyses.

Ethical Considerations

This research was approved by the Health Sciences Research Board, with reference number M182/2023, and the Ethics Board of Instituto de Salud Pública, attached to Universidad Veracruzana, with reference number CEI-ISP-UV-R08/2023. Additionally, a "No Coercion" form and approval from the Teaching and Research Coordination of the Hospital Clinic were obtained with reference number 002/038/466.

Discussion

This study analyzed the occupational health conditions among healthcare personnel during the first year of the pandemic. We found low satisfaction with the quality of work life among the medical and general services departments, as well as low and very low levels of safety perception in the work environment. Moreover, an unequal distribution of PPE and COVID-19 training was identified, resulting in statistically significant differences between the departments.

Regarding professional development inside of the institution, a considerable proportion of medical and general services workers did not receive COVID-19 training, as reported by Mera-Mamián et al. [23], where more than 50% of the personnel stated that training was limited or absent.

On the other hand, the literature has reported that PPE is one of the scarce resources. However, this study found that the most disadvantaged department was that of the general services compared to the medical and paramedical departments, which exceeded 80% of their staff receiving PPE [12]. The surgical mask, with more than 60%, was the most commonly used PPE across all staff, consistent with other studies where the proportion was similar [23-24].

Regarding the availability of PPE, unequal distribution was reported in Peru, the healthcare workers without contracts received less PPE compared to those with permanent contracts. Additionally, younger workers were found to receive incomplete PPE compared to those over 55 years of age [24]. The authors suggested that full PPE was prioritized for older adults due to their higher vulnerability to COVID-19. This corresponds to the measures taken by Mexico, where individuals aged 60 and above were considered at higher risk for complications from COVID-19 [7]. Shortages of PPE were associated with a decline in mental health and emotional exhaustion, particularly among frontline healthcare workers.

Concerning health characteristics, approximately 43% of healthcare personnel reported having a condition or disease that posed a risk for them. This proportion was similar to what was reported by Delgado-Valencia et al. [25], in 2020, where 45.5% of workers indicated having a chronic disease. The most prevalent conditions were obesity, hypertension, and diabetes mellitus.

Regarding hypertension, other studies on the Mexican population have found a higher prevalence up to 13%. For obesity, the sample analyzed in this study had a higher prevalence of 12%, while for diabetes mellitus the prevalence observed was similar to what has been reported in other studies among physicians and nursing personnel [25-27].

According to the analyzed variables regarding occupational health, low satisfaction with the quality of work life prevailed among the medical and general services departments. These results differ from those found by other authors in Latin America, since they have reported that more than 65% of healthcare personnel were moderately satisfied with their quality of working life [28,29]. Moreover, other studies have highlighted that training and institutional support are factors that contribute to satisfaction with quality of working life and creating a beneficial environment for professional development [16].

This could be attributed to the level of institutional support received, as these two types of personnel showed similar outcomes for training and PPE provision. Moreover, training was identified as an essential resource requiring reinforcement, as access to specific knowledge enhances the response to health emergencies. Conversely, inadequate training undermines healthcare workers' confidence in their ability to provision quality care [30,31]. Likewise, a study in the United Kingdom found that healthcare workers redeployed during staff shortages and lacking adequate, or any training were significantly more probable to experience symptoms of post-traumatic stress disorder [32].

Additionally, more than 40% of healthcare personnel perceived a low safety environment within the hospital. It is noteworthy that this situation predominantly affected the paramedical and general services departments. Interestingly, these departments had a higher proportion of personnel with children, which could imply greater sensitivity toward safety issues. The literature indicates that the fear of infecting a family member was a relevant factor contributing to the experience of fear and anxiety when working with infected patients [9,12].

A systematic review found that low-resource countries, healthcare workers experienced low satisfaction with the infrastructure and poorly ventilated rooms, as well as the poor conditions of isolation rooms for infected patients and the lack of institutional support to provide the correct PPE which put his physical and mental health at risk [33]. These results are in line with what is found in the literature, where low and very low safety levels are most common among healthcare personnel who worked during the COVID-19 pandemic [34,35].

Regarding physical discomfort, it has been reported that medical department show a higher prevalence of physical discomfort (pain), ranging from 60% to 80%, while the paramedical personnel show a lower prevalence [36]. The findings of this study are consistent with this, as the medical department was the most affected (58.5%). Additionally, this group also had a higher proportion of individuals with some condition or disease, as well as with occupational accidents and work-related diseases. It is important to highlight that musculoskeletal disorders (MSDs) are among the leading causes of disability worldwide [37]. Besides, a statistically significant association has been identified between MSDs and lack of physical activity (p = 0.024) [38]. In the same way, a high Muscle Mass Index has been associated with increased odds of developing low back pain, which is particularly relevant given that 27.7% of the healthcare workers in this study reported obesity [39].

Concerning mental health, the medical department showed the highest medians on the stress and anxiety subscales, while the general services department showed the highest scores on the depression subscale. However, it is important to note that these scores were below those reported by other studies [40]. It is noted that departments had the highest proportion of personnel who received no training, which could have negatively influenced and increased the scores in the mental health domain. This is relevant given that at the beginning of the pandemic, healthcare workers were concerned about infection prevention and control guidelines, as well as the uncertainty in treating COVID-19 patients [12,41]. A systematic review highlighted that workplace well-being interventions, significantly improved work engagement and quality of life while reducing emotional exhaustion and symptoms of stress, anxiety and depression. Relaxation techniques were identified as the most used strategies due to their facility of implementation [42]. Resilience-building strategies in health organizations during crises include staff training and promote collaboration with senior staff. These practices could strengthen well-being, which should be integrated into health workforce training programs [43].

Conclusions

The result of this study highlights significant disparities in occupational health conditions among health care departments, particularly affecting medical and general service personnel. Low levels of quality of life and perception of safety were observed in these groups, with general service personnel receiving a lower proportion of PPE compared to other departments, which shows inequalities in the allocation of resources. Just like, the unequal distribution of training and resources indicate the vulnerability of a significant part of the labor force.

Mental health impacts were most pronounced among medical and general services department, emphasizing that need for objective interventions. In addition, medical department reported the lowest scores in occupational health, reflecting their greater vulnerability during crisis situations. These findings emphasize the importance of implementing targeted programs focused on training, mindfulness, the promotion of healthy habits, and physical activity to improve the well-being and resilience of healthcare workers. In addition, continuing monitoring and support are essential to address inequality and improving occupational health.

This study is noted for analyzing several occupational health variables, as statistical analyses were done for type of personnel and used a robust multivariate analysis. These strengths help identify inequalities and propose an innovative perspective for further research. However, possible limitations include memory bias typical in its retrospective approach and the lack of stratification in the sampling by personnel and gender, which prevented us from obtaining a fully representative sample.

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