Introduction

A novel coronavirus disease (COVID-19) started in China in December 2019, spread rapidly throughout the world, and was announced as a pandemic by the World Health Organization (WHO) in March 2020 (WHO 2020a). Current numbers indicate the presence of more than 101 million confirmed cases and more than 2 million deaths (WHO 2020b). While it affects millions of individuals’ physical and mental health (Xiang et al. 2020), similarly to previous epidemics and pandemics (Kisely et al. 2020), the COVID-19 pandemic has placed an increased burden on healthcare workers (HCWs) (Lai et al. 2020), making them a high-risk group for the development of mental health issues (Pappa et al. 2020).

With the long and demanding shifts, and the changing nature of the work, WHO draws attention to HCWs potentially having to experience increased psychological distress, fatigue, and burnout, being stigmatised, and being subjected to psychological or physical violence (WHO 2020c). In addition to these factors, previous studies have reported heightened risk of depression (Rossi et al. 2020), anxiety (Matsuishi et al. 2012), insomnia (Lai et al. 2020), acute or posttraumatic stress, and sleep disturbances (Ho et al. 2005; Maunder et al. 2006; Magnavita et al. 2020). Moreover, HCWs may feel overwhelmed by concerns of being infected and infecting others (Ho et al. 2005; Goulia et al. 2010), lack of family support (Kisely et al. 2020) and issues related to work and the workplace (Goulia et al. 2010). However, preparedness can have a buffering effect to counter these negative consequences (Liu et al. 2020; Raven et al. 2018).

HCWs have been seriously affected by the negative mental health consequences of COVID-19 pandemic in many countries, such as China (Lai et al. 2020), Italy (Rossi et al. 2020), and the USA (Shechter et al. 2020). Similarly to HCWs in other countries, HCWs in Turkey have experienced a high amount of physical and mental health burden, especially at the beginning of the first wave of COVID-19. The first case was seen on 10 March 2020 in Turkey, and in 3 weeks, the disease expanded to all cities of Turkey, with a total case number of 15679 (Anadolu Agency 2020). The rapid increase of the number of cases led to overload in the healthcare system, leaving 601 HCWs infected with COVID-19 and one internist doctor dead due to the infection at the beginning of April 2020 (Anadolu Agency 2020), when the data of this study was collected.

Since the onset of the pandemic, a limited number of studies on HCWs have been carried out in Turkey. These studies concluded that health professionals showed a higher proportion of hopelessness and apprehension than the general population (Hacimusalar et al. 2020), and there were high rates of depression, anxiety, and psychological stress symptoms among healthcare workers (Şahin et al. 2020). Additionally, in a WHO report it was stated that violence against healthcare workers has been increasing all over the world (WHO 2020d), and some reports published in Turkey revealed similar cases (Sevimli 2020).

The findings from the literature show that problems arising during pandemics affect several aspects of HCWs’ lives. Therefore, to be able to understand the effects of the COVID-19 pandemic on HCWs’ mental health and take necessary actions, their difficulties and stressors need to be identified and examined comprehensively.

Previous studies have overwhelmingly focused on either one or a limited number of mental health factors (Matsuishi et al. 2012; Maunder et al. 2006), such as depression, anxiety, or insomnia, and were conducted either with limited sample sizes (Goulia et al. 2010; Ho et al. 2005) or in just one hospital or a restricted group of institutions (Goulia et al. 2010; Matsuishi et al. 2012; Maunder et al. 2006). Most of the preliminary studies consist of data obtained from some certain locations and it is seen that they mostly focus on the psychological consequences of HCWs (Barello et al. 2020).

An advantage of this study is the large sample size covering diverse professions and occupations from various institutions, regions, and cultures. Additionally, many problems faced by HCWs during the acute phase of the pandemic were investigated. Thus, the current study aimed to achieve a deeper understanding of the stressors and difficulties experienced by HCWs, and to offer suggestions with regard to future policies to maintain HCWs’ health, motivation, and working capacity; to enhance their wellbeing; and to ensure preparedness for future pandemics and crises. This study contributes to the literature by shedding a fresh light on the difficulties and stressors that affect the mental status of healthcare professionals.

Methods

An online survey was conducted from 2–4 April in 2020 during the early and challenging times of the outbreak in Turkey. Participants were recruited using the snowball technique with the help of the International Medical Rescue Teams Association (UMKE Derneği) of Turkey. Due to the pandemic conditions, we could not apply any proper randomisation method, and there was no chance for face-to-face interviews. All participants were working in health facilities of the Ministry of Health of Turkey. The type of health facility where participants were working and the cities where these facilities were located represented a diverse spectrum.

The General Health Questionnaire (GHQ-12) developed by Goldberg and Williams (1998) and adapted into Turkish (Kılıç et al. 1997) was used to assess the current mental health status of the participants. Higher scores on the GHQ-12 indicate more mental health problems. A questionnaire was developed by the authors following online meetings with key HCWs between 27 March and 2 April 2020, which included items on the sociodemographic characteristics of the participants and 26 COVID-19-related items. The questionnaire was pilot-tested using a sample of HCWs to evaluate the appropriateness of the items, and all necessary changes were made before conducting the survey. We performed a new categorisation process for the following variables: age, region of health facility, accommodation type, occupation, and type of health facility. Additionally, we grouped the responses related to COVID-19-specific stressors into never/rarely, sometimes, and often/always.

SPSS® 21.0 was used to enter, clean, and analyse data. For the study sample characteristics, we reported numeric variables as mean ± SD and categorical variables as frequencies and percentages. For descriptive information, frequency analysis and cross-tabulations were made, and statistical significance was determined using the chi-square test. We specified GHQ-12 score as the dependent variable. The association between GHQ-12 score and the independent variables was assessed in a multiple linear regression model using a backward stepwise procedure. All significant variables with a p value < 0.05 were entered into the multivariate analysis. Ethical approval for the study was obtained from the Ethics Board of İstanbul Bilgi University (No:2020-40082-63), and necessary research permissions were obtained from the Scientific Research Platform of the Ministry of Health of Turkey and UMKE Derneği.

Results

In total, 2506 HCWs participated in the study, of whom 71.5% (n = 1790) were women and 28.5% (n = 713) were men. One thousand and seventeen individuals (40.6%) were either nurses or midwives, 503 (20.1%) were other health service providers (psychologist, social workers, physiotherapists, child development specialist, physiotherapist, pharmacist, and dietician), 493 (19.7%) were health service technicians (X-ray, medical laboratory,emergency medical, and anesthesia), 281 (11.2%) were physicians/specialists/dentists, and 212 (8.5%) were administrative or support staff (security, cleaning, administrative, health information, and driver). One thousand one hundred and seventy-nine participants (47%) worked at high-risk health facilities during the initial phase of the pandemic, 479 (19.1%) at moderate-risk facilities, and 848 (33.8%) at low-risk facilities. Table 1 shows the sociodemographic characteristics of the participants.

Table 1 Sociodemographic characteristics of participants: Turkey, April 2020

With regard to frequency of experiencing COVID-19-related stressors, participants reported a higher frequency of often/always experiencing fear of infecting loved ones (83.7%, n = 2098) than being infected themselves (76.1%, n = 1908). Other stressors experienced often/always that had high frequencies were: maintaining favourable relationships with their teammates (90.7%, n = 2274), feeling anxious over ongoing uncertainty (90.2%, n = 2261), feeling anger and hopelessness due to the community's neglect of the precautions (84.2%, n = 2109), making great efforst to create a more hygienic environment at home (84.6%, n = 2121), being adversely impacted by news of teammates getting infected and/or quitting work as a result of potential infection (82.3%, n = 2063), and fear of exposure to violence (72.8%, n = 1825) (Table 2).

Table 2 Frequency of experiencing COVID-19-related stressors among participants: Turkey, April 2020

The mean GHQ-12 score was 6.03 (min = .00, max = 12.00). Table 3 shows that a substantial proportion of HCWs reported not being able to enjoy day-to-day activities (80.1%, n = 2007) and not feeling reasonably happy (79.1%, n = 1981); however, they felt that they have been playing a useful part in things (84.2%, n = 2110).

Table 3 Frequencies of psychological distress indicators of participants (General Health Questionnaire-12), Turkey, April 2020

Table 4 shows the results of the multiple linear regression analysis. Perceived levels of individual preparedness and training related to COVID-19 were negatively associated with GHQ-12 scores. Female gender, meeting basic needs during the pandemic, fear of being infected and infecting loved ones, and poor family relationships were positively associated with GHQ-12 scores.

Table 4 Multiple linear regression analysis of the association between GHQ-12 score and sociodemographic characteristics and COVID-19-related stressors, Turkey, April 2020

Discussion

The findings of the study showed that most participants faced several stressors and serious mental health consequences. Most of the participants reported a high frequency of anxiety rooted in uncertainty, anger, and hopelessness due to the community's neglect of precautions, striving to create a more hygienic environment at home, being adversely impacted by news of colleagues getting infected and/or quitting, and maintaining good relationships with teammates; however, these variables were not statistically associated with the mental health of HCWs. This may be due to an imbalance in the distribution. A future study including participants whose stress levels vary on a wide spectrum may provide a clearer understanding of the effect of these stressors. It has been reported that there has been an increase in violence against HCWs during the COVID-19 pandemic in some countries (Şahin et al. 2020; WHO 2020d). In parallel with these reports, many participants of the current study expressed anxiety about being exposed to violence.

Consistent with the literature (Rossi et al. 2020; WHO 2020c), fear of being infected and infecting loved ones was prevalent among HCWs and was related to worse mental health. Similarly to the findings of previous studies, female gender and lower perceived levels of individual preparedness (Matsuishi et al. 2012) and training (Maunder et al. 2006) related to COVID-19 were associated with an increased risk of mental health problems.

In addition to supporting earlier findings, the current study revealed that poor family relationships were strongly associated with poorer mental health among HCWs. Meeting basic needs was related to worse mental health; however, current accommodations may have played a moderating role in this relationship.

Limitations and conclusions

A limitation of the current study is that a probability sampling strategy could not be used due to pandemic conditions. As such, the sample may not be representative of the HCW population in Turkey. Additionally, the cross-sectional design of the study did not allow inference of causal relationships. Nevertheless, this study has several strengths. Considering the time of data collection, when uncertainty, demands, and needs peaked, and the large sample size, comprising diverse occupations, organisations, and regions, the findings of this study offer a comprehensive outlook for HCWs’ experiences during the early and challenging times of the pandemic. The results have utility for shaping future policies for overcoming crises and pandemics. First, risk groups facing more stressors and/or having worse mental health conditions should be triaged psychologically for interventions. In particular, women facing problems with their families and those with caregiver responsibilities should be monitored for their needs and provided with psychosocial support, including both mental health support and life facilitators such as free care facilities for children and older adults or handicapped relatives, if necessary. Second, effective communication and briefing should be provided regularly to HCWs by health managers to share information and allow HCWs to contribute to the decision-making process, thereby avoiding problems of uncertainty or fear arising due to the epidemic. Third, the need for personal protective equipment and other physical, psychological, and social needs should be identified and met regularly to ensure HCWs’ wellbeing and maintain their motivation for work. Moreover, well-prepared training, including practical demonstrations, should be designed, updated frequently according to the concrete needs of the field and concerns of HCWs, and offered regularly for the purposes of individual and organisational preparedness. It is vital that the management of COVID-19 is planned and sustained in a way that prioritises the psychological wellbeing of HCWs. To achieve this goal, psychological wellbeing programmes for both individuals and groups, such as teams working together, should be provided to ensure their individual resilience. We also maintain that HCWs and their families would benefit from sustained and intermittent psychological support. Finally, ensuring a safe working atmosphere for HCWs should be one of the priorities, as well as security measures, and community programmes should be implemented for the sake of community health.

Considering that the COVID-19 pandemic and its consequences will not disappear soon and pandemics will always be an issue of healthcare systems, the above-mentioned measures should be integrated into long-term health care policies by health policy makers and health managers.