The Psychological Impact and Associated Factors of the COVID-19 Pandemic on Health Care Providers at Chainama Psychiatry Hospital, Lusaka, Zambia

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The COVID-19 pandemic is spreading rapidly, and its global impact is comparable to that of wars and international conflicts [2]. To curb the spread of the virus, several organizations, including global health bodies such as the World Health Organization (WHO), have been making efforts. The role of healthcare workers has been crucial in controlling the pandemic. While the emphasis has been on monitoring, finding a cure, and preventing transmission, healthcare providers are facing a range of psychological challenges as they adjust to their new lifestyles and cope with the fear of the disease [3].
It is believed that the psychological impact of the COVID-19 pandemic, such as stress and anxiety, is a significant concern. A Chinese study found that over half of the participants experienced substantial psychological effects due to the pandemic [4]. Recently, there has been a surge in COVID-19 cases, exposing healthcare workers to various psychological stressors, including long working hours and a lack of personal protective equipment, making them more vulnerable than ever before [5]. The current situation of healthcare providers places them at risk of developing anxiety and depression-related disorders, which can affect their performance and decision-making abilities [6].
Anxiety and depression are common mental health disorders that can significantly impact a person's quality of life [7], [8]. There are many factors that can contribute to the development of these conditions, including genetics, environmental factors, life experiences, and even poor management of existing health-related problems [9]- [14]. One of the most significant risk factors for anxiety and depression is stress [15], [16]. When a person experiences chronic stress, their body and mind can become overwhelmed, leading to feelings of anxiety and depression [7], [17]. Other risk factors include social isolation, chronic medical illnesses, trauma, substance use disorders, and major life changes [16], [18]- [21].
In the ongoing battle against COVID-19, healthcare workers are at the forefront, and it is crucial that their mental and physical well-being be given top priority [22]. While various studies have examined the psychological distress experienced by healthcare workers in tertiary hospitals, not enough research has been conducted on psychiatric hospitals, which are expected to provide essential psychological aid. Despite the alarming rate of mental health issues among frontline healthcare workers, their psychological well-being is often overlooked. These workers, who are at high risk of developing mental illnesses such as burnout, suicide attempts, and stigmatization, cannot perform their critical role in curbing the spread of the outbreak without adequate support [23].
The outbreaks of infectious diseases such as SARS in 2003 and H1N1 influenza in 2009 demonstrated that the general population experienced significant fear and other forms of mental distress [24]. Studies have called for further research to better understand the psychological effects of infectious diseases and identify both risk and protective factors [25]. The outbreak of infectious diseases is often associated with adverse psychological outcomes, particularly regarding mental disorders such as depression, anxiety, thought disorders, and post-traumatic stress disorder (PTSD), which can be triggered or exacerbated by quarantine and social distancing measures [26].
Many psychiatric hospitals, including Chainama Hills College Hospital (CHCH) in Lusaka, Zambia, have been converted into COVID-19 wards, leading to the transfer of severely ill patients and increased stress for healthcare workers. Studies conducted during the SARS outbreak and the COVID-19 pandemic have shown that healthcare workers in high-risk situations experience psychological effects such as depression, anxiety, insomnia, and distress [25]- [28]. A recent survey in Canada reported that 47% of health workers dealing with the COVID-19 crisis required psychological support. There have also been reports of stigmatization toward healthcare workers treating COVID-19 patients, which can compromise their self-care and social support [28], [29]. These findings highlight the need for increased attention to the mental health needs of healthcare workers during pandemics.
Common risk factors for the development of psychological problems during the COVID-19 pandemic include a lack of social support and communication, maladaptive coping strategies, and insufficient training for healthcare providers [28]. Those directly involved in caring for COVID-19 patients are at a higher risk of depression, anxiety, and stress compared to those with more indirect roles. Factors such as inadequate facilities for hand washing, infected family members, and improper use of personal protective equipment (PPE) have been cited as affecting healthcare workers' mental health adversely.
On the other hand, providing sufficient information on COVID-19 transmission, accessibility to and trained use of PPEs, practicing response roles, implementing infection prevention and control (IPC) measures, and positive attitudes of work colleagues can help reduce COVID-19-related stress among health workers and enable better coping [30]. Despite being accustomed to witnessing trauma and dealing with loss, the high morbidity and mortality rates of the pandemic, along with the fear of becoming infected themselves or their family members, have caused significant anxiety for healthcare providers.
To mitigate the psychological impact, hospitals can provide the necessary PPEs to healthcare providers, while governments can promise basic salaries as additional allowances and life insurance cover if healthcare providers get infected. Studies have shown that these measures contribute to reducing the psychological effects of infection on healthcare providers [31].
Aside from exposure to COVID-19-related incidents, socio-demographic factors may also contribute to other risk factors. For instance, during the SARS outbreak, a study reported that females and low-income individuals experienced SARS-related trauma, including post-traumatic stress disorders [32]. According to the same source, the healthcare providers who were exposed to the SARS outbreak also exhibited symptoms of depression, post-traumatic stress disorder, and substance abuse, particularly those with highrisk exposure or those who required quarantine [32]. However, healthcare workers who received greater social support experienced fewer symptoms.
According to an Indian survey, healthcare professionals' morale may be boosted by positive motivating factors, such as supportive families and friends, positive role models, recognition from peers and patients, and a sense of validation of life and existence [33].
The impact of COVID-19 on mental health and psychosocial well-being is also significant, particularly among those directly or indirectly in contact with the virus, those vulnerable to biological or psychosocial stressors, individuals with mental health disorders, and healthcare professionals [2]. Similarly, it was noted that infected individuals, doctors, and nurses working in emergency and resuscitation departments are at a higher risk of mental exhaustion and burnout, which contribute to the shortage of healthcare professionals [34].
The increase in COVID-19 cases has exposed healthcare workers to various psychological stressors. A study found that healthcare workers' mental health is more precarious than ever due to extended working hours and a lack of personal protective equipment (PPE). Consequently, healthcare workers may experience fear, anxiety, depression, and insomnia, which could negatively impact their work performance and long-term well-being [5], [35].
Currently, no published article in Zambia has reported on the adverse psychological impact of COVID-19. Therefore, this study aims to determine the psychological impact and associated factors of COVID-19 on healthcare providers at Chainama Hills College Hospital (CHCH) in Lusaka, Zambia. By conducting this research, we hoped to shed light on the psychological effects of the pandemic on healthcare workers and inform efforts to provide necessary support and care for these critical frontline workers.

II. METHODOLOGY
The research conducted a quantitative cross-sectional descriptive study at the CHCH, which is the largest psychiatric hospital in Zambia and provider of healthcare care for COVID-19 patients. The study surveyed 194 eligible health workers at the hospital, including medical doctors, mental health nurses, physician assistants, ward assistants, allied health professionals, pharmacists, technicians, administrators, clerical staff, and maintenance workers.
To ensure equal participation among the healthcare professionals, the study used a probability sampling technique to randomly select participants from the population of healthcare workers who care for patients at CHCH.
The final questionnaire used in the study consisted of two parts. Part 1 included survey questions about the participants' demographic characteristics such as age, gender, education, marital status, and occupation, as well as their general health status, COVID-19-related variables (e.g., quarantine history, level of concern about the outbreak), perceived threat of COVID-19, perceived stress, anxiety, depression, posttraumatic stress, perceived social support, and coping strategies. Part 2 used the 'Depression, Anxiety, and Stress Scale 21' (DASS-21) to measure the psychological distress of the participants. The brief version of DASS-21 was used, which is composed of three subscales (each with seven items) measuring depression, anxiety, and stress. Participants rated their experience over the past month using a 4-point Likert rating scale. The Cronbach's alpha for the three subscales was 0.83, 0.80, 0.82, and 0.92 for the total DASS score in this study. The questionnaire was developed by Lovibond in 1995 to measure stress, anxiety, and depression through a total of 21 items [36].
The study participants were randomly selected and provided with self-administered questionnaires with closedended questions. Participants were informed about the questionnaire's duration, the identity of the researchers, and the study's aim before answering. The study clarified that only doctors, nurses, nursing assistants, hospital porters, healthcare support staff, and health science students were eligible to participate. No incentives were offered for participation, and all participants voluntarily signed an informed consent document before responding. The collected data were coded with numbers, and individual names were not used. The data collection sheets were stored in a cabinet at the study site.
The collected data was saved on a Microsoft Excel spreadsheet and analyzed using the Statistical Package for the Social Sciences (SPSS) 2020. Descriptive statistics were used to calculate socio-demographic characteristics and COVID-19-related variables. Linear regressions were employed to calculate the univariate associations between sociodemographic characteristics, COVID-19-related variables, and psychological outcomes (the DASS-21 subscales). Pearson correlation was used to assess the associations between adverse psychological outcomes and potential psychosocial factors of perceived threat. The Kolmogorov-Smirnov and Shapiro-Wilk tests were used to test for normality.
The use of the same questionnaire for all selected participants helps to ensure that the data collected is comparable and reliable. This practice avoids potential variations in the measurement tool that could affect the validity of the data. Additionally, using the same questionnaire for all participants simplifies the data analysis process, making it easier to compare and contrast the responses. Therefore, utilizing a standardized questionnaire is a crucial step in ensuring the reliability and accuracy of the collected data.

III. RESULTS
The gender distribution of the healthcare respondents sampled from CHCH is shown in Fig. 1 below. The figure demonstrates that the majority of the respondents, which constituted 55%, were male, while the remaining 45% were female.

55% 45%
Male Female Fig. 2 illustrates the age distribution of the sampled healthcare providers. The findings revealed that the largest group, 87 of the respondents, fell within the 26-35 age range. This was followed by 81 respondents who belonged to the 36-50 age range. Only 15 healthcare providers belonged to the 18-25 age range, while 11 were between the 51-65 age group. The marital status of individuals can impact how they manage stress and anxiety. Fig. 3 below presents the results on the marital status of the sampled healthcare providers. The findings showed that the majority (78%) of the respondents were married, 20% were single, and 2% were widowed.  The majority of the sampled healthcare providers, 40.2%, worked as mental health nurses at CHCH. Clinical officers (physician assistants) made up 20.6% of the sample, while 18.6% worked as nursing assistants, 8.2% as hospital porters, and 3.1% as medical doctors. However, 9.3% of the respondents did not disclose their professional activities or chose not to respond. Fig. 5 provides a summary of the department or unit in which the participants worked, which can help shed light on how their work experiences may impact their ability to manage depression and anxiety. The majority (52.6%) of healthcare respondents worked in general wards, while 22.7% worked in the filter (admission) clinic department, 12.9% were employed in social-sanitary work, and 4.6% worked in the COVID-19 center. 7.2% of participants did not disclose information about their department.  The amount of experience someone has can play a significant role in how well they are able to manage their emotions in certain situations. These findings are illustrated in Fig. 6. The majority (53.6%) of respondents reported having between 4 to 9 years of work experience, followed by those with 1 to 3 years of experience. Additionally, 17.0% of healthcare participants reported having more than 10 years of experience, while 3.1% reported having less than one year of experience.   The distribution of healthcare workers' shift durations is displayed in Fig. 8. The results indicate that the majority (52%) of hospital staff worked between 7 to 8 hours per shift, while 48% reported working between 8 to 10 hours per shift.  The findings related to participants' knowledge of the Covid-19 pandemic are presented in Table I. As per the results, the majority of respondents (95.4%) reported having knowledge about Covid-19. A small proportion of respondents (3.1%) did not provide a response to this question.  After analyzing how social demographic factors affected respondents' levels of depression, anxiety, and stress, the study discovered that variables such as gender, age, marital status, professional activities, work department, years of experience, professional working status, and hours worked per shift had an impact on their mental health. The healthcare workers who participated in the study were found to be experiencing high levels of stress due to the COVID-19 pandemic, which was influenced by their social demographic factors. The stress score on the DASS 21 was 92.0, and the data did not follow a normal distribution. Additionally, the participants showed mild symptoms of depression with a depression score of 13.0, but this score was also not normally distributed. Lastly, the respondents exhibited mild anxiety with an anxiety score of 12.0, which was normally distributed. Fig. 9 indicates that the stress score does not follow a normal distribution, with some scores falling well outside the positive or right-hand range. Based on Fig. 10, it was determined that the depression score does not exhibit a normal distribution. Some of the scores were observed to be significantly outside the left or negative range.    Based on the results, the stress score (s. Score) had a statistically significant impact (p-value = 0.000) at a significance level of 0.05, with test statistics of 0.423 and 0.310. Similarly, the depression score (d. Score) also had a significant impact (p-value = 0.000) at a significance level of 0.05, with test statistics of 0.184 and 0.895. The anxiety score (a. Score) was also found to be significant (p-value = 0.000) at a significance level of 0.05, with test statistics of 0.167 and 0.947.

IV. DISCUSSION
The research has clearly demonstrated that healthcare workers have been significantly impacted by the adverse psychological effects of COVID-19. The study also highlights the possible underlying factors that may contribute to mental health issues during the pandemic, including susceptibility to infection, lack of control over the situation, and various social demographic factors, such as gender, marital status, years of experience, department of employment, age, profession, and employment status. The spread of the virus, the health status of family members, and isolation have also been identified as significant factors that can affect the psychological response of healthcare workers, particularly in countries like Zambia.
The purpose of this study was to investigate the psychological effects of the COVID-19 pandemic on healthcare providers at CHCH. To achieve this, the researchers utilized the DASS 21 tool to analyze the impact of the pandemic on healthcare providers in relation to their social demographic factors. The study examined symptoms such as anxiety, depression, and stress as indicators of the psychological effects experienced by healthcare staff during the COVID-19 epidemic. The study reported values of 13.0 and 12.0 for anxiety and depression, respectively, on the DASS 21 scores, which is consistent with the findings of a similar study conducted in 2020 by [37].
The significant prevalence of mood and anxiety disorders among healthcare providers in hospitals in Lusaka can have detrimental effects on the quality of service provided to clients. If healthcare workers are suffering from depression, anxiety, or stress due to the COVID-19 pandemic and other related social and demographic factors, their ability to effectively perform their duties may be compromised. These findings are consistent with a study conducted in Ethiopia, which also highlighted the negative impact of COVID-19 on the mental health of healthcare workers [38]. It is crucial to address and prioritize the psychological well-being of healthcare providers to ensure they can provide optimal care to their patients during this challenging time.
The study revealed that the DASS-21 questionnaire effectively measured the emotional well-being of healthcare providers. The results indicated that healthcare providers were mostly affected by stress due to the COVID-19 pandemic, with a stress score of 92.0, which is considered high given the circumstances. This finding was statistically significant at a significance level of 0.05, with a p-value of 0.000.
Additionally, the study found that healthcare providers reported mild levels of depression and anxiety, with respective scores of 13.0 and 12.0 on the DASS 21 scale. These scores were also statistically significant at a level of 0.05. The availability of personal protective equipment (PPE) at the healthcare facility was found to be associated with the less psychological impact on the medical staff, which is consistent with a study conducted in Hunan, China, that also reported psychological benefits from access to PPE [30]. Conversely, a reduction in PPE was identified as a contributor to psychological distress, as reported in a study conducted in China [28].
The COVID-19 pandemic has led to an increase in workload and extended shifts for healthcare providers to meet the growing demand for medical care, resulting in significant pressure on them. Consequently, healthcare providers are experiencing severe stress, as well as mild anxiety and depression. This situation is reminiscent of the Ebola outbreak, where healthcare workers who worked tirelessly in settings without personal protective equipment and driven mainly by compassion suffered from mental health problems that were excessively higher than those of the general public [39].
A study conducted in Hunan, China, focused on the psychological impact and coping mechanisms of frontline medical staff. The study findings revealed that the provision of personal protective equipment had a positive impact on the psychological well-being of healthcare providers [30]. These results are consistent with another study conducted in China, which found that healthcare providers experienced high levels of stress, anxiety, insomnia, and depression [28].
Furthermore, the study highlights the importance of addressing the mental health needs of healthcare providers who are working tirelessly to provide care during the challenging conditions of the Covid-19 pandemic. A similar study conducted by [40] found that healthcare professionals reported feeling vulnerable, weary, and stressed while working in high-risk areas during pandemics. However, the study noted a lack of substantial previous work on safety and psychological counseling for healthcare workers who are exposed to patients during their work.
This study utilized factor analysis with the DASS 21 to evaluate the impact of the COVID-19 pandemic on healthcare providers. The results demonstrate a significant and concerning effect that the pandemic has on their mental health. Specifically, the findings indicate that healthcare providers are experiencing high levels of stress along with mild anxiety and depression. This presents a serious problem that requires immediate attention to ensure that healthcare providers can work in a safe and supportive environment during the Covid-19 pandemic. Appropriate interventions and support systems are necessary to address the psychological impact of the pandemic on healthcare providers and ensure their well-being.

V. LIMITATIONS
Since there were no published studies on the psychological impact of COVID-19 on healthcare workers at the time this study was conducted, it was challenging to identify which factors may have contributed to the psychological effects observed in this study. The reliability of the results may be limited by using self-reported surveys, which can be influenced by respondents' honesty and memory bias. The participants' socioeconomic status was not recorded, which could have been valuable in understanding the links between outcomes and developing targeted interventions. Some respondents refused to consent, some demanded to be paid to participate and some were scared to take part in the studying thinking the information may be used by the government.

VI. CONCLUSION
Depression, anxiety, and stress are emotional disorders that can affect people without them realizing it. With the onset of the COVID-19 pandemic, it is essential to give more attention and care to healthcare providers, who are at the forefront of the pandemic and general healthcare provision. The fact that healthcare providers recorded a high stress score of 92.0 is alarming and requires immediate intervention.
Notably, male healthcare providers are more prone to depression, anxiety, and stress than their female counterparts. Therefore, it is critical to pay close attention to the social demographic factors that contribute to their emotions and well-being, in addition to addressing the difficult working conditions created by the pandemic. This approach could help reduce the number and severity of cases of depression, anxiety, and stress among healthcare providers.
Furthermore, the study suggests that the government should create a safe and conducive working environment for healthcare providers by providing them with adequate personal protective equipment and motivation. It is hoped that by taking these measures, cases of emotional disorders among healthcare providers will reduce, and they can continue to provide essential services during the pandemic.

VII. RECOMMENDATIONS
Based on the research findings, it is recommended that the government take action in two main areas. Firstly, providing sufficient personal protective equipment (PPE) to healthcare providers in hospitals and clinics should be a priority. This will help protect healthcare providers and limit the spread of COVID-19. Secondly, the government should create a motivational package to support the mental health and well-being of healthcare providers who are experiencing stress and depression due to the pandemic.
The study also suggests the need for further research to be conducted on this topic. This could include expanding the study to cover more hospitals in the country and including additional variables that may contribute to the emotional well-being of healthcare providers. This would provide a more comprehensive understanding of the impact of COVID-19 on healthcare providers at the national level and could lead to better solutions. Furthermore, these research findings could inform government policies and decision-making.

ETHICAL CLEARANCE AND CONSIDERATIONS
This study was initiated after receiving ethical approval from the University of Lusaka (UNILUS) and the UNILUS School of Medicine & Health Sciences Research Ethics Committees of Zambia, and after obtaining permission from the head of clinical care of CHCH through the office of the senior medical superintendent of CHCH. Throughout the study period, ethical principles were strictly adhered to, including voluntary participation, non-coercion, or threat to participate, and the requirement for participants to sign a consent form. Participants who were unable to sign the consent form were allowed to provide their thumbprints instead. All consent forms were provided in English and interpreted in the participant's local language. All participants signed after reading, understanding, and agreeing to participate in the study. Confidentiality was upheld during the whole period of the study, and each participant was given an inclusion number and assured that their names would not be used in the report or published.