Mental health at the COVID-19 frontline: An assessment of distress, fear, and coping among staff and attendees at screening clinics of rural/regional settings of Victoria, Australia

INTRODUCTION

The first case of confirmed COVID-19 was detected in Victoria, Australia, on January 25, 2020,¹ and then subsequently found in other Australian states among returned travelers. The international borders were closed to all noncitizens and nonresidents in March 2020 to reduce the number of infections coming in from overseas.² However, as local transmission increased, a number of measures were put in place to reduce opportunities for infection. Those measures included increased access to COVID-19 screening, social distancing, working from home, restriction of visitors to home gatherings, closure of educational facilities (schools, TAFE, and universities), introduction of remote learning, and restrictions to visitors to health services and aged care residences.³ At that stage, the wearing of face masks was not compulsory. In June 2020, a second wave of infections affected Victoria, spreading rapidly, with a peak of 687 infections/cases being reported in 1 day. Another period of lockdown was commenced and mandatory mask wearing was introduced, along with nightly curfews and the restriction of movement to a 5 km radius, which remained until November 22, 2020. While COVID transmission in regional Victoria occurred at lower levels than in Melbourne and some restrictions were lifted earlier, there were several outbreaks and cases (n = 610) in the Barwon South West region of Victoria. Those outbreaks mostly occurred around workplaces, such as abattoirs and aged care, and were linked to the movement of people from infected metropolitan to regional areas.⁴

Rural or regional areas are resource-stretched with specialists, doctors, nurses, and mental health worker shortages commonplace.⁵ Globally, there have been examples where regional villages have managed to reduce COVID-19 spread by proactively undertaking community screenings, enforcing social isolation, communicating actively with their communities, and reducing contagion through restrictions.⁶ In response to the COVID-19 outbreak in Victoria, some regional health services focused their services to prepare and manage potential outbreaks and concentrate heavily on prevention, detection, screening, community communication, and clinical management of suspected cases. That involved redeployment of staff to areas, such as drive-through screening clinics and respiratory assessment clinics (RACs), which included the likely contact with active COVID-19 cases. Such modified service delivery from hospital settings, along with the ongoing fear of coronavirus spread in communities, might increase stress levels for patients with health conditions that put them at higher risk for COVID-19.

Australian government pandemic restrictions have resulted in social, economic, and health consequences, affecting both health-seeking behaviors of Australians and the manner of interactions with health care workers.^7, 8 A recent report in The Lancet highlighted the adverse effects of the pandemic, both on people with diagnosed mental illness and the general population’s mental health being exacerbated by fear, self-isolation, and stigma.⁹ In response to the growing global pandemic and potential COVID-19 spread across Victoria, COVID-19 screening clinics were established at Hamilton Base Hospital (300 km west of Melbourne) and South West Health Care, 256 km south west of Melbourne, to enable community members with respiratory symptoms or concerns of contact to be swabbed.^10, 11 Both Hamilton and South West Health Care catchments extend to the South Australian border with some of the region’s working population commuting or transporting goods and livestock into South Australia.

Frontline health care workers were redeployed and rostered to assess attendees clinically and collect swabs if they met the latest and ever-changing testing criteria. Attendees were then instructed to self-isolate at home until the results were returned, usually within 48 hours; however, initially this was up to 168 hours (7 days).¹¹ Pathology swabs had to be sent to Melbourne (300 km away) for analysis and then returned to the health service, resulting in delays of return of results to attendees.

Frontline health care workers reported stress due to the risk of transmission from confirmed, suspected, or asymptomatic cases, working with new and frequently shifting testing criteria, and the continual wearing of personal protective equipment (PPE).^12, 13 Health care workers also reported anxiousness when returning home and possibly exposing their families to the risk of COVID-19. Higher rates of infection were reported among health care workers globally, particularly in staff undertaking testing.¹⁴

Focusing on the psychological impact of current and future outbreaks was important, as evidence from previous epidemics suggests that not only short-term but also long-term impacts could occur.^15, 16 Improving our approach to community screening, whether through drive-through or community clinics, was important for both the current COVID-19 pandemic and for future operation. In this study, we aimed to assess the extent of psychological distress, fear of COVID-19, and coping strategies among attendees at 2 COVID119 screening clinics in regional/rural Victoria, Australia.

MATERIALS AND METHODS

RESULTS

A total of 10,599 people, who went through screening at both sites during the study period and had their mobile numbers listed, received the invitations to participate in this study. Among them, a total of 702 people (7%) participated. About two-thirds of the participants (452, 64%) had their tests undertaken at South West Healthcare at Warrnambool and the remainder (250, 36%) at Western District Health Service in Hamilton.

Mean age (±SD) of the participants was 49 (±15.8) years and the majority (386, 55%) were aged between 30 and 59 years. More than two-thirds were female (481, 69%), the majority (615, 88%) were born in Australia, and 302 participants (43%) identified themselves as frontline or essential service workers (such as health care workers, police, supermarket workers, ambulance, farmer, veterinarian, child protection, meat factory workers, taxi driver, petrol station attendants, teacher, and kerbside collection worker). About two-thirds (456, 65%) reported that COVID-19 did not have any impact on their financial situation and 16 participants (2%) reported losing their job due to the COVID-19 pandemic. A quarter of attendees (178, 25%) reported having multiple comorbidities and 121 (17%) reported having psychiatric/mental health issues. A quarter of the participants (175, 25%) reported smoking occasionally and 51 (7%) smoked at least monthly. Since July 2020, 46% (n = 19) of those who reported smoking daily (n = 41) increased smoking. More than two-thirds (486, 69%) reported current alcohol drinking, 21% (n = 101) reported consuming stronger alcohol, and 20% (n = 97) reported increased alcohol drinking since July 2020. Study participants had an average of 2 tests, 289 (41%) participants reported more than 1 test, and only 7 participants (1%) reported positive test results for COVID-19 (Table 1).

DISCUSSION

Those attendees with pre-existing mental health issues showed low resilience, high psychological distress and fear of COVID, and had multiple comorbidities, psychiatric/mental health problems, and had used health care services to overcome COVID-19-related stress. A number of factors could negatively affect people with existing mental health conditions, including poorer physical health, social isolation, reduced service utilization, and poorer adherence to prescribed medications. Additionally, during the COVID pandemic, changed health-seeking behaviors for those with chronic conditions have been reported, including a reticence to attend or follow-up.^24, 25 According to Neelam et al, people with pre-existing mental illness had significantly more psychiatric symptoms, anxiety, and depressive symptoms compared to others during a pandemic.²⁶ Surprisingly, Neelam et al also found that there was a reduction in both the utilization of mental health services and mental health-related hospitalizations during pandemics. That could be due to the barriers in seeking direct consultations with mental health care providers, as many of those providers had a preference for telehealth consultations during the pandemic, which might not meet patients’ preference for face-to-face contacts.²⁵ Those who did attend their health care providers (for any reason) to manage COVID-19-related stress also reported higher distress and fear.

While Australia had been largely shielded from the high numbers of mortalities experienced globally, there was ample evidence published to show that mortality and complications were high among people with physical comorbidities when coupled with COVID-19. The risk of severe disease, hospitalization, and death was strongly age-related, but it also included pregnant women, leading to greater anxiety and stress for these groups.²⁷ Using a model-based analysis, Holt et al found that hospitalization estimates for COVID-19 increased with age: 1.04% for people aged 20–29 years, increasing to 18.40% for those aged over 80 years.²⁸

Behavioral risk factors, such as smoking and alcohol consumption, also increased in this study. The finding was consistent with evidence showing that as anxiety increased, some people self-medicated using tobacco or alcohol to ameliorate the discomfort they experience due to stress or uncertainty, or to use as a coping mechanism.²⁹ Recent studies also reported association between coping during the COVID-19 pandemic and smoking rates, pointing to a need to develop programs that support coping for those most at risk of increased smoking behavior.³⁰ The World Health Organization (WHO) also argued that the pandemic made it harder, but more important than ever to quit smoking.³¹ Recommended strategies from WHO included proven effective strategies, such as free cessation services, support from primary health care, and nicotine replacement therapy.

Attendees affected financially (positively and negatively) experienced increased psychological distress and fear of COVID-19. Increased demand for essential workers (given the relatively high self-reported number of essential workers in this survey of 43%) might involve working extra shifts and longer hours, resulting in less leisure and self-care time. For health care workers and other essential frontline workers, the requirement to work with PPE, coupled with concerns regarding the adequacy, efficacy, and availability of masks and shields, resulted in adverse health effects, such as respiratory issues, dermatitis, and anxiety.³²

Unlike numerous other studies that found females to be more fearful and anxious about COVID-19, that was not found to be a factor in our study. Living alone was also not associated with more stress, fear, or less coping ability. While this survey did not ask about social media use, some research suggests that engaging with social media may have adverse effects on well-being, and other research reports social media producing positive outcomes.³³ In a recent paper, Pandey et al noted that digital interactions during the COVID-19 pandemic assisted in mitigating boredom, loneliness, and irritability caused by lockdowns or quarantining at home.³⁴ As this study focused on a rural and regional area, self-reliance for social connection and physical geographical distance was the nature of those environments and possibly those attributes might assist in higher coping and resilience during a pandemic.

CONCLUSIONS

Our study showed that people with pre-existing mental health issues, comorbidities, smokers, and alcohol consumers were high-risk groups in regional Victoria during the COVID-19 pandemic. Additionally, it highlighted the complexity of who was negatively affected psychologically, including those with negative financial impacts. The changed nature of health-seeking behavior, access to services, and modes of health service delivery affected many people throughout the pandemic and highlighted further disparities for vulnerable populations. The study also uncovered some unexpected findings that being female, aged over 60 years, and living alone were not associated with increased stress, fear, or lower resilience, the reasons for which would be interesting to explore in future studies. Policy makers and health service providers in regional settings of Australia could consider utilizing the findings from this study to plan health promotion activities and make support services available for the high-risk groups in regional settings. Specific interventions to support the mental well-being of these vulnerable populations along with engaging health care providers should be considered.