F1000Research 2022, 11:676 Last updated: 15 DEC 2022

RESEARCH ARTICLE

   The COVID-19 pandemic and mental health outcomes –

A cross-sectional study among health care workers in Coastal
South India [version 3; peer review: 1 approved, 1 approved
with reservations]
Rekha T , Nithin Kumar , Kausthubh Hegde, Bhaskaran Unnikrishnan ,
Prasanna Mithra , Ramesh Holla , Darshan Bhagawan
Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

v3 First published: 20 Jun 2022, 11:676 Open Peer Review

https://doi.org/10.12688/f1000research.111193.1
Second version: 01 Nov 2022, 11:676
https://doi.org/10.12688/f1000research.111193.2 Approval Status
Latest published: 15 Dec 2022, 11:676
https://doi.org/10.12688/f1000research.111193.3 1 2

version 3
Abstract (revision)
Background: Frontline health care workers (HCWs) are at increased 15 Dec 2022
risk of developing unfavourable mental health outcomes and burnout,
especially during the COVID-19 pandemic. Recognizing the early version 2
warning signs of mental distress is very important to ensure the (revision) view view
provision of quality patient care. 01 Nov 2022
Methods: In this facility-based cross-sectional study, HCWs of the
teaching hospitals affiliated to Kasturba Medical College, Mangalore
version 1
were assessed regarding their mental health status using a semi-
20 Jun 2022 view view
structured questionnaire. All doctors and nurses who were willing to
participate from these teaching hospitals were included in the study.
Data was collected over a period of four months (1st March -30th June 1. Sunil Kumar Raina, Dr. RP Govt. Medical
2021) till the required sample size was reached and analysed using College, Tanda, India
IBM SPSS and expressed using mean (standard deviation), median
(interquartile range), and proportions. Univariate analysis was done to 2. Devi Wulandari , Paramadina University,
identify the factors associated with mental health outcomes among Jakarta, Indonesia
the HCWs and the corresponding unadjusted odds ratio and 95%
confidence interval were reported. Any reports and responses or comments on the
Results: A total of 245 HCWs [52.2% (n=128) doctors and 47.8%
article can be found at the end of the article.
(n=117) nurses] were included in our study. The proportion of
participants with depressive symptoms, anxiety, and insomnia
assessed using PHQ-9, GAD-7, and ISI-7 scales were 49% (n=119), 38%
(n=93), and 42% (n=102) respectively. Depression, anxiety, and
insomnia were more likely to be experienced by HCWs aged > 27
years, females, and involved in COVID-19 patient care. (p>0.05)
Conclusions:  Our findings that 38% of the examined HCWs had
clinically relevant anxiety symptoms and 49% had clinically relevant

 
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depression symptoms draws attention to the importance of

systematically tracking the mental health of HCWs during this ongoing
pandemic. HCWs should monitor their stress reactions and seek
appropriate help both on a personal and professional level.
Appropriate workplace interventions including psychological support
should be provided to HCWs, to ensure provision of uncompromised
quality patient care.

Keywords
Mental Health, Pandemic, Health personnel, Depression, Patient
Health Questionnaire, anxiety

This article is included in the Manipal Academy

of Higher Education gateway.

This article is included in the Coronavirus

collection.

Corresponding author: Nithin Kumar (nithin.gatty@manipal.edu)

Author roles: T R: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources,
Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Kumar N: Conceptualization, Data
Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Writing –
Original Draft Preparation, Writing – Review & Editing; Hegde K: Data Curation, Investigation, Writing – Original Draft Preparation;
Unnikrishnan B: Conceptualization, Methodology, Validation, Writing – Review & Editing; Mithra P: Data Curation, Formal Analysis,
Validation; Holla R: Investigation, Supervision; Bhagawan D: Investigation, Supervision
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright: © 2022 T R et al. This is an open access article distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite this article: T R, Kumar N, Hegde K et al. The COVID-19 pandemic and mental health outcomes – A cross-sectional study
among health care workers in Coastal South India [version 3; peer review: 1 approved, 1 approved with reservations]
F1000Research 2022, 11:676 https://doi.org/10.12688/f1000research.111193.3
First published: 20 Jun 2022, 11:676 https://doi.org/10.12688/f1000research.111193.1

 
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REVISED Amendments from Version 2

The introduction has been updated with literature on how COVID affects the physical and mental well being of the
population.

In the results section, table depicting the socio-demographic information of study participants has been added. Also,
another table depicting the unfavourable mental health outcomes among the participants has been included.

The discussion on has been updated with explanation on how experience of more than 10 years in our study was found to
be significant factor for unfavourable mental health outcome. Also, factors like age, gender which were not found to be
significant in our study also have been discussed.
Any further responses from the reviewers can be found at the end of the article

Introduction
The coronavirus disease of 2019 (COVID-19), first identified in Wuhan, China at the end of December 2019, spread
rapidly, crossing geographical boundaries and infected millions of people worldwide. The World Health Organization
(WHO) acknowledged this outbreak to be of immediate public health concern and declared it a pandemic on March
11, 2020. Now, even after two years of the outbreak, and large-scale vaccination of the susceptible population, there is still
no sign of an end to the pandemic. As of 10th October 2022, WHO estimates close to 618 million confirmed cases and
around 65 million deaths due to the severe acute respiratory syndrome coronavirus 2 (SARS-COV2) virus worldwide.1
One of the major contributors to the global tally of COVID-19 cases, India has reported around 44 million confirmed
cases and 0.52 million deaths.1,2

To curb the rapid spread of COVID-19 infection, countries around the world imposed a nationwide lockdown, which was
extended with rise in the number of cases reported. Once the lockdown was ceased, quarantine zones were created and
region-specific restriction of movement of people was implemented. The social isolation and loss of livelihood brought
about by lockdown had a huge impact on the physical and mental wellbeing of the general population.

The risk of all-cause mortality, cardiovascular diseases including hypertension, type 2 diabetes and some cancers have
been linked with sedentary lifestyle.3 Frequent lockdown during the pandemic resulted in the disruption of physical
activity due to the closure of business, schools and recreational facilities like public parks and fitness centres, thereby
forcing sedentary life style among the population.4 A study in USA reported a 32% decline in physical activity during the
pandemic among those who were physically active.5

In addition, online classes and work from home also contributed immensely to the sedentary behaviour in general
population, including children and adolescents.

The disruption of non-emergency health services during lockdown affected the routine care of population with chronic
diseases like hypertension and diabetes, thereby increasing the risk of morbidities associated with the disease.6 Also,
those with chronic disorders were more at risk for severe COVID 19 infection.7

Good mental health is essential for overall health and well-being. However, the COVID 19 pandemic has also resulted in
increase in prevalence of mental health illness among the population. The economic crises due to the frequent lockdown
affected the mental and psychological well-being of the population, especially among those who were unemployed and in
financial debt.8

Social isolation, along with the inability to see the loved ones, loss of income due to unemployment, demise of closed ones
due to infection, and fear of infection are some of the triggers for mental health conditions, more so among those with pre-
existing illness.

Rise in alcohol and drug use, insomnia and anxiety have also been documented during the pandemic. Covid 19 infection
can itself lead to neurological and mental health complications like delirium, agitation, and stroke. During the pandemic,
disruption of mental health services further compounded the already existing mental health issues.9 The lack of physical
activity along with poor mental health affected the overall well-being of the population during the pandemic.

Not only the general population, the pandemic affected the psychological well-being of the frontline healthcare workers
(HCWs). Healthcare workers were one of the professionals who worked relentlessly during the pandemic. They were the
professionals who, despite the imposed lockdown, had to work not only their own shifts of duty but sometimes work
overtime or extra time to compensate for their sick colleagues.
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The physical and psychological stress the HCWs experience has been documented during the past outbreaks of avian and
swine influenza and other coronaviruses infection.10–12 During the pandemic, the HCWs must work relentlessly and for
extended hours, attending to huge caseloads and manage unforeseen medical complications. Frontline HCWs are directly
involved in care of COVID patients which not only puts them at risk of acquiring infection, but also the potential spread to
their family members. This fear of spreading the infection to their near and dear ones, along with unavailability of PPEs
and inadequate oxygen supply, lack of standard guidelines for treatment, especially during the initial days of the
pandemic and lack of psychological support have made the frontline HCWs vulnerable.13

Recent literature from around the world have reported that frontline HCWs are at more risk of developing anxiety and
depressive symptoms.14–19 A systematic review and meta-analysis of 239 studies involving 2,71,319 subjects reported
prevalence rates of anxiety and depressive symptoms of 42% and 33%, thereby providing evidence that HCWs are at
increased risk of unfavourable mental health outcomes during the COVID-19 pandemic.20

In India, HCWs involved in COVID-19 care were marginalized and stigmatized. HCWs in many parts of India had to
perform their duties under the constant threat of aggression and violence from patient caretakers which heightened their
mental distress. Refusal of entry into apartments and residences, resistance to the burial of dead bodies of HCWs,20–22 and
abuse of the doctors involved in screening and contact tracing were reported from different parts of the country.21

Recognizing the early warning signs of mental distress is important in any population, more so among HCWs.
Unfavourable mental health outcomes like anxiety, depression, insomnia, psychological distress, and burnout can affect
their health, and compromise the patient safety and the quality of care provided.23 Adequate interventions and coping
strategies can be implemented if the mental health status of HCWs is routinely evaluated. With this background and in the
context of the current COVID-19 pandemic in the district, the study was carried out to assess the mental health outcomes
among the HCWs in Mangalore and the factors associated with these outcomes.

Methods
Ethical approval
The ethical approval was obtained from the Institutional Ethics Committee of Kasturba Medical College, Mangalore
(IEC KMC MLR 05-2020/164). Electronic written informed consent was obtained from all participants on the google
form. Only consenting participants were able to access the online questionnaire.

Study area
The study was conducted in the coastal city of Mangalore, belonging to the District of Dakshina Kannada in the Southern
part of India. A major commercial and educational hub, an ivory town of hospitals and medical colleges, Mangalore
enjoys a high health care index24 catering to patients not only from the adjoining districts, but also from the neighbouring
state of Kerala.

Dakshina Kannada is among the top five highly affected districts in the State of Karnataka, by the ongoing COVID-19
pandemic. A total of 3.9 million cases have been reported till date25 with Mangalore being the major contributor to the
daily tally of cases.

Participants
This facility-based cross-sectional study was carried out among the health care workers (HCWs) – doctors and nurses of
the teaching hospitals affiliated to Kasturba Medical College, Mangalore.

A total of 245 HCWs were assessed for their mental health outcomes during the COVID-19 pandemic. The sample size
was calculated using the formulae for cross-sectional study26 design: N=4pq/d2. Considering the proportion of HCWs
experiencing depressive symptoms to be 50.4%,19 absolute precision of 7%, power of 80%, 95% confidence interval,
and a non-response error of 20%, the final sample size was calculated to be 245. Applying the population proportion to
size technique, a total of 128 doctors and 117 nurses were included in the study. The doctors and nurses who were willing
to participate, were included in the study, using the non-probability (convenience) sampling method, till the required
sample size was reached.

Data collection instruments

The study was conducted during the second wave of COVID-19 from 1st March 2021 to 30th June 2021. The information
related to the study variables was collected using a semi-structured questionnaire in English which had the following
sections:

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• Section A: General participant information which included age, gender, designation, whether involved in
COVID-19 care, and other personal details.

• Section B: Patient Health Questionnaire (PHQ-9)27 consisting of 9 statements assessed the presence of
depression-related symptoms among the participants. The total score ranges from 0 to 27 and is calculated
by assigning each statement scores of either 0,1,2 or 3, where 0 is not at all, 1 - several days, 2 - more than half
the days and 3 - nearly every day. The scores of 5, 10, and 15 represent cut points for mild, moderate and severe
depression, respectively. The interpretation of the total scores obtained is as follows: Normal (0-4), mild
depression (5-9), moderate depression (10-14), and severe depression (15-27).

• Section C: Generalised Anxiety Disorder (GAD-7) scale28 consisting of 7 statements assessed the presence of
anxiety among the participants. The total score ranges from 0 to 21 and is calculated by assigning each statement
scores of either 0, 1, 2 ,or 3, where 0 is not at all, 1 - several days, 2 - more than half the days, and 3 - nearly every
day. The scores of 5, 10, and 15 represent cut points for mild, moderate, and severe anxiety, respectively. The
interpretation of total scores obtained is as follows: Normal (0-4), mild anxiety (5-9), moderate anxiety (10-14)
and severe anxiety (15-21).

• Section D: Insomnia Severity Index (ISI)29 consisting of 7 items assessed the presence of insomnia across
dimensions like severity of sleep onset, sleep maintenance, and early morning awakening problems, sleep
dissatisfaction, interference of sleep difficulties with daytime functioning, noticeability of sleep problems by
others, and distress caused by the sleep difficulties. The statements were assigned a score of either 0,1,2,3, or 4,
where 0 was no problem, 1 - mild problem, 2 - moderate problem, 3 - severe problem and 4 - very severe
problem. The total score ranged from 0 to 28. The scores were interpreted as follows: Normal (0-7),
subthreshold insomnia (8-14), Clinical insomnia - moderate severity (15-21) and clinical insomnia - severe
(22-28).

Reliability of the questionnaires

The Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7) scale and Insomnia Severity Index
(ISI) are standard questionnaires which have been used worldwide for measuring depression, anxiety and insomnia in
various settings, with good reliability and internal consistency.27–29 The psychometric properties of PHQ-9 and GAD-7
in Indian population were found to be comparable to western settings.30 The internal reliability for PHQ-9 has been
reported to be excellent with Cronbach’s α of 0.89 in primary care studies.31 The GAD-7 and ISI-7 had an internal
consistency score of 0.92 respectively, with good test retest reliability.32,33

Pilot Testing

The questionnaire was pilot tested and validated for the content. The pilot testing was carried out in the month of February
2021 among 30 HCWs (15 doctors and 15 nurses). The participants were selected randomly using non-probability
sampling. These participants were excluded from the main study. The pilot was done to evaluate the feasibility of an
online survey and to finalize the questionnaire. Based on the pilot testing, questions on participants specialty, department
to which they belong, and teaching experience in medical college was removed to make section A uniform for both
doctors and nurses. No changes were made to Section B, section C, and section D, since they were standard questionnaires
and already pre-validated.

Data collection

After obtaining the requisite permission from the head of the institution and concerned authorities of the hospitals, a list of
doctors and nurses along with their phone numbers and email IDs working in the affiliated hospitals was obtained from
the Human Resource department.

To limit personal contact with the study participants due to the prevailing pandemic, a questionnaire was prepared in
Google forms (https://www.google.co.uk/forms/) and the link was sent to the participants via WhatsApp or email.

The information sheet and consent form were included in the Google form. Electronic consent was obtained from each
respondent on the first page of the form. Only the consenting participants were able to access the form and fill out their
responses. Any personal identifiers were excluded in the form to ensure confidentiality of the participants. The google
form link was circulated till the required sample size of 245 was reached.

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Data management and analysis

The collected data was extracted as a spreadsheet from Google drive and analysed using IBM SPSS (Statistical Package
for Social Sciences) Statistics for Windows Version 25.0. Armonk, NY: IBM Corp). The data is expressed using mean
(standard deviation), median (interquartile range), and proportions.

The interpretation of the scales used to assess the various mental health outcomes among the participants is as follows:

• General Anxiety Disorder - 7: Normal (0-4), Mild (5-9), Moderate (10-14), and severe (15-21) anxiety.

• Patient Health Questionnaire - 9: Normal (0-4), mild (5-9), moderate (10-14), and severe (15-27) depression.

• Insomnia Severity Index - 7: Normal (0-7), Subthreshold (8-14), Moderate (15-21), and Severe (22-28)
insomnia.

The cut-off scores for detecting symptoms of major depression, anxiety, and insomnia were taken from the standard
questionnaires. Participants were categorized to have severe symptoms if they had scored greater than the cut-off
threshold.

For comparison across the groups, (gender, type of HCWs, involved in COVID-19 care) the Mann-Whitney U test was
used and a ‘P’ value of <0.05 was considered statistically significant. Univariate analysis was carried out to identify the
factors associated with mental health outcomes like presence of depression, anxiety, and insomnia among the HCWs and
the corresponding unadjusted odds ratio and 95% confidence interval were reported.

Results
A total of 245 HCWs, which included 52.2% (n=128) doctors and 47.8% (n=117) nurses were assessed about their mental
health status in our study. The mean age of the doctors was 29.7 (7.9) years, while that of nurses was 26.3 ( 6.2) years.
A higher proportion of participants (n=66, 51.6%) among doctors were females. Majority (n=87, 68%) of the doctors and
47% (n=55) of the nurses were involved in the direct care of COVID-19 patients. The socio-demographic information of
the participants is depicted in Table 1.

The proportion of participants with depressive symptoms, anxiety, and insomnia assessed using PHQ-9, GAD-7 and
ISI-7 scales were 49% (n=119), 38% (n=93) and 42% (n=102) respectively (Table 2). The mental health status of the
study participants is depicted in Table 3. The proportion of depression was higher among doctors (51.6%) compared to
nurses (45.3%), however, this finding was not statistically significant (P>0.05). The anxiety-related symptoms were

Table 1. Socio-demographic information of the study participants (N=245).

Characteristics Doctors Nurses

N=128 N=117
n (%) n (%)
Age group (years)
≤25 43 (33.6) 75 (64.1)
26-30 53 (41.4) 27 (23.1)
31-40 19 (14.8) 11 (09.4)
>40 13 (10.2) 04 (03.4)
Gender
Male 62 (48.4) -
Female 66 (51.6) 117 (100)
Work experience (years)
≤10 93 (72.7) 93 (79.5)
>10 35 (27.3) 24 (20.5)
Involved in covid care
Yes 87 (68.0) 55 (47.0)
No 41 (32.0) 62 (53.0)

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Table 2. Proportion of study participants with unfavorable mental health outcomes (N=245).

Mental health outcomes Doctors Nurses

N=128 N=117
n(%) n(%)
Depression 66 (51.6) 53 (45.3)
Anxiety 50 (39.0) 43 (36.7)
Insomnia 49 (38.2) 53 (45.2)

Table 3. Mental health outcomes among the healthcare workers (HCW) (N=245).

Mental health outcomes Category of HCW Chi-square test

(p value)
Doctors (N=128) Nurses (N=117) Total (N=245)
n (%) n (%) n (%)
Level of depression (PHQ-9)
Normal (0-4) 62(48.4) 64 (54.7) 126 (51.4) 1.630 (0.661)
Mild (5-9) 37 (29.0) 33 (28.2) 070 (28.6)
Moderate (10-14) 15 (11.7) 09 (07.7) 024 (09.8)
Severe (15-27) 14 (10.9) 11 (09.4) 025 (10.2)
Level of anxiety (GAD-7)
Normal (0-4) 78 (60.9) 74 (63.2) 152 (62.0) 5.131* (0.159)
Mild (5-9) 27 (21.1) 28 (23.9) 055 (22.4)
Moderate (10-14) 15 (11.7) 14 (12.0) 029 (11.8)
Severe (15-27) 08 (06.3) 01 (00.9) 009 (03.7)
Level of insomnia (ISI-7)
Normal (0-7) 79 (61.7) 64 (54.7) 143 (58.4) 2.550* (0.451)
Sub threshold (8-14) 36 (28.1) 38 (32.5) 74 (30.2)
Moderate (15-21) 12 (09.4) 15 (12.8) 27 (11.0)
Severe (22-28) 01 (00.8) - 01 (00.4)
*Fisher exact test.

similar among doctors and nurses (doctors 39.0% vs. 36.7% in nurses). A higher proportion of nurses experienced
insomnia related symptoms compared to doctors (45.2% vs. 38.2%) (P>0.05).

Comparison of mental health outcome scores as assessed by the various scales is shown in Table 4. The median (IQR)
scores for depression (PHQ-9), anxiety (GAD-7), and insomnia (ISI-7) for all the participants were 4.0 (1.0-8.0), 3.0 (0.5-
7.0), and 6 (2-10) respectively. The median PHQ-9 and GAD-7 scores were higher among doctors compared to nurses,
while nurses had a higher ISI-7 median score. However, no significant difference in mental health scores was observed
across categories of HCWs, gender of the participants, and involvement in COVID-19 patients’ care (P>0.05).

The risk factors for developing mental health outcomes – depression, anxiety, and insomnia among HCWs is shown in
Table 5.

Depression was more likely to be experienced by HCWs aged >27 years (OR, 1.19; 95% CI, 0.70-2.05), female HCWs
(OR, 1.03; 95% CI, 0.58-1.84), and HCWs involved in COVID-19 care (OR, 1.22; 95% CI, 0.73-2.04). Insomnia was
more likely to be experienced by HCWs aged >27 years (OR, 1.59; 95% CI, 0.91-2.79) and HCWs with work experience
of more than 10 years (OR, 2.08; 95% CI, 1.10-3.92). Anxiety was more likely to be experienced by HCWs aged
>27 years (OR, 1.63; 95% CI, 0.92-2.91), nurses (OR, 1.10; 95% CI, 0.66-1.85), and HCWs with work experience of
more than 10 years (OR, 1.53; 95% CI, 0.82-2.92). However, none of these factors was significantly associated with
mental health outcomes (P>0.05), except HCWs with work experience of more than 10 years, which was significantly
associated with experiencing insomnia symptoms (P<0.05).

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 Table 4. Comparison of mental health outcome scores among health care workers (HCW) (N=245).

Scale Total participants Doctors Nurses p value* Male Female p value* Involved in COVID-19 P value*
care
Yes No
Median Median Median Median Median Median Median
(IQR) (IQR) (IQR) (IQR) (IQR) (IQR) (IQR)
PHQ-9, depression symptoms 4 (1-8) 6.2 (2-9) 5.4 (1-8) 0.200 5.8 (1-8) 5.7 (2-9) 0.604 6.2 (1-9) 5.2 (1-8) 0.320
GAD-7, anxiety symptoms 3 (0.5-7) 5.0 (1-8) 3.7 (0-5.5) 0.176 4.3 (0-7) 4.5 (1-7) 0.727 4.9 (0.8-7) 4.1 (0-7) 0.495
ISI, insomnia symptoms 6 (2-10) 6.6 (2-10) 7.4 (2-10) 0.645 7.2 (2-10) 6.0 (2-10) 0.406 6.8 (2-10) 7.3 (2-10) 0.837
*Mann-Whitney U test.

Table 5. Univariate analysis showing risk factors for mental health outcomes- depression, insomnia, and anxiety among health care workers (HCW) (N=245).

Experiencing Odds Ratio P value Experiencing Odds Ratio P value Experiencing Odds Ratio P value
symptoms of (95% CI) symptoms of (95% CI) symptoms of (95% CI)
depression insomnia anxiety
Yes No Yes No Yes No
(N=119) (N=126) (N=102) (N=143) (N=93) (N=152)
n (%) n (%) n (%) n (%) n (%) n (%)
Age group (years)
≤27 83 (69.7) 83 (65.9) 1 0.521 75 (73.5) 91(63.6) 1 0.104 69 (74.2) 97 (63.8) 1 0.093
>27 36 (30.3) 43 (34.1) 1.19 (0.70-2.05) 27 (26.5) 52 (36.4) 1.59 (0.91-2.79) 24 (25.8) 55 (36.2) 1.63 (0.92-2.91)
Gender
Male 88 (73.9) 94 (74.6) 1 0.907 25 (24.5) 105 (73.4) 1 0.000001 22 (23.7) 041 (27.0) 1 0.571
Female 31 (26.1) 32 (25.4) 1.03 (0.58-1.84) 77 (75.5) 038 (26.6) 0.12 (0.06-0.21) 71 (76.3) 111 (73.0) 0.84 (0.46-1.52)
Health care worker
Doctor 66 (55.5) 62 (49.2) 1 0.960 49 (48.0) 79 (55.2) 1 0.269 50 (53.8) 78 (51.3) 1 0.712
Nurse 53 (44.5) 64 (50.8) 0.78 (0.47-1.29) 53 (52.0) 64 (44.8) 0.75 (0.44-1.25) 43 (46.2) 74 (48.7) 1.10 (0.66-1.85)
Work Experience (years)
≤10 98 (82.4) 88 (69.8) 1 0.331 85 (83.3) 101(70.6) 1 0.021 75 (80.6) 111(73.0) 1 0.175
>10 21 (17.6) 38 (30.2) 0.49 (0.27-0.90) 17 (16.7) 042 (29.4) 2.08 (1.10-3.92) 18 (19.4) 041 (27.0) 1.53 (0.82-2.92)
Involvement in COVID care
Yes 72 (60.5) 70 (55.6) 1.22 (0.73-2.04) 0.433 60 (58.8) 82 (57.3) 0.94 (0.56-1.57) 0.819 54 (58.1) 88 (57.9) 1.0 (0.58-1.67) 0.979
No 47 (39.5) 56 (44.4) 1 42 (41.2) 61 (42.7) 1 39 (41.9) 64 (42.1) 1

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Discussion
Health-care workers (HCWs) have been at the forefront since the beginning of the pandemic providing uncompromising
care to those infected with COVID-19. However, the extended period of duty hours and the constant fear of getting
infected or spreading the infection to family members has negatively impacted their physical and mental health.
Unfavourable mental health outcomes – depression, insomnia and anxiety were also reported among our study
participants.

The prevalence of depression was 51.5% in our study. Anxiety was reported among 38%, while insomnia was present in
42% of the participants. The prevalence of unfavourable mental health outcomes in our study is high compared to a
similar study from another part of India where depression was reported among 47.4% of the HCWs, while anxiety and
insomnia were seen among 29.0% and 32.2% of the participants respectively.34 Similar studies conducted among the
HCWs during the pandemic from different parts of the world have reported a prevalence of depression ranging from 8.9%
to 77.2%,14–19,23,35–45 anxiety 14.5% to 88%,14–19,36–40,48–52 and insomnia 9.9% to 85.4%.37,38,40–51

Many factors can contribute to unfavorable mental health outcomes among HCWs. The long duty hours and overflowing
outpatient departments (OPDs), along with acute shortage of trained staff and personal protective equipment (PPE), fear
of contracting the infection and spreading the disease to their family members, and continuous performance evaluation
results in psychological distress in most HCWs, ultimately leading to burnout.37,52–57 HCWs are also faced with several
decision-making dilemmas during a pandemic including allocation of resources, care for a severely ill/dying patient, and
aligning patient needs with those of family members further resulting in mental distress.58,59 All this is compounded by a
prolonged period of separation from family members during the pandemic and/or a lack of any other form of support
system.10–13,33,34

Studies from different parts of the world have reported a variety of factors contributing to unfavourable mental health
outcomes. A study from the Eastern Mediterranean region reported that the presence of a pre-existing mental illness,
being isolated for COVID-19, and having children was significantly associated with experiencing depressive symp-
toms43 while insomnia was significantly associated with HCWs working in an isolation unit in a study in China.41 The
absence of psychological support at the workplace as a factor for experiencing poor mental outcomes was reported in
studies conducted in China and Albania,41,44 while fear of getting infected and transmitting COVID-19 was associated
with experiencing depressive symptoms among HCWs in Switzerland and China.40,41

The frontline HCWs being directly involved in the examination, diagnosis, and treatment of COVID-19 makes them
more vulnerable to contracting the infection. The constant fear of being at risk of getting infected may lead to
psychological distress and burnout among them. Several studies have reported that the HCWs involved in direct care
for COVID-19 patients were found to have unfavourable mental health outcomes.20,37,42,45

In our study, unfavourable mental health outcomes – depression, anxiety and insomnia were observed among HCWs >27
years of age, nurses, and those having work experience of more than 10 years. Similar observations were reported in
various studies among HCWs around the world.

A higher proportion of doctors and all the nurses in our study were females. Females were found to have a higher risk of
experiencing poor mental outcomes in studies conducted in Asia and Africa19,27,35,38,50 whereas another study from
Africa reported male HCWs and physicians to be more at risk for experiencing distress.45,46 In general, female
HCWS, especially nurses, were found to be more likely to experience depression and insomnia related symp-
toms.27,35,38,40,41,50 This vulnerability of nurses may be attributed to longer duration of time spent in patient care
compared to doctors, along with increased work load and frequent night shifts.38 Studies have shown that nurses were
more likely to have job uncertainty and financial concerns, which along with fear of getting infected due to prolonged time
spent in the ward, could have compounded the anxiety and insomnia experienced by them.60,61

In our study, work experience of more than 10 years was found to be significantly associated with experiencing insomnia
symptoms. A similar study from Nepal reported that HCWs having less than 5 years’ work experience were less likely to
experience insomnia related symptoms, compared to those with more than 5 years of experience. This is in contrast to
studies from Turkey62 and China63 where having less work experience was significantly associated with unfavourable
mental health outcomes. The most likely explanation for this observation would be that the HCWs with more than 10
years’ experience would be married and have a family, which would make them anxious due to fear of spreading the
infection to their family. Also, during the pandemic, the more experienced HCWs might have been given more
responsibilities as compared to the newer staff.

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 F1000Research 2022, 11:676 Last updated: 15 DEC 2022

A higher age usually corresponds to more experience in handling complex situations and prompt decision making
especially during the pandemic, when the health system was overburdened.38 However, in our study HCWs above 27
years of age were more likely to experience depression, anxiety and insomnia. A study in China reported that the HCWs in
the 31-40 years of age were worried about infecting their family, while those above 40 years of age were stressed due to
the concern regarding their own safety during the pandemic.60 In contrast, younger HCWs in the age group between 21-
30 years were found to experience unfavourable mental health outcomes in studies from Italy,37 Finland46 and Hong
Kong.50

Our study has many clinical implications. The presence of clinically relevant anxiety and depressive symptoms among
38% and 49% HCWs respectively in our study draws attention to the importance of regular and systematic tracking of
mental health status of HCWs during this ongoing pandemic. The result of our study reiterates the need for periodic
monitoring of the mental health status of the HCWs, especially during pandemic and provide appropriate and timely
interventions, not only to improve the quality of life of HCWs, but also the quality of patient care provided. It is important
that the measures taken address the key concerns of healthcare workers who are working in frontline such as adequate
availability of PPE, sufficient time to spend with family, and acceptable compensations to their family in case of death.

Limitations
There are certain limitations in our study. Firstly, our study was conducted in and around the healthcare facilities of
Mangalore, a tier 2 city in India and, due to the limited geographical reach of the study, it may not be possible to generalize
the results obtained. Secondly, we did not assess the mental health of the participants before the pandemic and hence their
prior mental condition may act as a confounding factor in our study. Thirdly, we did not take into consideration the socio-
economic parameters of the participants of our study. We recommend follow up studies to assess the progression of mental
health among the HCWs after implementing workplace intervention measures for the betterment of their mental health.

The COVID-19 pandemic has had alarming implications for personal and collective health along with social and
emotional functioning. The onus of maintaining the health of the society as well as the safety of their loved ones inserts a
substantial stressor on the mental health of the frontline workers, especially the doctors and nurses in hospitals. The novel
nature of the infection, inadequate testing, unknown long-term sequelae, limited availability of PPE, and extended work
hours along with the other emerging concerns summate together potentially overwhelming these workers. Thus, it
becomes important that the healthcare workers monitor their stress reactions, seek appropriate help both on a personal and
professional level including professional mental health interventions if indicated.

Conclusions
A higher proportion of doctors compared to nurses had symptoms of depression and insomnia, while the proportion of
doctors and nurses experiencing anxiety related symptoms is almost similar. Overall 49% of the HCWs had clinically
relevant depressive symptoms and 38% had clinically relevant anxiety symptoms. This draws attention to the importance
of systematically tracking the mental health of HCWs during this ongoing pandemic. The healthcare workers should
monitor their stress reactions and seek appropriate help both on a personal and professional level. Appropriate workplace
interventions including psychological support should be provided to HCWs, to ensure a sound mental health, so as to
provide uncompromised quality health care to the patients.

Data availability
Underlying data
Open Science Framework: Covid 19 pandemic and mental health outcomes – A study among health care workers in
Coastal South India. https://doi.org/10.17605/OSF.IO/MU9E8.64

This project contains the following extended data:

• Data (Anonymized responses in excel sheet)

• Data key (Codes for responses)

Extended data
Open Science Framework: Covid 19 pandemic and mental health outcomes – A study among health care workers in
Coastal South India. https://doi.org/10.17605/OSF.IO/MU9E8.64

Page 10 of 21

This project contains the following extended data:
• Questionnaire (Blank English copy of the questionnaire used in this study).
• Information sheet and consent form.
Reporting guidelines
Open Science Framework: STROBE checklist for ‘Covid 19 pandemic and mental health outcomes – A study among
health care workers in Coastal South India’. https://doi.org/10.17605/OSF.IO/MU9E8.42
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).
Acknowledgements
We thank the participants of the study, the Department of Community Medicine, Kasturba Medical College, Mangalore,
and the Manipal Academy of Higher Education for their support for this research and its publication.
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Open Peer Review

Current Peer Review Status:

Version 2

Reviewer Report 22 November 2022

https://doi.org/10.5256/f1000research.139956.r154705

© 2022 Wulandari D. This is an open access peer review report distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

Devi Wulandari
Department of Psychology, Paramadina University, Jakarta, Indonesia

Thank you very much for your revision. Overall, the present article has shown significant
improvements. There are several additional feedbacks to increase the article's credibility. 
1. The 2nd paragraph in the introduction: please add references regarding lockdown impacts
on physical, mental and well-being in the population 
 
2. Data collection instruments: please add information regarding the calculation of
participants score and reliability score for each instruments in the study 
 
3. in the result section, please add: a demographic table for the research participants before
table 1 to give an overall description 
 
4. Information regarding 51.5% prevalence of depression in the study should be informed in a
table for result sections
 
5. Paragraph 3 in the discussion should be added with more references 
 
6. Since only work experiences of more than 10 years was the only significant risk factors, the
discussion should only discuss the association of work experience with mental health
outcomes. 
 
7. Please also discuss the explanation regarding factors that were not statistically significance 

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Health psychology

I confirm that I have read this submission and believe that I have an appropriate level of
expertise to confirm that it is of an acceptable scientific standard, however I have

 
Page 14 of 21
 F1000Research 2022, 11:676 Last updated: 15 DEC 2022

significant reservations, as outlined above.

Author Response 03 Dec 2022

Nithin Kumar, Kasturba Medical College, Mangalore, Manipal Academy of Higher
Education, Manipal, India

Thank you sir for your valuable comments. We have modified the article as per your
suggestions.
 
1. The 2nd paragraph in the introduction: please add references regarding
lockdown impacts on physical, mental and well-being in the population.

Response: Thank you, sir. We have updated paragraph 2 of the introduction with the
impact of the lockdown on the physical and mental well-being of the population. The
reference list has been updated accordingly.
 
2. Data collection instruments: Please add information regarding the calculation
of participants score and reliability score for each instruments in the study.

Response: Thank you, sir. We have provided the information on the calculation of
participants' scores. However, we did not calculate the reliability scores for the
questionnaires, since they were standard questionnaires. However, we have provided
references depicting the reliability of the questionnaires, in Indian and western
settings.
 
3. In the result section, please add: a demographic table for the research
participants before table 1 to give an overall description.

Response: Thank You, sir. We have incorporated a table on demographic details in

the manuscript as per your suggestion.
 
4. Information regarding 51.5% prevalence of depression in the study should be
informed in a table for result sections.

Response: Thank you, sir. We have incorporated a new table depicting the proportion
of doctors and nurses with unfavorable mental health outcomes.
 
5. Paragraph 3 in the discussion should be added with more references.

Response: Thank you sir. We have supported the paragraph 3 of discussion with new
references.
 
6. Since only work experiences of more than 10 years were the only significant risk
factors, the discussion should only discuss the association of work experience
with mental health outcomes. 

Response: Thank you, sir. We have discussed the factors found to be significant in

 
Page 15 of 21
 F1000Research 2022, 11:676 Last updated: 15 DEC 2022

our study.
 
7. Please also discuss the explanation regarding factors that were not statistically
significance.

Response: Thank you sir. We have incorporated explanations for factors like gender,
and HCWs which were not found to be significant in our study.

Competing Interests: NIL

Reviewer Report 07 November 2022

https://doi.org/10.5256/f1000research.139956.r154706

© 2022 Raina S. This is an open access peer review report distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.

Sunil Kumar Raina

Department of Community Medicine, Dr. RP Govt. Medical College, Tanda, Himachal Pradesh,
India

The manuscript is approved for indexing.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Epidemiology

I confirm that I have read this submission and believe that I have an appropriate level of
expertise to confirm that it is of an acceptable scientific standard.

Version 1

Reviewer Report 03 October 2022

https://doi.org/10.5256/f1000research.122887.r149463

© 2022 Wulandari D. This is an open access peer review report distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

 
Page 16 of 21
 F1000Research 2022, 11:676 Last updated: 15 DEC 2022

Devi Wulandari
Department of Psychology, Paramadina University, Jakarta, Indonesia

1. The work was clearly presented however the study cited 72% of current literature. Adding
more current literature, especially in the introduction section will suffice.
 
2. Appropriateness of study design. There is some information that needs to be completed in
the method section, such as criteria for the cutoff score and information regarding the
reliability of the measurement.
 
3. Statistical analysis. There are some questionable interpretations such as the proportion of
participants with depressive symptoms higher among doctors but in fact the result (chi
square) was not significant.
 
4. Conclusion. Since there are several questionable results from the study, thus the conclusion
were not adequately supported. 

Is the work clearly and accurately presented and does it cite the current literature?
Partly

Is the study design appropriate and is the work technically sound?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?
Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?
Yes

Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Health psychology

I confirm that I have read this submission and believe that I have an appropriate level of
expertise to confirm that it is of an acceptable scientific standard, however I have
significant reservations, as outlined above.

Author Response 17 Oct 2022

Nithin Kumar, Kasturba Medical College, Mangalore, Manipal Academy of Higher

 
Page 17 of 21
 F1000Research 2022, 11:676 Last updated: 15 DEC 2022

Education, Manipal, India

1. The work was clearly presented however the study cited 72% of current literature.
Adding more current literature, especially in the introduction section will suffice.

Response: Thank you sir. We have incorporated current literature in the introduction
and discussion as per your suggestion.  
 
2. Appropriateness of study design. There is some information that needs to be
completed in the method section, such as criteria for the cut off score and
information regarding the reliability of the measurement.

Response: Thank you sir. Since the scales used to assess depression, anxiety and
insomnia in our study was standard, cut-offs scores mentioned by the scales were
used. A note on reliability of the scales have been added in the methods section. The
cut-off scores used are also mentioned in the methods section.  
 
3. Statistical analysis. There are some questionable interpretations such as the
proportion of participants with depressive symptoms higher among doctors but in
fact the result (chi square) was not significant.

Response: Thank you sir for pointing out the error. We have modified the statement
and added the P value so that the interpretation is clear.
 
4. Conclusion. Since there are several questionable results from the study, thus the
conclusion were not adequately supported. 

Response: The conclusion has been re-written according to the results.

Competing Interests: NIL

Reviewer Report 19 July 2022

https://doi.org/10.5256/f1000research.122887.r142248

© 2022 Raina S. This is an open access peer review report distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.

Sunil Kumar Raina

Department of Community Medicine, Dr. RP Govt. Medical College, Tanda, Himachal Pradesh,
India

The article is relevant in the context of the prevailing COVID 19 pandemic and the taxing effect it

 
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has, not only on the physical health of the HCWs, but also their mental health.

The manuscript is well written. However, there are few queries I would like the author to address
in the manuscript.
○ Has the questionnaire used in the study been validated?
 
○ Was the questionnaire translated to the local vernacular language for the nurses?
 
○ How was the data collected?
 
○ For how many health care professionals' questionnaires were distributed in order to reach
the required sample size? What was the non-response rate?
 
○ How can you attribute the present mental health status to COVID 19? Can it be due to
existing mental health condition or health status prior to COVID 19 pandemic ? Did you
gather information regarding past mental health status?

Is the work clearly and accurately presented and does it cite the current literature?
Yes

Is the study design appropriate and is the work technically sound?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?
Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?
Yes

Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Epidemiology

I confirm that I have read this submission and believe that I have an appropriate level of
expertise to confirm that it is of an acceptable scientific standard, however I have
significant reservations, as outlined above.

Author Response 28 Jul 2022

Nithin Kumar, Kasturba Medical College, Mangalore, Manipal Academy of Higher

 
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Education, Manipal, India

Thank you for your review of our paper titled The COVID-19 pandemic and mental health
outcomes – A cross-sectional study among health care workers in Coastal South India"

Kindly find our reply for your queries below:

1. Has the questionnaire used in the study been validated?

The Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7)

scale, and Insomnia Severity Index (ISI) -all are standard questionnaires which are
pre-validated.

However, a pilot testing was carried out among 30 HCWs (15 doctors and 15 nurses),
to check the usability/feasibility of the questionnaire.

Based on the pilot testing, changes were made to Section A (General participant
information)-like income of the participants and permanent addresses were removed.

No changes were made to Section B (PHQ-9), Section C (GAD-7) and ISI (Section D).
 
2. Was the questionnaire translated to the local vernacular language for the
nurses?

The questionnaires were not translated into the local vernacular language. Pre-
validated standard questionnaire in English language was sent to all the study
participants – doctors and nurses via google form link. All the nurses were proficient
in English language.
 
3. How was the data collected?

To limit the personal contact with the study participants due to the prevailing
pandemic, the questionnaire was prepared in Google forms and the link was sent to
the participants via WhatsApp or email.
 
4. For how many health care professionals' questionnaires were distributed in
order to reach the required sample size? What was the non-response rate?

To reach the sample size of 245 (128 doctors and 117 nurses), the link was sent to 280
health care workers, which included 150 doctors and 130 nurses.

The response rate for doctors was 85.3% and 90.3% for nurses.
 
5.  How can you attribute the present mental health status to COVID 19? Can it be
due to existing mental health condition or health status prior to COVID 19
pandemic? Did you gather information regarding past mental health status?

Yes. We did not take into consideration the existing mental health condition of the

 
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health care professionals and that is the limitation of our study.

Competing Interests: nil

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