Psychosociological Issues in Human Resource Management

9(2), 2021, pp. 7–20, ISSN 2332-399X, eISSN 2377-0716

COVID-19 Pandemic-related Emotional Anxiety,

Perceived Risk of Infection, and
Acute Depression among Primary Care Providers

Sarah Cohen
sarah.cohen@aa-er.org
The Cognitive Computing Technologies
Research Unit at AAER, Glasgow, Scotland
(corresponding author)
Elvira Nica
elvira.nica@ase.ro
The Center for Human Resources and Labor Studies
at AAER, New York City, NY, USA;
The Bucharest University of Economic Studies, Romania

ABSTRACT. This article presents an empirical study carried out to evaluate and
analyze COVID-19 pandemic-related emotional anxiety, perceived risk of infection,
and acute depression among primary care providers. Building our argument by
drawing on data collected from ACEP, ACHA, Bain & Company, BMA, CDC,
Ginger, GWI, HMN, MHA, Morning Consult, Pew Research Center, PHW, and
Statista, we performed analyses and made estimates regarding how the COVID-19
crisis emergency has resulted in distressing job conditions for frontline medical
workers in terms of increased anxiety symptoms, sustained psychological distress,
emotional exhaustion, clinically significant depression, and perceived risk of
infection, configuring cognitive, emotional, and behavioral disorders. Data collected
from 5,700 respondents are tested against the research model. Descriptive statistics
of compiled data from the completed surveys were calculated when appropriate.
JEL codes: H51; H75; I12; I18; D91

Keywords: COVID-19; emotional anxiety; perceived risk of infection; acute depression

How to cite: Cohen, S., and Nica, E. (2021). “COVID-19 Pandemic-related Emotional
Anxiety, Perceived Risk of Infection, and Acute Depression among Primary Care
Providers,” Psychosociological Issues in Human Resource Management 9(2): 7–20.
doi: 10.22381/pihrm9220211.

Received 19 April 2021 • Received in revised form 9 November 2021

Accepted 12 November 2021 • Available online 25 November 2021

7
1. Introduction
Frontline healthcare workers do not display an escalation in depressive or
anxious symptoms relative to the general population, while showing a signif-
icant rise in trauma-related symptoms. In contrast to secondline healthcare
workers, primary care providers exhibit increased levels of adverse affective
post-traumatic symptoms. (Rossi et al., 2020) Nurses experience traumatic
work situations due to the increased demand for specialized care, with fear
impacting job stress (Lăzăroiu, 2013; Lăzăroiu, 2017; Lăzăroiu et al., 2021) in
addition to escalated staff resignation rate. (De los Santos and Labrague, 2021)

2. Conceptual Framework and Literature Review

The COVID-19 crisis may considerably impact the mental health of frontline
medical staff. (Pappa et al., 2020) Job status constitutes a relevant predictor
of dysfunctional anxiety associated with COVID‐19: contracted nurses are
undergoing more increased levels of anxiety than permanent ones because of
insufficient comprehension of the unit or ward operations, specific procedures,
and care management for infected patients. (Labrague and De Los Santos,
2020) Sleep deprivation represents a determinant of diminished neurobehav-
ioral performance among COVID-19 frontline medical staff. (Azoulay et al.,
2020) Reliance on COVID-19 infection-control measures (e.g., the utility of
face masks) may decrease risk perception (Lăzăroiu et al., 2017; Lăzăroiu et
al., 2020;) and enable an adaptive stress reaction. (Lam et al., 2020) Im-
moderate workload, persistent interaction with COVID-19 patients and
psychological features associated with their care result in escalated levels of
burnout. (Giusti et al., 2020) Resilience functions as a determining mediator
between COVID-19 fear and mental health issues. (Yıldırım et al., 2020)
With the swift rise in the volume of COVID-19 patients, medical personnel
are bearing the brunt of increased work intensity. (Wang et al., 2020)

3. Methodology and Empirical Analysis

Building our argument by drawing on data collected from ACEP, ACHA,

Bain & Company, BMA, CDC, Ginger, GWI, HMN, MHA, Morning Con-
sult, Pew Research Center, PHW, and Statista, we performed analyses and
made estimates regarding how the COVID-19 crisis emergency has resulted in
distressing job conditions for frontline medical workers in terms of increased
anxiety symptoms, sustained psychological distress, emotional exhaustion,
clinically significant depression, and perceived risk of infection, configuring
cognitive, emotional, and behavioral disorders. Data collected from 5,700 re-
spondents are tested against the research model. Descriptive statistics of com-
piled data from the completed surveys were calculated when appropriate.
8
4. Study Design, Survey Methods, and Materials
The interviews were conducted online and data were weighted by five vari-
ables (age, race/ethnicity, gender, education, and geographic region) so that
each European country’s sample composition reliably and accurately reflects
the demographic profile of the adult population according to the most recent
census data.

Data sources: ACEP, ACHA, Bain & Company, BMA, CDC, Ginger, GWI,
HMN, MHA, Morning Consult, Pew Research Center, PHW, and Statista.
Study participants: 5,700 individuals provided an informed e-consent.

The data was weighted in a multistep process that accounts for multiple
stages of sampling and nonresponse that occur at different points in the survey
process. All data were interrogated by employing graphical and numeric
exploratory data analysis methods. Multivariate analyses, and not univariate
associations with outcomes, are more likely to factor out confounding co-
variates and more precisely determine the relative significance of individual
variables. Results are estimates and commonly are dissimilar within a narrow
range around the actual value.

Test data was populated and analyzed in SPSS to ensure the logic and ran-
domizations were working as intended before launching the survey. To ensure
high-quality data, data quality checks were performed to identify any respon-
dents showing clear patterns of satisficing (e.g., checking for high rates of
leaving questions blank). Sampling errors and test of statistical significance
take into account the effect of weighting. Question wording and practical dif-
ficulties in conducting surveys can introduce error or bias into the findings
of opinion polls. The sample weighting was accomplished using an iterative
proportional fitting process that simultaneously balanced the distributions of
all variables. Stratified sampling methods were used and weights were
trimmed not to exceed 3. Average margins of error, at the 95% confidence
level, are +/-2%. The design effect for the survey was 1.3. For tabulation
purposes, percentage points are rounded to the nearest whole number. The cu-
mulative response rate accounting for non-response to the recruitment surveys
and attrition is 2.5%.

Confirmatory factor analysis was employed to test for the reliability and
validity of measurement instruments. Addressing a significant knowledge
gap in the literature, the research has complied with stringent methodology,
reporting, and data analysis requirements. The precision of the online polls
was measured using a Bayesian credibility interval.
Flow diagram of study procedures
9
5. Statistical Analysis
This survey employs statistical weighting procedures to clarify deviations in
the survey sample from known population features, which is instrumental in
correcting for differential survey participation and random variation in sam-
ples. Descriptive analyses (mean and standard deviations for continuous
variables and counts and percentages for categorical variables) were used.
Descriptive statistical analysis and multivariate inferential tests were under-
taken for the survey responses and for the purpose of variable reduction in
regression modeling. Independent t-tests for continuous variables or chi-
square tests for categorical variables were employed.

AMOS-SEM analyzed the full measurement model and structural model.

Mean and standard deviation, t-test, exploratory factor analysis, and data
normality were inspected using SPSS. To ensure reliability and accuracy of
data, participants undergo a rigorous verification process and incoming data
goes through a sequence of steps and multiple quality checks. Descriptive and
inferential statistics provide a summary of the responses and comparisons
among subgroups. The break-off rate among individuals who logged onto
the survey and completed at least one item is 0.2%.

An Internet-based survey software program was utilized for the delivery and
collection of responses. Non-response bias and common method bias, com-
posite reliability, and construct validity were assessed. Panel research repre-
sents a swift method for gathering data recurrently, drawing a sample from a
pre-recruited set of respondents. Behavioral datasets have been collected,
entered into a spreadsheet, and cutting-edge computational techniques and
empirical strategies have been harnessed for analysis. Groundbreaking
computing systems and databases enable data gathering and processing,
extracting meaning through robust deployment.
Flow diagram of statistical parameters and reproducibility

6. Results and Discussion

Effective measures against COVID-19 may comprise increasing the volume
of primary care providers and batch management according to patients’ basic
condition and gravity of symptoms. (Chen et al., 2021) Nurses are signifi-
cantly affected in the COVID-19 burden by having a significant risk of in-
fection as a result of their constant interaction with infected patients. (Ning
et al., 2020) Increased quantities of COVID-19 patients treated are related to
escalated levels of depressive symptoms. (Firew et al., 2020) The heterogeneity
of COVID-19 patients’ care needs and insufficient amount of nursing staff in-
tensify assigned work and physical fatigue. (Galehdar et al., 2020) (Tables 1–15)
10
Table 1 In the last three months, which of the following feelings have you been
regularly experiencing? Check all that apply. (%)
Stress 92
Anxiety 87
Frustration 85
Exhaustion/Burnout 80
Overwhelmed 76
Sadness 76
Unappreciated 73
Anger 68
Fear 64
Loneliness 63
Powerless 58
Disconnected 47
Grief 41
Gratitude 32
Hope 27
Pride 24
Sources: MHA; our survey among 5,700 individuals conducted October 2020.

Table 2 How would you say that your mental health

has been affected, if at all, during the COVID-19 crisis? (%)
Greatly worsened 31
Slightly worsened 51
Not been affected 11
Slightly improved 5
Greatly improved 2
Sources: GWI; our survey among 5,700 individuals conducted October 2020.

Table 3 Over the past 2 weeks, have you been concerned

with the following? Select all that apply. (%)
How long the pandemic will last 88
How many more people will become infected 86
People you care about contracting COVID-19 85
Your personal sense of safety and security 88
Personally contracting COVID-19 89
Sources: HMN; ACHA; our survey among 5,700 individuals conducted October 2020.

Table 4 How worried, if at all, are you for your own personal health and for
the health of the people you live with during the COVID-19 outbreak? (%)
Worried about Worried about health of
personal health people you live with
Very worried 54 52
Somewhat worried 37 35
Not very worried 6 8
Not worried at all 3 5
Sources: Statista; our survey among 5,700 individuals conducted October 2020.
11
Table 5 Healthcare workers on COVID-19 frontlines battle
physical, mental and financial strain. Select all that apply.
79% are very concerned about their own health and safety.
59% report receiving no additional mental health resources.
13% expect their compensation will be lower this month.
Sources: Bain & Company; our survey among 5,700 individuals conducted October 2020.

Table 6 Have you experienced any of the following potential causes

stress or burnout since the start of the COVID-19 pandemic?
(%, yes). Select all that apply.
Concern about family/friends contracting COVID-19 86
Concern for your personal health & safety around contracting COVID-19 82
Concerns around your job or financial security 24
Lack of personal protective equipment or other necessary resources 44
Concern for patients/being able to handle the number of patients 68
Overworked 49
Sources: ACEP; Morning Consult; our survey among 5,700 individuals conducted October 2020.

Table 7 % who say they are very/somewhat concerned that they…

will get COVID-19 and require hospitalization. 86
might unknowingly spread COVID-19 to others. 83
Sources: Pew Research Center; our survey among 5,700 individuals conducted October 2020.

Table 8 Symptoms of mental health conditions and levels

of psychological well-being. Select all that apply. (%)
Depression 26
Suicidal ideation 3
Anxiety 39
Flourishing 2
Serious psychological distress 18
Loneliness 14
Resilience 16
Sources: HMN; ACHA; our survey among 5,700 individuals conducted October 2020.

Healthcare professionals who treat COVID-19 patients have a high risk of

virus exposure. (Liu et al., 2020) Subsyndromal mental health issues con-
stitute a typical reaction to the COVID-19 outbreak. (Rajkumar, 2020)
COVID-19 frontline medical staff encounter perceived threatening and ex-
hausting situations. (Duarte et al., 2020) The COVID-19 crisis emergency has
resulted in distressing job conditions for frontline medical workers, taking
into account their unexpected relocation to other hospital units, atypical tasks,
and toiling under escalated workload conditions. (Lasalvia et al., 2021a)
The COVID-19 pandemic has affected medical professionals in terms of
increased anxiety symptoms. (Gorini et al., 2020) Healthcare personnel are
both sorrowful and strained because of the morbidity, mortality, and unfore-
seeable risks of the COVID-19 pandemic. (Kackin et al., 2020)
12
Table 9 The impact of the COVID-19 pandemic
on collective mental health (%, relevance)
Vulnerable populations have been particularly hard-hit, as COVID-19 has 93
worsened already-present health inequities for older adults, low-income
families, and people in substandard or congregate living conditions.
Once physical distancing measures are lifted, many people 85
will still approach social activity with vigilance.
Public transportation, office environments, and other public fora 80
may still cause anxiety for large swaths of the population.
If anxiety isn’t addressed, it may lead to a diagnosable mental health 82
disorder or endure for years to come.
Even when life does return to normal, perceived loss of control and 78
sustained feelings of helplessness across social, economic, and health
dimensions may persist.
COVID-related stress and anxiety are causing serious sleep disruptions. 78
short-term consequences of sleep disruption include increased stress,
emotional distress and mood disorders, and cognitive, memory, and
performance deficits. Chronic sleep deprivation is associated with
a number of physical and psychiatric problems, with men experiencing
an increase in mortality.
Social isolation is creating barriers to recovery from substance use disorder. 67
Individual and collective grief from having lost loved ones 65
and over having survived the pandemic when others didn’t.
Sources: Ginger; our survey among 5,700 individuals conducted October 2020.

Table 10 % with adverse mental health symptoms, increased substance use, or

suicidal ideation during the COVID-19 pandemic. Select all that apply.
Started or increased substance use to cope with 7
COVID-19 pandemic-related stressor emotions
Seriously considered suicide 2
One or more adverse mental or behavioral health symptom(s): 42
anxiety/depression/trauma/stressor-related disorder
Sources: Statista; CDC; our survey among 5,700 individuals conducted October 2020.

Table 11 If you have been fit tested for a mask/respirator, which of the following
best describes your experience? (%)
I passed the fit testing first time. 61
I had to try one or more alternative masks/respirator before passing. 25
I failed the fit testing. 4
I have not been fit tested. 6
I do not need to be fit tested. 4
Sources: BMA; our survey among 5,700 individuals conducted October 2020.

Table 12 “In the last week…” (%, yes) Select all that apply.
have you felt lonely? 14
have you felt isolated? 15
have you been worrying about your mental health and wellbeing? 77
Sources: PHW; our survey among 5,700 individuals conducted October 2020.
13
Table 13 If you have specific/special needs for personal equipment,
how confident are you that you will have sufficient fully
fit-tested and adjusted PPE during the next wave of the pandemic? (%)
I do not need specific/special PPE. 10
Fully confident 42
Partly confident 29
Not at all confident 19
Sources: BMA; our survey among 5,700 individuals conducted October 2020.

Table 14 What are your top three work-related stressors

over the last three months? Check all that apply. (%)
Uncertainty about when things will settle down/return to normal 67
Burnout 60
Heavy/Increased workload 66
Concern of getting sick myself 73
Concern of spreading COVID-19 72
Insufficient communication from leadership 64
Insufficient PPE 57
Working too many hours 75
Job security/Employment status 62
Insufficient training 65
Distress about how to effectively treat COVID-19 patients 67
Inappropriate role designation 57
Working at a new location 37
Witnessing high number of deaths 39
Treating coworkers with COVID-19 3
Sources: MHA; our survey among 5,700 individuals conducted October 2020.

Table 15 How has your access to mental healthcare been

affected by the COVID-19 pandemic? (%)
Much more difficult 65
Somewhat more difficult 26
No significant change in access 7
Less difficult 2
Sources: HMN; ACHA; our survey among 5,700 individuals conducted October 2020.

Burnout constitutes a significant apprehensiveness for COVID-19 frontline

medical staff (Lasalvia et al., 2021b), in terms of anxiety, acute stress, and
depersonalization symptoms. (Miguel‐Puga et al., 2020) Medical staff con-
stantly participating in the battle against COVID-19 are undergoing doubtful-
ness, despondency, work excess, and role conflicts. (Mo and Shi, 2020) By
gaining increased experience during the COVID-19 crisis, medical workforce
have become considerably knowledgeable in managing adverse situations and
optimizing psychological resilience. (Bozdağ and Ergün, 2020) The COVID-
19 pandemic has configured high standards for primary care providers’
psychological adaptation and stress resistance. (Jia et al., 2020)
14
7. Conclusions, Implications, Limitations,
and Further Research Directions

The COVID-19 crisis emergency has resulted in distressing job conditions

for frontline medical workers in terms of increased anxiety symptoms,
sustained psychological distress, emotional exhaustion, clinically significant
depression, and perceived risk of infection, configuring cognitive, emotional,
and behavioral disorders. This article focuses only on COVID-19 pandemic-
related emotional anxiety, perceived risk of infection, and acute depression
among primary care providers. Limitations of this research also include a
convenient sample, small sample size, and cross-sectional data collection,
thus limiting generalizability. Certain variables were dichotomized because of
small cell sizes throughout the analysis. The sample size and the richness of
the cohort study dataset enable the control for numerous potential confounders
in the multivariable analysis, and provide novel data on the topic. More data
gathered either cross-sectionally or longitudinally that utilize larger study
populations are required to check and support the conclusions drawn in this
study. Further research should consider psychological distress, moral trauma,
and burnout syndrome among COVID-19 frontline medical personnel.

Sarah Cohen, https://orcid.org/0000-0002-1472-4988

Elvira Nica, https://orcid.org/0000-0002-7383-2161

Research method
Cross-sectional design employing self-report questionnaires.

Data analysis
The gathered data were entered into a spreadsheet and analyzed. The ana-
lytical procedures included heterogeneous descriptive statistics for all em-
ployed variables in the tables.

Software information
To process and inspect the collected data, IBM SPSS 24 and AMOS 20 tools
were used.

Survey result aggregation

Responses were classified into categorical variables for quantitative analysis.

Data and materials availability

All research mentioned has been published and datasets used and inspected
during the current study are available from respective outlets. All raw, results,
15
and key source data supporting the conclusions, statistics, models, and codes
generated or used, together with the details of the study design and the proce-
dures for information analysis, are provided with this article. Note: The pub-
lisher is not responsible for the content or functionality of any supporting in-
formation supplied by the authors. Any queries (other than missing content)
should be directed to the corresponding author for the article. Other modeling
input assumptions are available on reasonable request.

Compliance with ethical standards

Ethical approval
All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or national
research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Informed consent
The ethical consequences of this research have been carefully considered.
Best practices have been respected so as to inform the participants and
protect the data and integrity of the interviewees whose participation was
voluntary and who were given a plain language document with information
as regards the research. The data have been processed in a way that ensures
appropriate security of personal data against unauthorized or unlawful proc-
essing, accidental loss, destruction or damage, employing appropriate tech-
nical or organizational measures. All the information provided by the inter-
viewees has been anonymized for confidentiality reasons. Study participants
were informed clearly about their freedom to opt out of the study at any point
of time without providing justification for doing so. If a participant began a
survey without completing it, that was withdrawal of consent and the data
was not used. To prevent missing data, all fields in the survey were required.
Any survey which did not reach greater than 50% completion was removed
from subsequent analysis to ensure quality. Throughout the research process,
the total survey quality approach, designed to minimize error at each stage as
thus the validity of survey research would be diminished, was followed. At
each step in the survey research process, best practices and quality controls
were followed to minimize the impact of additional sources of error as regards
specification, frame, non-response, measurement, and processing. Only par-
ticipants with non-missing and non-duplicated responses were included in
the analyses. Individuals who completed the survey in a too short period of
time, thus answering rapidly with little thought, were removed from the ana-
lytical sample.
Animal studies statement verification
This article does not require animal studies verification.
16
Code availability
This project has employed statistical analytical techniques standard in all
statistical packages.

Funding information
This paper was supported by Grant GE-1325687 from the Internet of Things-
based Healthcare Monitoring Systems Research Unit, Melbourne, Australia.
The funder had no role in study design, data collection analysis, and inter-
pretation, decision to submit the manuscript for publication, or the preparation
and writing of this paper.

Author contributions
All authors listed have made a substantial, direct and intellectual contribution
to the work, and approved it for publication. The authors take full respon-
sibility for the accuracy and the integrity of the data analysis.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any
commercial or financial relationships that could be construed as a potential
conflict of interest.

Disclosure by the editors of record

The editors declare no conflict of interest in the review and publication
decision regarding this article.

Transparency statement
The authors affirm that the manuscript represents an honest, accurate, and
transparent account of the research being reported, that no relevant aspects
of the study have been left out, and that any inconsistencies from the research
as planned (and, if significant, registered) have been clarified. The study
questionnaires were carried out in an inclusive manner.

Publisher’s note
Addleton Academic Publishers remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

Acknowledgments
We are grateful to the anonymous peer reviewers for their incisive and con-
structive comments.

17
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