Psychological distress and associated factors related to COVID-19 pandemic among primary care physicians in Spain (STREPRIC study)

Background The COVID-19 pandemic is affecting people in all nations worldwide. In Spain, the epidemic has become especially severe. The lack of protective measures is a major concern and may have caused emotional stress to Primary Care Physicians (PCPs). This study aimed to address the sources of psychological distress among Spanish PCPs during the COVID-19 pandemic. Methods This observational, cross sectional study was conducted using a survey questionnaire that consisted of 24 expressions to be answered by PCPs working in family healthcare centres in Spain during the pandemic. A specic scale, the “Examination of Anomalous Self-Experience”, EASE scale was used to determine the distress related to the care of COVID-19 patients among Spanish PCPs. A multivariate linear regression analysis was performed. Results In all, 518 PCPs belonging to different regions of Spain participated in this survey, of which 123 (23.7%) obtained high psychological distress scores. Only half of them had received information about the appropriate use of personal protective equipment (PPE). PCPs factors associated with higher levels of distress include female gender (1.69; CI 0.54, 2.84); Age (-0.43 (-0.61, 1.48)); working setting (rural) (0.84 (-0.34, 2.01)); lack of training in protective measures (1.96 (0.94, 2.99)). The absence of sick leave among colleagues, increased availability of PPEs, improved cleaning and hygiene conditions in health care centers facilities and the detection of COVID-19 RT-PCR for health care workers were associated with lower levels of distress. Conclusions One in four PCPs rated a high score for psychological distress. The availability of PPEs, training on their use, cleanliness and hygiene conditions in health care facilities and the availability of COVID-19 RT-PCR analyses for health workers, among others, are factors associated with the psychological distress of PCPs.

professionals to become aware of the emotional overload they may be enduring, and second, it can be used to measure the degree of affectation in order to avoid the progression towards more severe psychopathological conditions.
The survey was administered using Google forms and was sent directly to PCPs from the two organizations mentioned (redGDPS and semFyC).Approval of the ethics was granted by the Ethics Committee of the San Juan University Hospital in Alicante.

Statistical analysis approach
Assuming a conservative estimation that 25% of the PCPs would rate a high score for psychological distress, the study would require a sample of at least 441 PCPs for estimating the expected proportion with 4% absolute precision and 95% con dence interval.Categorical variables were analysed using the Chisquared or Fisher Exact Test.An ANOVA test was conducted to analyse quantitative variables.A multivariate linear regression analysis was carried out, where the EASE score was considered as a dependent variable, and the factors included sex, age, setting (rural vs urban), and whether the PCP had been trained to apply the adequate protective measures.Data analysis was performed using SPSS v.26 statistical software.

Results
A total of 518 PCPs belonging to different regions of Spain responded to the survey.The majority were females (70.8%) and those working urban areas (71.4%).All the PCPs had observed their pattern of action change during the critical phase of the pandemic (moving to telephone care).During this period, care for patients with chronic conditions and home visits were reduced (Table 1).Approximately half of the PCPs were trained in the use of Personal Protective Equipment (PPE) (45.8%).Most of them, received PPE thanks to the collaboration of entities that donated material (66.6%) (Table 1).
The mean direct score on the distress scale was 10.31 points (SD 6.01, CI95% 9.79-10.83)(Table 2).In all, 123 (23.7%)PCPs scored above 15 points.The main sources of distress included the fear of infecting the family upon returning home and not being able to disconnect from work after the workday was over (Table 2).
Women, younger professionals, those working in rural areas, and PCPs who had not received training in the correct use of PPEs reported the highest level of distress in the care of patients with COVID-19 (Table 3).
The improved cleanliness and hygiene of the health centre, availability of PPEs and the availability of doctors at work helped to mitigate the distress.The origin of PPEs (the Health Service itself or the donations) did not affect the levels of distress.Systematic reverse-transcription polymerase chain reaction (RT-PCR) testing of PCPs (reported by 150 physicians) reduced fear and anxiety responses (p=0.032).

Discussion
During the COVID-19 pandemic, the usual dynamics of work in primary care (personalised and individualised attention in the clinic, follow-up by the same family doctor) were broken.Usual care was also discontinued, except in cases involving consultations, unproven emergencies, or common variable immunode ciency related pathologies [9].The availability of PEP was reduced to decrease the risk of infection, especially in the early stages.A quarter of the participants reported experiencing acute stress, which was more intense when there was a perceived increased risk of SARS-CoV-2 infection.
Regarding speci c training in the use of PPEs, we found a clear lack of training in the health professionals surveyed.Less than half received speci c training on the use and correct placement of PPEs.This contrasts with World Health Organization's recommendations that specify the need for prior training for workers who will be using PPEs [9].This is also supported by studies that report the consequences of lack of training; the FREMAP study conducted in 2011 concluded that only 13.6% of professionals had used PPEs correctly, largely due to the absence of training programmes and their insu cient content [10].
At the time of writing, April 2020, scienti c societies throughout Europe, such as the Royal College of Surgeons in England and the European Society of Intensive Care Medicine, conducted different surveys to nd out about the protection measures of the health care workers, as well as their level of prior training.At the moment, we are unaware of the current situation of training in the use of PPEs among European health care workers.However, it is worth noting that during the Ebola health crisis, several studies revealed a lack of training of health workers in the use of PPEs [11][12][13][14][15].
The protocols developed by the Spanish Ministry of Health for the management of COVID-19 specify that PPEs must be composed of standard and contact precautions, along with precautions for transmission by drops [16].This contrasts with the results obtained, according to which more than half of those surveyed stated that they had supplemented their PPEs through donations.About 40% of the participants reported having incomplete PPEs, thus exposing their safety and highlighting the lack of resources to which they had been subjected while providing care to COVID-19 patients.It should also be noted that on the date of the survey, i.e. 42 days after the state of emergency was declared, some health professionals still reported that they did not have adequate protective equipment.
These data are consistent with the information that the Ministry of Health has included in the document of 'Procedure for action for occupational risk prevention services against exposure to SARS-CoV-2', an annex specifying 'alternative strategies in crisis situations' [17] in order to provide alternatives in situations where resources are limited, supporting in this way, the results obtained in the survey.The lack of availability of adequate protection material, as well as the possibility that some of the donations received may not have passed through the adequate quality certi cation could have contributed decisively to the high number of healthcare providers infected by COVID-19 in Spain, emphasising the fact that health professionals did not perceive increased stress because this material was donated.
Regarding the questions on the distress scale, it was highlighted that despite being capable of dealing with stressful situations, considering that such situations are part of their normal work routine, 23.7% (n = 123) of the participants obtained a score higher than 15 on the acute stress scale validated in COVID-19 patient care, with an average score of 10.31 points.This indicates that the majority of them would nd themselves in an emotionally distressing situation, with a high percentage of participants in a situation of emotional overload.The main sources of stress included ability to infect the family on returning home and inability to disconnect from the workplace.Since the beginning of the outbreak, its impact on the mental health of the healthcare workforce has usually been pointed-out among the hospital professionals [18][19][20][21][22].
These results underline this effect also in primary care.Moreover, these results show a similar trend con rming the fear of infecting the family and not being able to disconnect at the end of the shift the two consequences most often cited by professionals as signs of distress.The rst study in 4 Latin American countries using this same scale found, among professionals working in primary care, an overall average score of 9.5, slightly lower than that found in this study [23].When making comparisons it is necessary to consider the incidence of COVID-19 in each of the countries as the level of acute stress has been directly related to care pressure [23].
On the other hand, despite the stress levels, most participants believed that they could continue to maintain their decision-making capacities as well as their abilities to empathise with patients.
Among the factors associated with a higher level of distress, female sex, work in rural settings, and younger professionals were particularly prominent.With regard to younger professionals, this could be justi ed by the lack of work experience and of dealing with critical situations, as well as the fact of not having faced previous situations with similar characteristics, such as the health crises of Ebola, SARS, or In uenza A. However, the youth did not seem to have had higher levels of job stress in general, which is in line with other studies.On the other hand, different studies have related the female sex with a greater emotional involvement in different analyses involving labour.Moreover, it has been established that women are twice as likely to experience negative emotions in stressful situations than men [24].
Additionally, it was found that the participants who did not receive speci c training in the use of PPE reported higher levels of distress, which shows the emotional impact that lack of training on available resources can produce in the perception of work stress, which has also been con rmed in previous studies on the emotional impact on the health work environment [25][26][27].Regarding rural health workers, there are no previous studies that indicate higher levels of stress as compared to urban health workers.However, some determining factors that generally increase their stress levels have been identi ed in other studies, such as role overload and ambiguity.These factors were undoubtedly experienced during the acute phase of the pandemic [27].
On the other hand, in this study, several factors were identi ed that contributed to mitigating the level of perceived distress among the participants.These included availability of PPEs, reinforcement in the cleaning and hygiene tasks of the health care centres, and absence of health workers on sick leaves due to COVID-19.Likewise, performing COVID-19 RT-PCR signi cantly reduced fear and anxiety responses.These data emphasise the need to provide material resources as well as tests to health care professionals involved in the management of COVID-19 patients in order to improve their distress levels.These results con rm previous conclusions from studies conducted in other countries during the pandemic [28].
Regarding the representativeness of the physicians who responded, it was observed that the age ranges of the participants were mostly between 30-64 years, clearly representing the professionals involved in healthcare, especially in primary care in Spain.There is a clear predominance of the female sex, a fact that may be due to the predominance of females among the healthcare professions.Thus, a 2018 study estimated that the average age of PCPs in Spain was 49.2 years, involving 61.6% women [29].
Regarding the impact that COVID-19 has had on the work structure, our study highlights the changes made in the healthcare model by PCPs in health care centres during the acute phase of the pandemic.Telephonic consultation has become a main function, reducing the follow-up of chronic patients.This highlights the need to provide primary care professionals with telemedicine tools that would allow better management of chronic healthcare demands.Regarding other situations like attending American veterans from Irak war, only 20% of the primary care providers rated their mental health treatment skills as high and only about 8% reported that they had adequate knowledge of current mental health treatment strategies [30].

As compared with other countries, on
There are several limitations of this study.Its objective was not to achieve a representativeness of all the regions of the country, but to reach a minimum number of surveys that were diverse in a short time.This would help in understanding the situation rst hand and providing relevant information in a short time in order to contribute points of re ection for an improvement plan in the situation related to COVID-19.Similarly, the survey was sent to PCPs linked to various scienti c societies, who were especially motivated regarding the subject.Although there may be some common elements with other health emergencies (following a terrorist attack with multiple victims, natural disaster, or war) and there are some differences which mean that comparisons should be made with caution.Among others absence of guidelines and protocols, risks for relatives when returning home, continuous negative news in all media, all over the World, and during the rst days of the outbroke home con nement when returning home.
Among the strengths of the study, it is worth highlighting the large sample size, representing various PCPs with different conditions and workplaces involved in health care and distributed throughout the Spanish geography.Similarly, the questionnaire developed by the research team was previously tested to examine its suitability, and was endowed with necessary validation.It was prepared and reviewed by professionals with extensive knowledge and experience on the subject.
Changes in responsibilities during COVID-19 pandemic I have done the same job I have attended more emergencies I have switched to phone support I have done less home care I have seen fewer patients with chronic

Table
Scores on the distress scale of primary care physicians during the COVID-19 pandemic in Spain (n = 518).

Table 3 .
Factors that in uence a higher level of distress (Linear regression analysis).