Analysis of the Coping Ability and Mental Health of Medical Staff toward COVID-19 in Henan, China


 Background Outbreak of COVID-19 imposed great pressure on the professional work and psychological health of medical staff, especially in the early stage. To assess the coping ability and mental health status of medical workers and find influencing factors on them during the early stage of the COVID-19 outbreak.Methods A cross-sectional study was conducted among medical staff in Henan from January 29th to February 4th with a total of 1739 participates involved. A self-made questionnaire used to evaluate the coping ability and mental health condition.Results The majority of the participants (96.8%) had coping ability scores (Median, 81; IQR, 75~87) above the passing line. The mental health scores of all the respondents were 58 (median; IQR, 44~68). Multivariate logistic regression analyses showed that older age, higher education level, and distrust in unofficial information were facilitating factors for better emergency copying ability among medical workers. For mental condition, medical workers had 3 promoting factors: older age, distrust of unofficial information, and not involved in the event. On the other hand, poor physical health was a risk factor. (P<0.05)Conclusions In the early stage, the overall coping ability and mental health of medical workers in Henan were relatively good, but the government needs to pay more attention to the coping capacity and mental health of medical workers who are younger, less educated, blind to unofficial information and in poor physical condition.

with over 8 million people diagnosed and 400,000 deaths so far.
Front-line hospitals and medical personnel are the main force in response to the epidemic. However, some studies have pointed out that the emergency public health response capacity of primary hospital workers was not satisfactory [5][6][7][8]. In the face of COVID-19, knowledge of prevention and control is an integral part of response capacity, which directly re ects the level of response capacity and relates to the treatment, prevention and control of the epidemic. Medical workers need to correctly grasp and strictly implement the knowledge of infectious disease control measures to improve their ability to ght the highly infectious viruses, but research on this aspect is temporarily not enough.
In the face of the high risk of self-infection, an increasing number of cases, long-hour and intensive work and sacri ce of colleagues, tremendous psychological pressure was posed on medical workers. Especially in the early stage of the epidemic when not all information about the virus was clear and most people were still in a state of shock and fear, medical personnel were particularly vulnerable, and the adjustment of mental state proved to be crucial. Worrying about the long-term effect on health, security of family members and so on, they may get psychological diseases such as excessive anxiety [9][10][11]. But studies focusing on this area were few. [12] Therefore, it is necessary to understand the status of the coping capabilities and mental health condition of medical personnel, especially in the early stage of the epidemic outbreak when information about the epidemic is still unclear. In this study, we aim to conduct a quick assessment of the knowledge condition and psychological status of medical workers in Henan during the initial outbreak of COVID-19 and examine in uencing factors on them. This will help to protect the health of medical staff, promote long-term prevention and control of the epidemic and provide a reference for other public health emergencies. Method:

Study Design
This cross-sectional study was conducted through an online questionnaire via www.wjx.cn on the WeChat platform from January 29th to February 4th. The investigation period was the rst two weeks of the lockdown, just the beginning of the outbreak when information about the epidemic is still unclear. (Fig. 1) All participants were medical staff of the designated hospital in Henan Province.
The study was approved by the Zhengzhou University Life Science Ethics Committee and was in accordance with the guidelines of the Helsinki Declaration. The survey was conducted in the form of an anonymous online questionnaire and did not involve any private and sensitive issues, and participants could terminate the survey at any time. Verbal informed consent was obtained from all participants prior to enrollment in the survey, and the ethics committee approved this procedure. A total of 1739 medical workers responded to the questionnaire.
After excluding missing or invalid responses, there were 1735 validated participants included in the nal analysis with an effective questionnaire rate of 99.77%.

Questionnaire
Based on the Technical guide for COVID-19 virus infection prevention and control in Medical institutions ( rst edition) (Published on 22 January 2020) and COVID-19 diagnosis and treatment plan (trial version 4) (Published on 27 January 2020), we designed a questionnaire to get basic information and assess the psychological status and knowledge condition about diagnosis and management toward the COVID-19 [13,14]. After evaluation, the questionnaire had good reliability and validity.
Basic information contains demographic information included age, gender, marital status, educational level and occupation, access and attitude to the information, concerns about the epidemic, mask-wearing situation, surrounding infected people and the view of the situation.
We used 22 questions including 16 single choice questions and 6 multiple choice questions about occupational protection, epidemiological characteristics and clinical features to assess the knowledge condition of them. 5 points for each knowledge question, with the total score being 110 points: for single choice questions, 5 points for a correct answer and 0 points for a wrong answer; for multiple-choice questions, no score for a wrong choice, and 1 point will be deducted for each missing choice. The median score of all the respondents was set as the threshold. Those who are higher than the median was classi ed as high score group, and others were classi ed as low score group.
The psychological condition of medical personnel was evaluated through 11 questions about nervousness, anxiety, worry, anger, pessimism, fatigue, and other psychological symptoms. Participants were asked to report the frequency of conditions during the epidemic, on a scale of ve degrees including hardly, seldom, sometimes, regularly and frequently. The scores were set to 2, 4, 6, 8 and 10 based on the ve levels of psychological question answers (from 2 "hardly" to 10 "frequently"), with a total score of 110 points for all the 11 mental condition questions. Those whose scores were higher than the median was considered as the poor group, whereas those who were below the median score were considered as the better group.

Statistics Analysis
The Chi-square analysis was performed to test for differences in proportions of categorical variables between two or more groups. Multivariate logistic regression analysis was used to evaluate the effects of various factors on psychological quality and knowledge condition. Logistic regression analysis was performed using coping ability (0 = low score, 1 = high score) and mental health status (0 = poor group, 1 = better Group) as the dependent variable, and other factors as independent variables. Variables that were statistically signi cant in the Chi-square analysis were included in the logistic regression analysis. All statistical analyses were performed using R (version 3.6.2; R Project for Statistical Computing, Vienna, Austria) with a signi cance level of 0.05.

Results:
Characteristics of Study Participants Table 1 shows the basic demographic characteristics of the participants. Among all 1735 participants, most of them (84.96%) were females and 70.20% were between 30 and 50. More than 80% (81.15%) of them had a bachelor's degree and 68.41% were nurses. Almost all participants (99.54%) were very concerned about the progress of the epidemic, and only a few of them (1.04%) had infected people around them. Many participants (97.43%) people believed that the emergency plan could control the development of the incident promptly, and the vast majority (87.20%) believed that the epidemic would be brought under control within a short period of time. More than 70% (78.39%) participated in the handling of this public health emergency. (Table 1)  of trust in uno cial information (χ 2 = 12.14, P < 0.05) and participation in the event (χ 2 = 5.15, P < 0.05) were the major factors affecting coping capacity. (Table 1) The psychological condition score of all the respondents was 58 (Median; IQR, 44 ~ 68). Results showed that age (χ 2 = 16.31, P < 0.001), gender (χ 2 = 11.14, P < 0.001), education level (χ 2 = 19.1, P < 0.001), occupation (χ 2 = 34.81, P < 0.001), degree of trust in uno cial information (χ 2 = 12.14, P < 0.05), participation in the event (χ 2 = 5.15, P < 0.05) and physical condition (χ 2 = 168.87, P < 0.001) were the major factors in uencing mental health. (Table 1) In   What's more, we found no interaction between coping ability and mental condition.

Discussions:
Hospitals are the key places to provide diagnosis and medical treatment and medical staff are the main force to deal with public health emergencies. The coping ability of medical staff has a direct impact on the regional or national response to public health emergencies and the mental health of them is also crucial in the long run.
Our study was the rst study focusing on the coping ability and mental health of medical staff during the early stage of the outbreak of COVID-19, providing a reference for improving the emergency response and corresponding measures to deal with the epidemic timely and effectively. In this study of 1789 medical staff in Henan Province, the overall coping ability and mental health were relatively well. More than 90% of the participants scored above the passing line in the assessment of coping ability, and about 70% of them had a relatively good mental status. Age, education level, distrust in uno cial information and health condition were main in uencing factors on coping ability and mental health condition.
All participants were medical workers with medical backgrounds or engaged in medical-related work, so most of them were very concerned about the epidemic and they held a positive attitude towards the situation. Their knowledge about coronavirus was mainly obtained from o cial sources and professional knowledge, which ensured the correctness of their knowledge. At the same time, we can discover the importance of government and professional media. When an epidemic breaks out, even professional personnel such as medical staff also need to acquire knowledge and skills through these channels [15]. The uneven information in the external media would affect medical workers and will also seriously in uence the knowledge and psychology condition of ordinary people [16][17][18]. Fortunately, participants in this study had a low level of trust in uno cial information channels. In this way, the re-education of infectious diseases should be strengthened under the situation that the information from the outside public is mixed [19,20].
Medical workers are mainly responsible for preventing and controlling the epidemic and treating patients, playing an important role in public health emergency response and control. Medical staffs with a high level of protection awareness are essential to prevent the spread of secondary infection and secondary transmission [21]. In this study, the answer status of the questionnaire showed that the participants had a good grasp of most of the epidemic prevention and control knowledge and had corresponding response capabilities toward the COVID-19. However, some previous studies showed that medical staff didn't have satis ed ability toward public health emergencies [5][6][7][8]. This may be due to the fact that since the outbreak of SARS in 2003, Chinese medical personnel has paid more attention to their ability to respond to public health emergencies and the similarities between COVID-19 and SARS. In our study, age, education and whether trust in uno cial information were the main in uencing factors on medical workers' knowledge of epidemic prevention and control [8,19]. Older ages represent more experience and higher title, and some of them have even participated in SARS-epidemic control in 2003 in China [19]. The extensive clinical experience became the basis for their practice in facing the epidemic. A higher education level means a deeper and wider grasp of medical knowledge, which serves as the theoretical basis for medical workers [8,19]. By keeping vigilant and skeptical attitude towards uno cial information, comparing and analyzing information from different channels, especially trust in o cial information, medical staff could get correct information and knowledge and improve the coping ability.
Medical workers on the front line dealing with public health emergencies and ghting against epidemic were under tremendous psychological pressure. Especially in the early stages of the outbreak, even when many aspects of COVID-19 have not been fully understood, they still persisted in their posts and tried their best to help patients [22]. Previous studies showed that exposure to a public health emergency can cause mental health problems, depression and even PTSD [9,23,24]. From the results of the present study, the psychological status of the participants was not bad. Most of the psychological scores were in the upper-middle level. In line with previous studies, age, participation in the event, health condition and trust in uno cial information were the main in uencing factors to mental health [25][26][27][28][29]. Contrary to a recent study, age worked as a facilitating factor to mental health. This may be because older participants have more experience, which makes them have a calm attitude [29]. Participation in outbreak control means close contact with infected patients, which increases the risk of infection and causes anxiety among health care workers [28]. And, we also found that the mental condition of nurses was worse compared to other occupations, which may be due to their more time and frequency of contact with patients [23]. In the face of the severe situation, poor health is a possible risk factor for infection [28]. In addition, the distrust of uno cial information contributes to a better psychological state, which may be due to a more comprehensive understanding of the epidemic through the integration of multiple sources of information, which in turn reduces anxiety and contribute to a good mental state. The Chinese government has provided mental health services for civilians and medical workers [30,31], but more attention should be paid to medical workers who may face more serious mental problems in the long run [10,11].
Some of the possible contradictions between this study and existing research may be due to the fact that this study was conducted at the beginning of the outbreak when neither the prevalence nor the mortality rate has yet reached its peak. In the later period of the epidemic, with the gradual enrichment of information, the release and update of o cial response guidelines, the improvement of training, the supplement of medical supplies, so, the coping ability and mental status of medical workers could change accordingly. Moreover, the study was carried in Henan Province, China, which had performed relatively well in epidemic control and prevention and had not experienced any large-scale spread of the epidemic. In fact, most of China's provinces have not experienced a signi cant spread of the disease, so the results of this study could be representative of their situation.
This study was conducted at the beginning of the outbreak ( rst two weeks of the lockdown), and through a direct investigation of primary health care workers, the psychological and coping condition of health care workers at that time can be truly re ected. There are also some limitations. It is a cross-sectional study, so it is di cult to draw robust causality, other follow-up studies are needed. The study subjects were medical personnel in Henan Province, which may not be representative enough to present the entire national situation.
The situation is constantly changing, and this study can only show the results of the investigation at the time it was conducted and can't re ect the changes over time and condition of the general population. Thus, the longterm condition needs further investigation. The online survey was used for this study. Although it is convenient and quick, some factors may in uence the results, resulting in a bias. Other undiscovered in uencing factors may also have an impact on the results of the study.

Conclusions
Page 11 /16 In conclusion, our study showed that the overall coping ability and mental health of medical workers in Henan were relatively good. However, the young, the under-educated and those who blindly trust uno cial information tended to have the worse coping ability. Moreover, mental health is poorer among the younger age group, those who ignorantly believe uno cial information and those in poor health. Although the condition was not bad, the government still need to pay more attention. Ethics approval and consent to participate

Abbreviations
The study was approved by the Zhengzhou University Life Science Ethics Committee and was in accordance with the guidelines of the Helsinki Declaration. The survey was conducted in the form of an anonymous online questionnaire and did not involve any private and sensitive issues, and participants could terminate the survey at any time. Verbal informed consent was obtained from all participants prior to enrollment in the survey, and the ethics committee approved this procedure.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. supplementarymaterial.docx