Burnout Components, Perceived Stress and Hair Cortisol in Health Workers During the Second Year of Covid 19 Pandemic

doi:10.21203/rs.3.rs-4075574/v1

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Burnout Components, Perceived Stress and Hair Cortisol in Health Workers During the Second Year of Covid 19 Pandemic

https://doi.org/10.21203/rs.3.rs-4075574/v1

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This study evaluates the impact of the COVID-19 pandemic on healthcare workers in Argentina, during the second wave in 2021. The aim is to assess stress, burnout, and anxiety levels, incorporating the assessment of hair cortisol levels as a biomarker of chronic stress. A total of 496 healthcare workers from three different hospitals were included in this study. Two of these hospitals depend on the Buenos Aires City Ministry of Health and the third hospital belongs to Buenos Aires University. Hair samples were obtained using scissors from the posterior vertex, as close to the scalp as possible. Each sample was weighed, and cortisol was extracted and then measured using an automated chemiluminescent method. Notably, 10% of the population exhibited hair cortisol levels above 128 pg/mg. Anxiety scores surpassed medians for 38%, 52%, and 39% of healthcare workers at Argerich, Clínicas, and Durand Hospitals, respectively. Associations were found between high hair cortisol levels and age, workload, emotional exhaustion, and depersonalization. In addition, burnout, identified in 11% of participants, correlated with higher perceived stress, lower social support, and higher anxiety scores. Binary logistic regression revealed associations between burnout and perceived stress, anxiety, and age. Finally, mediation analysis showed depersonalization as a mediating variable in the relationship between hair cortisol concentration and emotional exhaustion. In conclusion, this study highlights the complex relationships between anxiety, stress, cortisol levels, and burnout. Prioritizing interventions and research is essential to support the well-being of frontline healthcare professionals, ensuring their resilience during challenging times.

Biological sciences/Biochemistry

Biological sciences/Psychology

Earth and environmental sciences/Environmental sciences

Health sciences/Health care

Health sciences/Health occupations

Towards the end of 2019, severe and unusual cases of viral pneumonia emerged in Wuhan, China. Subsequently, three months later, the World Health Organization declared this new disease (SARS-CoV-2, also known as COVID-19) as a pandemic. This worldwide health crisis has caused more than 600 million infections and 6 million deaths [1]. In certain countries, healthcare systems have come under significant strain resulting in intensive care units reaching their maximum capacity and a rising death toll. Health workers have been central in the effort against this disease, finding themselves on the front lines, facing exhausting workload, great uncertainty, and fear. Therefore, it is worthwhile to assess long-term stress, anxiety and burnout experienced by health practitioners [2].

During 2021, COVID-19 emerged as the leading cause of death in individuals aged 25 to 74 in Argentina and other countries in the region. Although the absolute number of deaths was low in younger age groups, the SARS-CoV-2 virus ranked as the second leading cause of death in people over 74 years old, following cardiovascular diseases. Mortality rates revealed a higher impact on the oldest age groups, with the highest number of deaths recorded in individuals over 55 years old [3].

Buenos Aires and its metropolitan area constitute one of the largest cities in the world with a population of 15,257,673 inhabitants. To deal with the pandemic, the Argentine health system increased the availability of intensive care units by more than 40 percent. This involved adding beds, trained human resources, and equipment to provide care to critically ill patients [4].

The Argentinian health ministry reported in December 2020 that 60,145 people performing healthcare and administrative functions within the health system contracted the COVID-19 disease, constituting 4.3 percent of the total cases. Within this group, 362 died representing 0.96 percent of all COVID-19-related deaths, with a lethality rate of 0.60 percent. In this critical context, healthcare workers were at the forefront, actively engaged in assessing, diagnosing, and treating patients with COVID-19 [5].

Several studies have documented increased levels of chronic stress, anxiety conditions, and burnout among healthcare professionals [6, 7, 8]. Reports indicate a high prevalence of psychological distress among frontline healthcare workers, with a meta-analysis suggesting that 41% experienced such distress during the COVID-19 period [9]. These findings are hardly surprising given the significant stressors faced by workers throughout the pandemic. For instance, during the initial COVID-19 wave in 2020, we discovered that 40% of healthcare workers exhibited altered hair cortisol levels, a biomarker of chronic stress [10].

The aim of this study was to evaluate stress, burnout, and anxiety in a new cohort of healthcare workers from three different hospitals as well as measuring hair cortisol levels as a stress biomarker during the second wave of COVID-19 in 2021.

496 healthcare workers from three different hospitals were included in this study. Two of these hospitals depend on the Buenos Aires City Ministry of Health (Cosme Argerich Hospital, n = 190; and Carlos G Durand Hospital, n = 150). The third hospital belongs to Buenos Aires University (Hospital de Clínicas “Jose de San Martin”, n = 156).

Individuals undergoing treatment with glucocorticoids or psychotropic drugs, those with hypothalamic-pituitary-adrenal (HPA) axis alterations, or a history of mental health disorders were excluded from the study. Moreover, individuals with less than 3 cm hair length on the posterior vertex were also excluded. The study employed a cross-sectional observational design. Participants did not receive any form of compensation for their involvement in the study, and all provided former written informed consent. The study was prior approved by the Ethics Committee of the respective hospitals. All methods were carried out in accordance with the Declaration of Helsinki.

Hair sample collection and hair cortisol measurement

Hair samples were obtained using scissors from the posterior vertex, as close to the scalp as possible. To assess hair cortisol levels over the past 3 months 3 cm segments were collected, considering an average hair growth rate of approximately 1 cm per month. Each sample was stored in a paper envelope at room temperature until processing. Subsequently, three centimeters were measured from the root segment adjacent to the cutting. Each sample was weighed, and cortisol was extracted and then measured using an automated chemiluminescent method (Immulite 2000 autoanalyzer, Siemens, LA, USA). The results were expressed in pg/mg. Hair cortisol concentration reference interval in healthy individuals with low levels of stress is 40–128 pg/mg hair (P2.5- P97.5) [11].

Epidemiological data and psychological tests

All participants were requested to complete an epidemiological sheet: providing information on: age, sex, weight, height, family, medication, hair dye usage, shampoo usage, any cosmetic hair treatment, smoking habits, profession, workplace, and pre-existing pathologies. In addition, they completed the following surveys: perceived stress [12], social support [13]. and State-Trait Anxiety Inventory (STAI). Perceived stress survey consists of 4 items, answered on a 5-point Likert scale ranging from “never” to “very often”. Social support survey consists of 5 items, answered using a Likert scale ranging from 1 to 4 each item. For the analysis, median values were used as follows, for social support (median score 14), perceived stress (median score 8). The State-Trait Anxiety Inventory (STAI) was employed to assess anxiety. This inventory differentiates between transient state anxiety (STAI-S) and more enduring trait anxiety (STAI-T), with participants reporting their feelings at the time of the test and generally in their daily lives. Each subscale consists of 20 items, with total scores ranging from 20 to 80 [14]. Typically, scores between 20 and 40 are associated with moderate anxiety [15].

Burnout

Burnout was assessed by Maslach Burnout Inventory - Human Services Survey (MBI - HSS), consisting in 22 items distributed into three subscales: emotional exhaustion (EE) scoring from 0 to 54, depersonalization (DP) scoring from 0 to 30 and personal accomplishment (PA) scoring from 0 to 48. Item responses range from 0 (never) to 6 (every day) [16]. High EE (score > 26), high DP (score > 9) and low PA (score < 34) are required to define Burnout. The reliability of MBI – HSS inventory [17] has been tested in human services workers and nurses from Europe and the United States [18].

Statistical analyses

Initially, we assessed the distribution of variables using normality tests (kurtosis and skewness). Results were presented as mean ± standard deviation (SD) or median (range), depending on the distribution of the data. Pearson test (for parametrically distributed data) or the Spearman test (for non-parametrically distributed data) were employed to evaluate correlations between variables. Depending on the data distribution, median differences were tested using either the t-test or the Mann–Whitney test. For scenarios involving more than two groups, Kruskal-Wallis test was applied to assess differences between medians. A binary logistic regression analysis was performed to explore whether hair cortisol, perceived stress, social support, and anxiety could predict burnout. This analysis was controlled for confounders, such as age and BMI. Finally, a mediation analysis was performed using Hayes PRO- CESS macro in SPSS statistical software [19].

Sociodemographic and psychological characteristics of the study population

A total of 496 healthcare workers samples from Cosme Argerich Hospital, Hospital de Clínicas “Jose de San Martin” and Carlos G Durand Hospital were studied. Sociodemographic data is presented in Table 1 as well as medians (range) of each burnout component: depersonalization (DP), emotional exhaustion (EE), personal accomplishment (PA), and anxiety, perceived stress, social support,

Table 1

Sociodemographic and psychological characteristics of the study population.
Variable	Results
Age (years, mean ± SD) Gender % (n) BMI (Kg/m2) Average working hours per week Number of guards per week Smoker (%) Dyed hair (%) Cosmetic hair treatment (%) Anti-dandruff shampoo (%) Profession/Occupation Physician Nurses Residents Other health professionals Administrative staff Maintenance assistants Auxiliary health technicians Psychological scale (score) Perceived stress Social support Anxiety Personal accomplishment (AP) Depersonalization (DP) Emotional exhaustion (EE)	42 ± 11 F:88.5 (439); M: 11.5 (57) 20 (12–50) 35 (5–70) 4 (0–10) Yes (18) No (82) Yes (61) No (39) Yes (22) No (78) Yes (16) No (84) (n, %) (n = 109, %=22) (n = 76, %=15.3) (n = 61, %=12.3) (n = 146, %=29.4) (n = 62, %=12.5) (n = 8, %=1.65) (n = 34, %=6.85) Median (range) 8 (2–13) 14 (6–20) 24 (11–42) 37 (7–48) 5 (0–30) 26 (0–54)

Stress, anxiety, and hair cortisol concentration

Within the cohort of volunteers, 10% of the population showed hair cortisol levels greater than 128 pg/mg of hair. In terms of anxiety, median scores were surpassed by 38%, 52%, and 39% of the healthcare workers at Hospital Argerich, Hospital de Clínicas, and Hospital Durand, respectively.

Table 2 presents significant associations identified in the entire studied population. Notably, among individuals with hair cortisol levels above the median, significant associations were observed with age, workload, emotional exhaustion, and depersonalization (r=-0.236, p < 0.0001; r = 0.204, p = 0.006; r = 0.185, p = 0.006; r = 0.172, p = 0.010). Additionally, for individuals with a high perceived stress score, associations were found between hair cortisol and age as well as hours worked. (r=-0.270, p < 0.0001; r = 0.146, p = 0.047, respectively).

Table 2

Statistical Associations in the whole studied population
Variable	Anxiety	Burnout
Variable	Anxiety	Emotional Exhaustion	Personal Achievement	Depersonalization
Hair Cortisol	NS	r = 0.129, p = 0.005	NS	NS
Perceived stress	r = 0.240, p < 0.0001	r = 0.269, p < 0.0001	NS	r = 0.102, p = 0.026
Workload	NS	r = 0.228, p < 0.0001	NS	NS
Anxiety	NS	r = 0.300, p < 0.0001	NS	NS
Social support	NS	NS	r = 0.183, p < 0.0001	NS
*NS = not significant
Standard Error (SE) = 0.0138

For individuals with a low social support score, associations were found between hair cortisol levels and age, the number of weekly shifts, as well as with EE, DP, and PA (r=-0.234, p < 0.0001; r = 0.199, p = 0.022; r = 0.136, p = 0.036; r = 0.167, p = 0.010; r=-0.171, p = 0.008).

In individuals with a high anxiety score, associations were found between hair cortisol levels and age, BMI, as well as the number of hours worked per week and weekly shifts (r=-0.245, p < 0.0001; r=-0.224, p = 0.001; r = 0.160, p = 0.022; r = 0.299, p = 0.002).

Burnout and hair cortisol concentration

The 11% (n = 54) of the studied population presented burnout (high emotional exhaustion, low personal achievement, and high depersonalization). Individuals with burnout reported higher perceived stress score, lower social support score and higher anxiety score (p = 0.013; p = 0.007; p = 0.016, respectively). Additionally, these individuals reported working more hours and performing a greater number of shifts (p = 0.001; p = 0.003).

Interestingly, the two acute care hospitals, Argerich and Durand, exhibited a similar percentage of burnout (13%, n = 25; 12%, n = 18, respectively), while the University Hospital reported a lower percentage (7%, n = 11). Stratifying the population by occupation revealed varying burnout percentages: 18.8% for doctors, 6.5% for nurses, 29.4% for residents of the different medical specialties, 4.8% for administrative staff, 12.5% for maintenance personnel, and 9% for health technicians.

Finally, the binary logistic regression analysis revealed associations between burnout and perceived stress, anxiety, and age (p = 0.024, OR: 1.258 [IC1.030-1.536]; p = 0.025 OR: 0.894 [IC0.810-0.986]; p = 0.001 OR: 0.954 [IC0.926-0.981], respectively).

Analysis of mediation

The mediation analysis showed that depersonalization acts as a mediating variable in the relationship between hair cortisol concentration and EE (indirect effect: b = 0.0325, SE = 0.0138, CI = 0.054–0.0596, p = 0.019) as shown in Fig. 1.

Stress, anxiety, and burnout were evaluated in healthcare workers from different hospitals in Buenos Aires, during the second wave of COVID-19 pandemic. In a prior study conducted during the first outbreak, we discovered that 40% of individuals had elevated hair cortisol levels above the reference value of 128 pg/mg [10]. However, in the current study, conducted during the second wave, only 10% of the population exhibited altered hair cortisol levels. The observed temporal variation in hair cortisol levels prompts consideration of factors influencing mental health throughout the pandemic. Mental health issues among healthcare workers have shown significant variation during the pandemic. In the early stages, when the spread of the virus was uncontrollable without any vaccine or treatment, healthcare workers tended to experience mental health problems more frequently.

This study provides valuable insights into the prevalence of anxiety and its relationship with a stress biomarker such as hair cortisol. Our findings highlight a significant prevalence of anxiety among healthcare professionals across different hospitals, consistent with research conducted by other authors. For instance, during the peak of the pandemic in China, a study revealed that 44.6% of staff exhibited symptoms of anxiety [8]. Similarly, Nayak et al. [20] reported rates of anxiety and stress in healthcare workers in Trinidad and Tobago at 56.2% and 17.97%, respectively. In contrast, a study conducted in Singapore between February and March 2020 found lower rates of anxiety and stress: 14.5% and 6.6%, respectively [21].

Among individuals with high anxiety scores, a remarkable association was observed between cortisol levels and anxiety. This finding aligns with observations reported in other studies [22, 23]. This association suggests that elevated cortisol levels, indicative of chronic stress, may contribute to higher anxiety levels among healthcare workers [24]. Furthermore, factors such as age, BMI, weekly working hours, and the number of weekly shifts appear to be associated with anxiety levels, highlighting the multifaceted nature of anxiety and its potential connections to both personal and occupational factors [25, 26].

Concerning hair cortisol levels, only 10% of individuals exhibited levels surpassing the reference value. This could be attributed to the enhanced training of healthcare personnel in COVID-19 infection control, considering the experience gained during the initial wave of infections. Additionally, the advent of vaccination and increased expertise in patient management may explain the improved stress management in our population [27]. The rates of anxiety found were high, reaching 46%. It is important to note that we lack previous data for any of the hospitals included in the study.

The prevalence of burnout identified during the second wave was notably lower (7% vs. 12%) at Hospital de Clínicas than the rate obtained in July 2020 [10]. These findings suggest a positive trend in the management of burnout among healthcare workers at this institution, indicating potential improvements compared to the earlier stages of the pandemic.

In the other two hospitals, the percentages were similar, with 13% (Argerich) and 12% (Durand), agreeing with those observed during the initial wave at the University Hospital. In these two hospitals in Buenos Aires, we lack previous data on burnout during the first wave. Nevertheless, we could presume that burnout rates were likely higher among healthcare workers in these frontline hospitals during the initial wave.

The mediation analysis revealed that depersonalization serves as a mediating variable in the relationship between perceived stress and hair cortisol concentration, consistent with the findings of our previous research during the first wave. This suggests a potential mechanism by which perceived stress influences cortisol levels, with depersonalization playing an intermediary role.

This result is particularly relevant, since depersonalization has been consistently associated with anxiety, significant stress levels, and emotional hyperactivity in various studies [28]. Additionally, existing research indicates that when individuals lack personal resources to cope with conflict situations, depersonalization often operates as a dysfunctional coping strategy [29].

In summary, this study emphasizes the persistent mental health challenges faced by healthcare workers, particularly in the realms of anxiety and stress. It sheds light on the intricate interplay between psychological factors, cortisol levels, and burnout. Addressing these challenges and promoting mental well-being among healthcare professionals remain crucial priorities to ensure the resilience and effectiveness of the healthcare workforce in times of crisis. Further research and targeted interventions should be explored to support the mental health needs of these essential frontline workers.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Author Contribution

D.G, F.F, A.F, C.I,J.J performed the analytical determination, discussion of the results, search and analysis of references and writing the manuscript.G.N,E.D, P.O, M.C, F.M, F.Fu, L.F, N.C, G.G,C.A: in charge of the patients recruitment and manuscript revision.D.J, B.F, S.I, S.A,G.B: Contributed to the statistical analysis, discussion of the results and references.

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No competing interests reported.

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You are reading this latest preprint version

Burnout Components, Perceived Stress and Hair Cortisol in Health Workers During the Second Year of Covid 19 Pandemic

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Abstract

Figures

Introduction

Materials and methods

Hair sample collection and hair cortisol measurement

Epidemiological data and psychological tests

Burnout

Statistical analyses

Results

Sociodemographic and psychological characteristics of the study population

Stress, anxiety, and hair cortisol concentration

Burnout and hair cortisol concentration

Analysis of mediation

Discussion

Conclusion

Declarations

Data availability

Competing interests

Author Contribution

References

Additional Declarations

Status:

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