Mental Health Status Among Frontline Prison Police During The Prevention and Control of The COVID-19 Epidemic: A Cross-Sectional Survey From China

A global public health emergency triggered by the Coronavirus Disease 2019 (COVID-19) epidemic may have a remarkable psychological impact on the population. There is still limited psychological research on police ocers, especially on prison police. The present study aims to identify prevalence and inuencing factors on mental health status among frontline prison police in China during the prevention and control of the COVID-19 epidemic. A cross-sectional survey with a sample of 981 frontline prison police was conducted by using snowball sampling approach. The self-administered questionnaire consisted of 4 parts: (i) informed consent form; (ii) socio-demographic section; (iii) work and life situations during the prevention and control of the COVID-19 epidemic; (iv) the Chinese version of the 12-item General Health Questionnaire (GHQ-12). Univariate analysis and multivariable logistic regression were performed to identify factors inuencing mental health status.


Page 3/19
Background Since the late December 2019, the 2019 Coronavirus Disease  has spread to all countries, areas or territories of the world. On January 30, 2020, the epidemic was declared a global public health emergency by the WHO Emergency Committee [ 1]. There have been more than 100 million con rmed cases, including 2,147,411 deaths were reported worldwide as of January 26, 2021 [ 2]. Countries took different safety measures and precautions to limit the spread and risk of the epidemic, such as obligatory lockdowns, travel was halted, airports were shut down, many work spaces, schools and universities were closed, and prison visits were cancelled [ 3,4]. The crisis of public health triggered by epidemic and the preventive measures taken to control it have become the major threats to both physical and mental health of the population, especially to frontline staffs [ 5,6].
As a result of the rapidly spread of the epidemic, prisons in several countries have experienced a serious problem with COVID-19 infection. For example, con rmed cases were reported in prison of British, France, United States, Pakistani, India and Brazil, etc [7][8][9][10][11]. Lessons from COVID-19 infections in both domestic and foreign prisons were learned deeply by the penitentiary system in China. The prison authorities have formulated and implemented many effective measures to prevent and control the epidemic, and achieved major results of no infections, no outbreaks, and no deaths. This achievement was obtained mainly from the perseverance and dedication of frontline prison police. The work patterns of prison police have been divided into three types during the prevention and control of the COVID-19 epidemic, which were work in closed jail for 14 days, centralized isolation and preparation for 14 days, and home quarantine and preparation for 14 days [12]. The stressful task of preventing the epidemic and supervising criminals placed a huge burden on frontline prison police.
During pandemic outbreaks, the frontline warriors including healthcare workers and police staffs were under unprecedented pressure from the heavy workload, risky workplace environment, and nonavailability of adequate leaves/duty off periods [5,13]. These severe situations caused them to be especially vulnerable to mental health issues, such as anxiety and depression symptoms [14,15]. The psychological problems would negatively interfere with the e ciency of frontline warriors to ght the epidemic, and may pose a threat to their overall well-being. Previous studies have acknowledged concerns about the psychological problems of frontline doctors, nurses and paramedical staffs [5][6]15], and the psychological assistance for healthcare workers have been provided by many countries [16]. A latest study also showed that COVID-19 duties during the lockdown period of police personnel exhibited signi cant anxiety, depression symptoms, and perceived signi cant stress [13]. However, there is still no systematic research involving the mental health of prison police.
A cross-sectional survey has been conducted to investigated the psychological issues among frontline prison police during the prevention and control of the COVID-19 epidemic. The aim of the current study was also to explore which factors may in uence the mental health of prison police. These ndings will aid local governments and prison administrators to formulate effective policies, regulations and actionable psychological interventions for promoting mental wellbeing of frontline prison police in public health emergencies.

Study design and participants
This cross-sectional study was implemented using a anonymous web-based survey from March 28 to April 20, 2020. The purpose of the survey lasting for nearly a month was to investigate as much as possible subjects who have experienced all work patterns during the prevention and control of the COVID-19 epidemic. The participants of present study comprised part of frontline prison police in western China. Those who have been diagnosed with a history of mental disorder, refused to participate in survey, and unable to operate smart phone or computer devices were excluded.

Procedure and survey questionnaire
In order to minimize face-to-face communication and contact, recruitment of participants was done using snowball sampling approach. The survey was executed through an online survey platform called "Questionnaire Star" (Changsha Ranxing Science and Technology, Shanghai, China). The questionnaire link was circulated by WeChat or other social tools, after seeking permission from the prison authorities. Finally, a total of 1035 questionnaires were completed without assistance, of which 981 questionnaires were valid.
The survey questionnaire was developed with 4 parts of informed consent, socio-demographic factors, items on work and life situation of frontline prison police, and mental health status. (i) Participants were informed that the right to take a voluntary participation was absolute, and the completion of the questionnaire imply providing the consent. (ii) Demographic characteristics of the participants included variables such as gender, age, marital status, education, and working years, etc. (iii) A self-designed questionnaire was used to collected the informations about recent work mode, number of night shifts, diet, physical exercise, smoking, physical condition, disease history, and communication with family members. (iv) The Chinese version of the 12-item General Health Questionnaire (GHQ-12) was used to measure mental health status in present study [17]. The self-administered scale composed of 12 items with answers scored from "better than usual / not at all = 0" and "same as usual / no more than usual = 0" to "less than usual / rather more than usual = 1" and "much less than usual / much more than usual = 1" [18]. All item scores were are added to give GHQ-12 total score, which the possible score range from 0 to 12. The scale with higher total scores indicating higher degrees of disturbance of the mental health status [19]. In this study, the GHQ-12 was reliable and repeatable and showed good internal consistency (Cronbach's alpha was 0.895). An additional table le shows this questionnaire in more detail [see Additional le 1].

Ethical considerations
This study protocol was approved by the Ethical Review Board of West China Medical School at Sichuan University. All participants have signed the informed consent form via the "Questionnaire Star" after explaining the purpose of the study. Their personal information was collected anonymously, and all data were used for research purposes only.

Statistical analysis
Statistical analysis was performed with SPSS 24.0 software (SPSS Inc, Chicago, IL, USA). Enumeration data were presented as the numbers (n) and percentages (%), and compared between individuals with and those without tendency of mental health problems using chi-squared (χ 2 ) test for categorical variables. Measurement data of the GHQ-12 score were computed using the means (SD). Multivariable logistic regression was performed to determine the association of multiple potential predictors (independent variables, seted as X) with mental health (dependent variable, seted as Y) by calculating the odds ratios and their 95% con dence interval. The independent variables that were signi cant by χ 2 test were selected, and mental health status (Y = 1, with tendency of psychological problems; Y = 0, without tendency of psychological problems) was the dependent variable. Data were considered statistically signi cant at the level of a p-value less than 0.05.

Results
General characteristics of the participants A total of 981 frontline prison police, including 262 (26.71%) of female and 719 (73.29%) of male, participated in this study with the response rate of 94.78 %. The age of the respondents range from 20 to 57 years, and the mean age was (29.56 ± 6.13) years. The marital status of being married (46.59%) was similar to that of being single (53.41%). Majority of the sample had a bachelor degree and above (73.80%), and 26.20% had a college degree and below. 55.56% have been working less than 5 years in their profession, followed by between 5 years and 10 years (30.17%). Table 1 presented the general characteristics of the participants, and the groups signi cantly differed on gender, working years, recent work mode, number of night shifts, diet, physical exercise, smoking, physical condition, disease history in the past year, and communication with family members (all p-value < 0.05).

Prevalence of self-reported mental health problem
Previous studies have demonstrated that GHQ-12 total scores of four or above indicated tendency of mental health problems in mainland China [20,21]. To investigate the prevalence of psychological problems, the self-reported survey was conducted using GHQ-12 scale. The result found that one-third of frontline prison police may have a tendency toward mental health problems during the prevention and control of the COVID-19 epidemic (33.43%, 328/981). The distribution of the GHQ-12 score was shown in Fig. 1, which was not normally distributed by Kolmogorov-Smirnov test (p-value < 0.05).

Psychological factors among frontline prison police
Many factor-analytic studies have suggested that the GHQ-12 could be divided into three factors, including anxiety and depression (Factor I, item of 2, 5, 6, and 9), social dysfunction (Factor II, item of 1, 3, 4, 7, 8, and 12), and loss of con dence (Factor III, item of 10 and 11) [22,23]. As shown in Table 2, the mean scores were ranked higher with Factor I than with Factor II and III. Meanwhile, the highest total scores were for item 9, 2, and 5. These results indicated that the frontline prison police suffered from psychological problems associated with anxiety and depression, which main symptoms were unhappy and depressed, lost sleep over worry and constantly under strain.

Discussion
The frontline healthcare workers and police staffs were always the major force that ghted the COVID-19 epidemic. Increasing attention has been paid on the mental health issues of frontline warriors during the global public health emergency [5,13]. However, the security personnel especially prison police who also actively engaged in preventing and controlling this epidemic were largely neglected. To the best of our knowledge, this study was rstly conducted to evaluate mental health status of frontline prison police in China during the COVID-19 epidemic, and to identify factors that in uence psychological distress.
A total of 981 frontline prison police participated in the cross-sectional Web-based survey, which was considered large enough to draw de nite inferences. The current study found that a 33.43% prevalence of psychological health issues among the police who prevented the COVID-19 epidemic from spreading to prison. The ndings obtained in the study were higher than those obtained among healthcare professionals and the general population (21.3% − 33.0%) [15,24,25]. There was no any data and previous research evaluating the mental health of prison police, resulting in a impossible comparison with the prevalence ndings during other periods. However, respondents with prison police during the prevention and control of the COVID-19 epidemic reported signi cantly higher levels of psychological problems than those with Chinese adults surveyed in 2019 (3.6% − 5.0%) [26]. These results re ected that frontline prison police reached a level of mental health problems, which could not be ignored and required further evaluation.
The 12-item General Health Questionnaire (GHQ-12) was an effective instrument for screening mental disorders, and has been widely used in Chinese community samples [17,20]. The three-factor model of GHQ-12 proposed by Worsley and Gribbin (1977) [22], including anxiety and depression, social dysfunction, and loss of con dence, was veri ed to give the best t [23]. Psychological factors analysis showed that frontline prison police mainly experiencd mental health issues associated with anxiety and depression, and issues related to these symptoms were unhappy and depressed, lost sleep over worry and constantly under strain. These ndings were consistent with several researches, which suggested that anxiety, depression, sleep issues [27], and stress [28] were the most common psychological problems caused by COVID-19 epidemic. Excessive anxiety might lead to several harmful consequences including lower quality of life [29], suicidal ideation and attempts [30], physical chronic conditions [31] and relationship complications [32]. Many emotional and physical health problems, as well as decreasion of the ability to function at work and home, could be elicited by depression [33,34]. It implied that psychological intervention should be carried out for frontline prison police early to help alleviate their psychological symptoms.
Despite it was necessary to evaluate the prevalence of psychological symptoms in frontline prison police, the further analysis for identifying risk and protective factors contributing to mental health issues was more importantly. Data from the present study showed that male frontline prison police was more likely to suffer from mental health problems compared with female prison police. This contrasted with ndings in the general population [35], healthcare workers [36], and police personnel [13] during the COVID-19 epidemic. Reason for the nding was attributed to men might take more responsibility leading to psychological distress symptoms [37]. The participants with work in closed jail recently were about 2.203 times (OR = 2.203) more likely to have mental health problems than that with home quarantine and preparation, which might be because a person in a closed environment could develop psychological problems [38]. Our results suggested that more night shifts have increased the risk of mental health problems in frontline prison police. Consistent with earlier study, more night shifts could cause sleep disturbances, and burnout and mental disorder among employees [39]. The frontline prison police with tendency of mental health problems smoked signi cantly more and were therefore at greater risk [40].
Moreover, participants who were poor physical condition and chronic or serious illness history had a higher risk of psychological issues. It might indicate that mental health defense of this prison police subgroup with weak physical function has been negatively affected.
Previous studies have con rmed that healthy diets and exercise regularly could promote mental health for the adult population [41,42]. Our data proved that regular diet and more physical exercise were protective factors for mental health among frontline prison police, and the incidence of psychological problems were 0.779 and 0.702 times that of the opposite. The present study also revealed that comunication with family members was another protective factor associated with mental health of the prison police during the prevention and control of the COVID-19 epidemic. This might be due to the fact that providing emotional support from family and friends and maintaining contact were positive treatment to protect mental health [43].
Since the early phase of COVID-19 epidemic control, the prison authorities in China have been constantly implemented psychological interventions, including published the mental health handbook for prison police, established psychological assistance hotlines, and assigned mental health professionals to provide timely psychiatric help. These measures have e ciently alleviated the psychological problems of frontline prison police, thereby reducing the rate of work errors. As the normalization of epidemic prevention and control will continue for a long time, this study may provide practical guidance for the development of a psychological support strategy. According to the current ndings, the targeted interventions should be performed to relieve mental health problems among frontline prison police. First, prison authorities should formulate and implement a viable strategy to adjust duty hours to the optimization, and provide solid logistical support to guarantee prison police' quality of life with sleep, diet and exercise, so that their physical and mental health problems can be reduced. Second, the mental health of frontline prison police should be dynamically monitored to provide appropriate information on treatment and psychological intervention for affected people, and supply continuity of regular mental health care services among the whole population. Third, the prison police should maintain a good living habits to promote mental health, and learn to use emotion regulation strategies for reducing psychological stress. Fourth, the authorities need to emphasize the role of family support during this epidemic, increase opportunities for frontline prison police to communicate with family members, so as to avoid their psychological disorders caused by closed information between each other. Fifth, our government and relevant authorities should strengthen the psychological evaluation, online psychological counseling, psychological crisis prevention and intervention of frontline prison police during epidemic control and in the future.
There have been several limitations in present study, which were as follows: (1) our respondents were all from China, which might not fully represent the mental health status of frontline prison police around the world.
(2) Given the particularity and complexity of COVID-19 epidemic prevention and control, we have conducted an online survey using snowball sampling approach, which the participants were limited to using smartphones or computers with network link service. Moreover, the prison police on duties might be overworked, leading to the consequence that many shared links were not responded.

Conclusion
To sum up, the present study indicated that mental health problems were serious among frontline prison police during the prevention and control of the COVID-19 epidemic. This study also suggested that male, work in closed jail, more night shifts, more smoking, poor physical condition, chronic or serious illness history, regular diet, more physical exercise, more communication with family members were the in uence factors of mental health. These ndings highlighted that the need for prison authorities to continuously monitor the psychological impact of public health emergency on frontline prison police, and timely develop and implement targeted interventions to tackle mental health problems.