COVID-19 Contamination, Changes in Work Routine and the Impacts on the Mental Health of Primary Care Professionals in Salvador-Ba, Brazil, 2022

Work


Introduction
Primary Health Care is the gateway to the Brazilian health system and represents an important pillar in emergency health situations, such as COVID-19, directly contributing to the reduction of morbidity [1,2]. It is worth reinforcing that, among its principles and guidelines, the territorial and community approach would allow actions to reduce the spread of the disease through health promotion and prevention, primary support for the diagnosis of suspected cases, care for mild and moderate cases of the disease, thus mitigating the collapse of health systems. In addition, it is capable of monitoring cases in isolation at home, supporting communities during social distancing, identifying and managing situations of individual or collective vulnerability, and contributing to access to health care and the necessary referral to specialized services [3][4][5][6].
However, despite the availability of prevention guidelines and recommendations on the control of infection in the pandemic [7,8] studies on the knowledge, attitudes, and occupational risks of health professionals point to a high risk of contamination, either by caring for symptomatic patients, as well as inadequate use of PPE and insufficient supply [9,10] long hours of work and negligence in washing hands after contact with suspected patients, in addition to the parameters of community or family transmission [11]. Contamination of primary care professionals in Brazil described so far ranged from 25% 12 to 41.9% [13], the latter analyzing only nursing professionals.
All these changes in the work routine can have effects that go beyond the physical and physiological spheres and negatively impact the psycho-emotional conditions of workers, compromising their well-being, quality of life, and work performance [14,15]. Direct consequences are psychic stress, which is expressed in generalized anxiety disorder, sleep disorders, depression, chronic fatigue and lack of energy, Burnout Syndrome, with a decrease in alertness, coordination, and efficiency; increased reaction time; impaired cognition, emotional dullness or mood swings, fear of getting sick and dying and fear of contaminating colleagues and family [16,17]. Aymerich et al [14], in a meta-analysis, pointed out that of the 271,319 health professionals, 33% of those infected with COVID-19 manifested depressive symptoms, 42% anxiety characteristics, 40% acute stress, 32% post-traumatic symptoms, and 42% insomnia.
In this sense, this study aimed to identify the prevalence of contamination of the disease in primary care professionals in Salvador-Ba, Brazil, work activities changed by the pandemic, and the impacts on the mental health of these professionals.

Methodology
A cross-sectional study was carried out, from December 2021 to April 2022, with the reference population of health professionals (Doctors, Nurses, Nursing Technicians, Dentists, Assistants, and Oral Health Technicians) from the Family Health Units of primary care from Salvador-BA (N=1675). All professionals who were active during the pandemic period were invited to participate in the study.
A link to an electronic form with a questionnaire was sent electronically (message via cell phone, email) involving 9 blocks of questions: I-socioeconomic-demographic (gender, age, education, income, professional category, household size, household density); II-health history and reported comorbidities; III-work routine (activities performed) and working hours; IV-use of personal protective equipment; V-SARS-CoV-2 contamination; VI-contact tracing, isolation and signs and symptoms of COVID-19; VII-COVID-19 testing and vaccination; VIII-Assessment of Generalized Anxiety Disorder by the GAD-7 Scale; IX-Evaluation of the Burnout Syndrome by the Maslach Burnout Inventory (MBI) scale.
The GAD-7 scale is an instrument with the objective of tracking "Generalized Anxiety Disorder". This instrument has seven items related to anxiety symptoms that have occurred in the last week, with four response options: 0-not at all, 1-several days, 2-more than half the days, and 3-almost every day, which correspond to the scores of 0, 1, 2 and 3, respectively. Thus, the score can vary from 0 to 21, with values corresponding to No anxiety: 0 to 4 points; mild anxiety: 5 to 9 points, moderate: 10 to 14 points, and severe: 15 to 21 points [16].
The Maslach Burnout Inventory (MBI) Scale is aimed at assessing Burnout Syndrome. This instrument assesses how workers experience their work according to the three established dimensions Emotional Exhaustion (9 items), Professional Fulfillment (8 items), and Depersonalization (5 items), totaling 22 items [19] The following cutoff points are used: emotional exhaustion (low: zero to 15; medium: 16 to 25; and high: 26 to 54), depersonalization (low: zero to 2; medium: 3 to 8; and high: 9 to 30) and professional achievement (low: zero to 33; medium: 34 to 42; and high: 43 to 48).
The data were exported to an electronic spreadsheet and the descriptive statistics of the variables were analyzed based on measures of central tendency and dispersion, absolute and relative frequencies.

Results
The study population consisted of 321 health professionals. Most were female (83.18%) aged between 22 and 65 years, 57.94% were married, and brown -53.89%. Dentists had a greater participation in the research 33.64%. Of the total, 66.04% of professionals had a family income greater than 5 minimum wages 35.83% of health professionals lived alone or with just one person (Table 1)  On the subject of the history of comorbidities and general health status, hypertension was more frequent (n=34; 10.59%), and 8 of them also had associated diabetes. In total, 12 professionals had diabetes (3.74%). 20.2% made continuous use of medication due to some comorbidity. The use of antidepressants and anxiolytics before the pandemic represented 7.8% and 5%, respectively. During the pandemic, the use of these drugs increased to 8.7% and 10.9%.
As for working hours during the pandemic, the majority (97.20%) worked full-time (40 hours a week). Regarding employment, 76.01% reported being civil servants while the rest were hired temporarily. Regarding contamination by COVID-19, 64.79% declared having already been contaminated in one. As for the signs and symptoms presented, 42.8% reported fever, 62.5% sore throat, 33.7% loss of taste, 36.5% loss of smell, 19.7% intestinal problems, 17.8% of air, and 60.1% had body aches. Only 4% required hospital care. Regarding vaccination, 77.9% of professionals received the Coronavac vaccine as the first dose (late 2020 and early 2021) and 95.6% already had the third dose administered when the questionnaire was applied.
Regarding the work routine, the results are shown in Table 2 -80.7% participated in the screening and reception team for patients with or suspected COVID-19 and 52.3% took rapid tests. However, only 28.7% stated that they received training to manage these patients. The continuity of routine care during the pandemic was maintained by 63.2% of professionals and 70.4% indicated that new assignments were requested. Home visits were carried out by 29.3% of health professionals (  When analyzing the impacts of the pandemic on the mental health of workers, 34.27% state that for many days they feel nervous, anxious, or on edge and 41.43% that they are not able to stop and control the worry at all, and 35 .83% stated that they worried about many different things for many days, and found it difficult to relax. (Figure 1). When evaluating the intensity of anxiety among health professionals, the results showed that 32.71% were without anxiety; 27.41% with a mild degree of anxiety, 24.61% with moderate anxiety, and 15.26% had a severe degree of anxiety. To evaluate the Burnout Syndrome, through the Maslach Burnout Inventory Scale (MBI), the final results are presented in (Table 3) Table 3: Burnout rates (emotional exhaustion, depersonalization and professional accomplishment) in primary care professionals in Salvador-Bahia, Brazil, 2022 (n=321).

Discussion
The prevalence of self-reported contamination by health professionals in this study was 64.79%. This percentage was high when compared to the results of international studies that evaluated the contamination rate among professionals working in PHC in Barcelona-30.8% with positive RT-PCR [20] and Algado-Selles et al [21], also in Spain, with 14.7% in primary care.
It was also higher when compared to national studies, such as the one by Gallasch et al 22, covering professionals from different spheres of Health Care -30.89%, with 27% working in PHC; and those of Ferreira [14], which revealed 25% of contaminated professionals throughout Brazil. Still in Brazil, Correia et al [11]. obtained a positive IgG result of 30%.
The heterogeneity between these results can be attributed to the different collection strategies used (serological tests X self-reported disease), different sample sizes, and types of populations. It is emphasized that the production of knowledge on this subject is timely, especially since it is precisely in this sector that the responsibility for the care of patients with sequelae of the COVID-19 disease and the continuity of the planning of preventive actions in the community lies.
It is important to plan actions to support and strengthen the local area in the fight against COVID-19 within the scope of Primary Health Care in the Municipality, with measures to prevent and manage occupational risks, considering that it is precisely these professionals who are responsible for the early detection of the disease through rapid tests, tracking of identified cases, supervision, and care of sick patients, preparation of referral flows, referrals, and counter-referrals, educational activities in the territory and awareness of the population, as well as application of the vaccine, assistance to patients with sequelae of the disease [1,4,5] in addition to continuity of care for other patients with chronic diseases, prenatal care, and child care [2,6,23].
A reformulation and/or improvement of existing surveillance actions was necessary to expand care to the community and to face the pandemic [5,23,24] which meant that they had to reconcile the updating of new routines with the demands that emerged with the pandemic and the continuity of their regular activities [2,25].
This was a highlight of this work. The reorganization of services was a reality in the municipality's PHC -70.4% of professionals highlighted that new attributions were requested during their workday, 80.70% needed to be part of the reception team for patients suspected of having the disease and 52 .3% were part of the testing team and reported work overload. This reality was repeated in many other locations [20,23,24,25].
In this study, the majority (63.2%) maintained the exercises of their routine assignments, validating the importance of maintaining care for the general health of the population [25,26], but on the other hand, few professionals (29.3%) remained with the home visiting activities. It is also observed that, in general, in the European Union, face-to-face consultations have decreased and there has been an increase in teleconsultations [5].
The modality of care through these was not evaluated in this study, but it is worth emphasizing that it was a fundamental tool, applied by several countries [5,25,26]. as a measure of organization of assistance to patients for their care and follow-up. However, even with some limitations such as digital exclusion 24 and lack of physical contact [2,27]. it was guaranteed by Ordinance No. 467, of March 20, 2020, by the Brazilian Ministry of Health [28].
In the assessed group, 67.28% of health professionals had some degree of anxiety. It is worth noting that the data showed that 8.7% began using antidepressants and 10.9% anxiolytics with the onset of the pandemic. When compared to other investigations, Shi et al [29], 2022, in China, presented similar results -68.1%. Lower prevalences were found in studies by Lobo et al, in Brazil, in which 52% had anxiety up to 8.3% [30]. Described in the study by Maroto et al [31], among physicians working in Primary Care in Spain.
In Brazil, high degrees of mental disorders and impact on quality of life have also been described in Recife. 17  was 47.06%, with 68.84% of depersonalization at the high level and 99.06% considered the level low professional achievement. When compared to studies carried out in PHC in Brazil, it was observed that results in the studies by Ferreira et al [32] showed that 52.9% of health professionals in PHC in Montes Claros-MG had Burnout Syndrome, with higher prevalence in the high level with 54, 8% for exhaustion, 77.6% for depersonalization and a value close to 98.6% for low personal fulfillment. Pedrosa et al [33], had higher results for the high level of exhaustion with 59.2%, however, lower values for depersonalization with 29.6%, and only 1.4% did not feel professionally fulfilled among doctors and nurses in primary care to health in the city of Recife-PE. Although the studies by Santos et al [34], in the Amazonia, present a lower prevalence of 33.5% when compared to exhaustion at a high level, their results are superior with 84.8% of depersonalization at a high level, and with the proximity in low professional achievement with 93.3%.
When compared to studies involving Burnout Syndrome in health professionals working in PHC, from other parts of the world, it was observed that in studies by Baptista et al [35], evaluating primary care physicians in Portugal, they presented high levels in the 3 dimensions of Burnout: 65.9% personal, 68.7% work-related, and 54.7% patient-related. Smaller results were reported in the studies by Lasalvia et al [36]. in Italy, with a general prevalence of 25.4% of Burnout Syndrome also in the medical category of the APS. Apaydin et al [37]. identified that 43.4% of health professionals working in PHC had the syndrome.
It is evident that limitations exist in this study -it is a study based on cross-sectional data, with a limited sample and asymmetrical participation between different geographic areas and professional categories in the municipality. The option to search only health professionals who worked in the Family Health Units also does not represent the entire PHC in the municipality. In addition, the data obtained through the questionnaire may have biases, either due to memory or the voluntary omission of the respondent. However, it is worth noting that this is one of the few works on the contamination of Primary Health Care workers in the municipality, it highlights important elements of the work and health of health workers during the pandemic and can, therefore, provide elements that contribute to the workers' health surveillance.