Introduction

In January 2020, the World Health Organization (WHO) declared the outbreak of the new coronavirus epidemic (COVID-19) to be a Public Health Emergency of International Concern. COVID-19 was declared pandemic on March 12, 2020, and on the same day there were 15,113 people infected and 1,016 deaths in Italy. Subsequently, on March 27, 2020, Italy the most affected became the country in the world by the spread of coronavirus, counting over 86,000 confirmed cases. On April 1^st, Italy counted 28,403 hospitalizations of which 4,035 in intensive care [1].

Healthcare workers (HCWs) were among the hardest hit by this event from both a working and psychological point of view.

The contagion and the burden on health services was not distributed evenly across the national territory but affected mostly the regions of northern Italy, with areas such as Lombardia, Piemonte, Veneto and Emilia-Romagna, for a total of 72.110 cases; in the remaining 16 Italian Regions were registered 35.559 cases (April 21^st, 2020) [2].

On April 29^th, 2020, the Italian Ministry of Health published a paper dealing with the “Operational indications relating to the activities of Occupational Physicians (OPs) in the context of measures to contend and contain the spread of the SARS-CoV-2 virus in the workplace and in the community”. In this document, the role of the occupational physician had a central position in the anti-contagion measures, in the active surveillance of workers and in all the preventive activities aimed at guaranteeing the protection of worker’s health upon the resumption of working activities. OPs have been invited to identify and report to employers, any situation of weakness among company personnel and to manage the reintegration of subjects with previous COVID-19 infection.

Several studies have shown how severely the well-being of Physicians can be affected in pandemic periods. In fact, during the previous SARS epidemic of 2003 significant psychosocial effects were reported on HCWs and experiences with very stressful challenges that can trigger common mental disorders, including anxiety and depression, that can, ultimately, result in hazards that exceed the consequences of the COVID-19 pandemic itself [3–7].

Recently, a meta-analysis has studied a population of physicians engaged in the management of new viral outbreaks, investigating its psychological aspects. It has shown how young Physicians with little working seniority, being parents, and experiencing a long quarantine suffered an important psychological distress [8].

In addition, lockdown measures (closing of schools, universities, all non-essential businesses and parks, social distancing, limitation of movements and transport, etc.), imposed by many governments, including the Italian one (the “lockdown” was introduced in Italy on March 9^th, 2020) in order to slow down the spread of the virus, resulted in a reduced perception of health and an increased feeling of distress in the general population, even if there is a lack of studies that explore this relationship [9].

In this dramatic national scenario, the figure of the Occupational Physician was important in all the essential businesses (Hospitals at first) to implement anti COVID-19 prevention measures in the workplaces and in the active health surveillance of workers, during the lockdown.

The aim of this web-based cross-sectional study is to assess well-being and psychological distress on Italian occupational physicians’, in relation to demographic and occupational characteristics, lifestyle and habits during the lockdown period.

Materials and methods

Results

A total of 202 participants completed the questionnaires (Response rate of 71,4%). Whereas the population of OPs in Italy is approximately 7400 units, the sample size achieved is consistent with a margin error of 7% and a confidence level of 95%. These results demonstrate adequate sample size of the study. All the results about prevalence and univariate analysis are shown in Table 1.

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Table 1. Sample characteristics.

https://doi.org/10.1371/journal.pone.0243194.t001

Psychological distress and perceived well-being

The evaluation by the GHQ-12 demonstrated the prevalence of psychological distress:

1. higher in females than males (91.14% vs 87.80%, P = 0.458);
2. higher in participants working in the most affected Regions than those from the least affected ones (96.61% vs 86.01%, P = 0.028);
3. higher in Ops who “don’t feel sheltered in their home” than those who “feel sheltered in their home” (98.28% vs 75.00%, P = 0.001);
4. higher in OPs who “suffer loneliness” than those who “don’t suffer loneliness” (100.00% vs 87.82%, P = 0.001);
5. higher in OPs who “don’t feel comfortable at the home” than those who “feel comfortable at home (100.00% vs 84.50%, P = 0.020);
6. higher in OPs who reported poor well-being at WHO-5 than others (96.77% vs 82.57%, P = 0.001).

The evaluation by the WHO-5 demonstrated the prevalence of poor well-being:

1. in 46.04% of total specimens, higher in females than in males (55.70% vs 39.84%, P = 0.027);
2. higher in those aged ≤50 than in those aged >50 (54.00% vs 38.24%, P = 0.025);
3. higher in participants working in the most affected Regions than those from the least affected ones (61.02% vs 39.86%, P = 0.006);
4. higher in those with a lower job seniority than others (53.70% vs 37.23%, P = 0.019);
5. higher in OPs who “don’t feel sheltered in their home” than those who “feel sheltered in their home” (75.86% vs 8.33%, P<0.001);
6. higher in OPs who “suffer loneliness” than those who “don’t suffer loneliness” (95.24% vs 40.38%, P<0.001);
7. higher in OPs who don’t feel comfortable at the home” than those who “feel comfortable at home (69.23% vs 37.98%, P = 0.007);
8. higher in OPs who changed their eating habits than those who did not (59.09% vs 35.96, P = 0.001).

The analysis of variance (one-way ANOVA) demonstrated:

1. differences between males and females (F = 4.82, P = 0.029) with a contrast of -0.75 in GHQ-12 score (standard error = 0.34);
2. differences in respect of the statement "feel sheltered at home" (F = 22.52, P<0.001), in this case, a Tukey post-hoc test revealed that mean GHQ-12 score differ between “no” vs “yes” (2.82 ± 0.42 GHQ-12 score, P<0.001), between who answered “sometimes” vs “yes” (1.15 ± 0.38 GHQ-12 score, P = 0.009) and “sometimes” vs “no” (-1.66 ± 0.36 GHQ-12 score, P<0.001);
3. differences in respect of the statement “suffer from loneliness" (F = 7.93, P<0.001), in this case, a Tukey post-hoc test revealed that mean GHQ-12 score differ between “no” vs “yes” (-2.13 ± 0.54 GHQ-12 score, p<0.001), between who answered “sometimes” vs “yes” (-1.54 ± 0.69 GHQ-12 score, P = 0.067) and “sometimes” vs “no” (0.58 ± 0.50 GHQ-12 score, P = 0.478);
4. differences in respect of the statement "feel comfortable at home” (F = 11.16, P<0.001), in this case a Tukey post-hoc test revealed that mean GHQ-12 score differed between “sometimes” vs “yes” (1.67 ± 0.36 GHQ-12 score, P<0.001), between who answered “no” vs “yes” (1.05 ± 0.67 GHQ-12 score, p = 0.260) and “sometimes” vs “no” (0.62 ± 0.70 GHQ-12 score, P = 0.651).

Results of ANOVA analysis of the mean GHQ-12 scores and Tukey post-hoc test are shown, respectively, in Tables 2 and 3.

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Table 2. One-way Anova of the General Health Questionnaire-12 score.

https://doi.org/10.1371/journal.pone.0243194.t002

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Table 3. Tukey post-hoc test of the General Health Questionnaire-12 score.

https://doi.org/10.1371/journal.pone.0243194.t003

Discussion

This study focused on occupational physicians, assessing their psychological distress, perceived well-being and lifestyle changes during the lockdown caused by the COVID-19 pandemic.

As previously demonstrated, COVID-19 pandemic and subsequent lockdown measures had a strong impact on doctors’ wellbeing and mental health [16]. Many studied carried out in Italy during this period, also demonstrated the negative effects of the quarantine on people’s mental and physical health. Increasing violence, worsening of pre-existing psychiatric illness and of physical health in patients with comorbidities, represented an additional source of stress for the medical category [17–20].

The General Health Questionnaire (12 items version) derives from an original version consisting of 60 items developed by Goldberg and colleagues in 1978. Many different shortened versions are available and all of them have been validated [21]. The 28-item version has been successfully used in the past to assess HCWs psychological distress during the H1N1 influenza pandemic [22].

It cannot indicate a specific diagnosis (depression, anxiety, etc.), but it represents a general indicator of distress and/or potential problems. This tool has previously demonstrated to have a good psychometric value and to be able to assess work-related stress amongst HCWs [23, 24].

What clearly emerged from this web-survey, is the high prevalence of OPs with high risk of psychological distress and low self-reported well-being.

This tendency was also demonstrated in relation to the operating Regions, with OPs working in the most affected Regions experiencing worst psychosocial conditions. As previously demonstrated by our study group, gender differences are extremely important in the perception of stress, in fact women are more affected by poor well-being and have worse scores than males in the GHQ-12 questionnaire, indicating an increased risk of psychological distress [25]. Previous studies have demonstrated how this phenomenon is influenced by different coping strategies: males tend to adopt problem-focused coping behaviours when confronted with emerging problems while females prefer emotional-focused coping behaviours, which make them more susceptible to mental distress [26].

Lockdown measures, put in place to slow down the spread of the virus, damaged both economies and societies. Our study shows how they also impacted on the mental health of OPs, forced to reorganize their activities in a context of social isolation. The questions of the survey exploring their emotions (“Do you feel sheltered at home?”, “Do you feel alone?”, “Do you feel comfortable at home?”) have been related to their perceived well-being and psychological distress [27, 28].

The results of this study should be considered in the light of some limitations. Firstly, the design of a cross-sectional study is limited in assessing temporal relationship between exposure and outcome, and it cannot demonstrate the existence of a causal relationship between lifestyles and socio-demographic characteristics and measured outcomes. Secondly, since the study is based on a convenience sampling of OPs and on the spontaneous participation of the respondents, the raw results could lack in generalization. Indeed, our results are not immune from possible responding bias, i.e. the risk that the willingness of the OPs to participate in the survey could be directly or indirectly related to their attitude to COVID-19 pandemic. Therefore, it should be considered that a web-based survey is the most rapid and universal method to collect substantial data in a short period (like a lockdown) and the analysis of the sample size is consistent with the generalizability of the data with a certain approximation.

This study emphasizes the need to preserve the well-being and mental health of OPs. The COVID-19 pandemic intervened in the already complicated working conditions of the medical category, in a context of increasing violence against health workers, medical-legal problems, reduction of funds for healthcare systems [29]. Even if there is still no consensus on which preventive measures are the most appropriate to prevent the occurrence of mental disorders among OPs [30], it is urgent to put in place policies of psychological support and well-being preservation for the medical class, not only in terms of the protection of the health of the worker, but also in the interest of the proper functioning of the health system and of the quality of care for citizens.

Supporting information