On 30th January 2020, the World Health Organization, reported the discovery of the novel coronavirus and designated it a Public Health Emergency of International Concern under the International Health Regulation.1 The emergence of the COVID-19 pandemic resulted in a high percentage of viral infection-related deaths as well as psychological and emotional consequences.2 Healthcare workers (HCWs) had to respond to this pandemic by becoming actively involved in the diagnosis and treatment of COVID-19 patients, risking exposure to the novel virus and thereby bearing the brunt of physical, psychological, and behavioral health issues.3

It has become evident that extreme pressure while working affects the physical, emotional, and mental health of the HCWs.4 Furthermore, it has been reported that most HCWs experienced depression, insomnia, stigma, and frustration during the pandemic. Southeast Asia had lower rates of anxiety, depression, and sleeplessness compared with other regions, as evident from comparing two meta-analyses.5 The discrepancy is compounded when contrasted with South European nations like Spain, France, Italy, and Greece. Southeast Asia’s lower prevalence rates may be attributed to the region’s recent experience with epidemics and the use of early interventions similar to those in China and East Asia to improve HCWs' mental health.5

According to the Oxford COVID-19 Government Response Tracker, India was the most impacted country in terms of confirmed COVID-19 cases, after only the USA, Brazil, Russia, Spain, and the UK.6 Among the Indian population, stress, anxiety, and depression were reported to be present among 28.9%, 35.6%, and 17.0% respectively, during the COVID-19 lockdown.7 The mental health issues experienced by HCWs impacted competency and motivation, increasing the risk of emotional exhaustion and hindering the healthcare response to COVID-19.8 A cross-sectional study from India identified the prevalence of anxiety (23.9%) and depression (20%) among HCWs.9 However, to date, there is no robust evidence on the magnitude of stress, anxiety, and depression among HCWs in India and its context as a mental health problem in the Indian healthcare system. Therefore, the purpose of this mixed-methods systematic review was to measure the impact of COVID-19 on the mental health of HCWs in India and to identify the contributing factors to contextualize evidence to inform policies to meet the mental health needs of HCWs in the future.

Methods

This review adopted a results-based convergent approach incorporating quantitative and qualitative data.10,11 We began with quantitative survey data to determine the prevalence of mental health problems faced by HCWs in India during the COVID-19 pandemic and integrated quantitative (meta-analysis) and qualitative data (themes) to identify the contributing factors and coping strategies across six domains: individuals, family, peers, community, health services, and the wider society.

This systematic review protocol was registered in PROSPERO (CRD42021236500) (https://www.crd.york.ac.uk/PROSPERO). We adhered to the Preferred Reporting Items for Systematic Meta-analysis (PRISMA) framework to report this systematic review.

Search strategy

The search was limited to papers published in the English language until 28 February 2022. An electronic search of four databases (PubMed-Medline, CINAHL, Web of Science, and ProQuest) was conducted to identify peer-reviewed articles focusing on the impact of COVID-19 on the mental health of HCWs in India. The search process is reported using the PRISMA diagram [Figure 1]. Initially, each database was searched, and the title and abstract were screened independently by two reviewers based on the inclusion and exclusion criteria [Table 1]. Subsequently, the full text of each article was thoroughly reviewed independently by two reviewers. Reference lists of relevant studies were examined to identify the additional studies. Discrepancies between the two reviewers were resolved through discussion with a third reviewer.

Data extraction

The studies that met the inclusion criteria were exported from each database into an Excel sheet. Two reviewers independently performed the data extraction using the piloted data extraction form. The form included information on the authors, year of publication, study design, sample size, outcomes, and study findings.

For the included qualitative studies, the same two reviewers independently reviewed them and conducted line-by-line coding of the findings to identify themes. Common themes were derived after summarizing the findings, and supporting quotes were drawn from the qualitative studies. Any disagreement between the two reviewers was resolved through consultation with a third reviewer.

Critical appraisal

The methodological quality of the included quantitative and qualitative studies was assessed using the Joanna Briggs Institute (JBI) quality assessment instruments,12,13 and the Mixed Methods Appraisal Tools Version 2018 as appropriate.14 The first and second reviewers independently assessed the quality of the included studies. Any discrepancies between the two authors were resolved in a discussion with a third reviewer. The quality assessment is presented in Tables 2, 3, and 4.15–45

Data synthesis

The data synthesis was conducted in three stages following the framework described in another study.46 Firstly, a meta-analysis was performed using Stata software (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.) to determine the pooled prevalence of anxiety, stress, and depression among the HCWs during the pandemic, based on quantitative studies. A heterogeneity (I2) statistic between estimates was assessed, which describes the percentage variation. I2 value > 75% indicates a high heterogeneity. We anticipated significant I2 and used the random effects model for meta-analysis. Forest plots were generated for each outcome, and the results were presented as pooled prevalence with a 95% CI. Next, we conducted a thematic synthesis of the findings from the qualitative studies. Finally, a conceptual matrix was utilized to integrate the findings of quantitative and qualitative synthesis. This integration provided a clear explanation of the factors related to individuals, family, peers, community (living and working conditions), health services, and wider society that influenced the mental health of HCWs during the COVID-19 pandemic.

Results

Studies selection

A total of 334 studies were retrieved from four databases [Figure 1]. After removing 9 duplicated records, the remaining 325 studies underwent title screening, resulting in the exclusion of 270 studies. The remaining 55 studies were assessed against the eligibility criteria, leading to the exclusion of 24 articles (four editorials and commentaries, four studies unrelated to COVID-19, two studies did not involve HCWs, five studies conducted outside of India, and nine studies including outcomes beyond the scope of this review). Finally, 31 studies met the inclusion criteria and were included in this review (27 quantitative studies, three qualitative studies, and one mixed-methods study). However, for meta-analysis, 26 studies were included (25 quantitative and one mixed-methods study). However, two studies reported the findings using mean and SD and were not included in the meta-analysis.19,23 For the qualitative synthesis, data from three qualitative studies and one mixed-methods study were incorporated.

Characteristics of the included studies

The review included a total of 10 043 HCWs as participants. The age of the participants ranged from 18 to 78 years, and they were employed in both governmental and non-governmental organizations across various parts of India. The participants comprised nurses, doctors (including residents), paramedical staff, and support staff. Table 5 provides a summary of the included studies.

Assessment of publication bias

The publication bias among the included quantitative studies was assessed using Egger’s test which indicated no evidence of publication bias
(p > 0.05) [Table 6].

Findings from the quantitative studies

DEPRESSION

Sixteen studies reported the prevalence of depression.15–18,20,22,26,30,31,33,35–39,41 Other characteristics of the study findings are presented in Table 5. The calculated pooled prevalence by the random effect model was 32.96% (95% CI: 23.74–42.90, I2 = 98.47%; p < 0.00) [Figure 2].

ANXIETY

Twenty-two studies (21 quantitative studies and one mixed method study) reported the prevalence of anxiety among HCWs.15–18,20–22,25,26,28–31,33,35–41,45 Other characteristics of the study findings are presented in Table 5. The pooled prevalence of anxiety [Figure 3] was calculated using the random effect model, and it was found to be 29.49% (95% CI: 21.52–38.13, I2 = 98.39%; p < 0.00) [Figure 3].

Stress was reported in 16 studies (15 quantitative studies and one mixed method study.15,16,20–22,24, 26,27,29,31,32,34,35,38,41,45 Other characteristics of the study findings are presented in Table 5. The pooled prevalence of stress was 33.47% (95% CI: 18.45–50.43, I2 = 99.36%; p < 0.00), as depicted in Figure 4.

Findings from the qualitative review

Qualitative data were extracted from four studies. The data from three qualitative studies42–44 and one mixed-methods study45 were synthesized [Table 5].

The three included qualitative studies used different approaches to data analysis. Banerjee et al,44 used ‘Charmaz’s grounded theory approach’, followed ‘Colaizzi’s protocol’, and Chakma et al,42 did not use any preconceived theoretical framework but performed descriptive content data analyses. George et al,45 used the framework approach for data analysis. Thematic synthesis resulted in the following themes:

CHALLENGES

1. Fear of contracting the disease and spreading it to family: a common theme in all four studies was fear of contracting the virus and spreading it to family members. Due to their daily contact with infected patients and the high infectivity of the novel virus, HCWs expressed fear of becoming infected themselves. They were also concerned about the possibility of transmitting the virus to their families, particularly vulnerable individuals such as children and elderly parents with chronic health conditions. Participants mentioned that severe infection and death were topics of conversation within their families.
2. Extreme stress, anxiety, and frustration: all four studies also provided data on the high levels of stress experienced by HCWs. They expressed stress due to their high susceptibility to contracting the virus as well as the increased workload resulting from the high volume of patients, leading to exhaustion and frustration.42,45 One study highlighted that HCWs not only had the responsibility of providing care, but also the additional emotional burden of offering psychological and emotional counseling and assurance to patients, families, and colleagues.
3. Work fatigue and disruption of everyday life: HCWs were expected to work for extended periods, to meet demand and cover staff illnesses. This resulted in significant fatigue and physical tension, impacting their mental health and decision-making abilities. The management’s ability to cope with the unprecedented pandemic situation exceeded their previous training and experience, resulting in overworking and excessive duty hours, leading to burnout. HCWs also faced challenges in balancing their work commitments with their family life, with separation from their families for extended periods being a significant disruption.
4. Social stigma: findings from the qualitative study findings revealed that HCWs attending to COVID-19 patients experienced social discrimination and rejection. Neighbors, friends, and even family members treated them as potential spreaders of COVID-19, often influenced by media coverage. They faced unpleasant remarks and hesitancy from society to engage with them, leading to avoidance.
5. Personal Protective Equipment (PPE) concerns: HCWs expressed concerns about wearing PPE kits for prolonged periods, as it caused physical exhaustion, discomfort due to heat, and limited access to basic needs such as eating, drinking, and using the washroom easily. The quality of PPEs also was a cause of concern for the HCWs, undermining their confidence in providing care.

COPING STRATEGIES

1. Family and peer support: HCWs expressed that the support they received from their immediate family, friends, and co-workers was crucial in helping them cope with the challenges they faced. Co-workers were a significant source of support, and sharing their difficult experiences with them was encouraging Having another family member on COVID-19 duty was a powerful motivator for HCWs. They also mentioned that appreciation from higher authorities and recognition on social media were uplifting for them.
2. Self-care and lifestyle modifications: HCWs adopted individual coping strategies focused on self-care and making lifestyles modifications. They engaged in wellness activities and specific relaxation techniques such as yoga, meditation, listening to music, going for walks, and exercising to improve their physical and mental well-being.43
3. Higher purpose through God/religion: for some HCWs, their faith in God and religious beliefs played a role in coping with the challenges they faced. Praying and spiritual dependency provided them with a sense of higher purpose and strength.42
4. Value of duty and passion: many HCWs expressed that they felt a sense of duty and a calling to serve patients, even at the risk of their own lives. They recognized the value and strength of being healthcare professionals and believed that their passion for their work helped them cope.42,44

Synthesis of quantitative and qualitative findings

The quantitative and qualitative findings were integrated using the social determinants of health framework.47 The following domains were identified:

INDIVIDUAL DOMAIN

Fear of contracting and spreading COVID-19, as well as physical and emotional exhaustion, contributed to the significant stress and anxiety experienced by the HCWs. Individually, HCWs coped by engaging in self-initiated well-being activities, fulfilling moral and social obligations, and drawing strength from their own spiritual beliefs.

INTERPERSONAL (FAMILYAND PRESS)

HCWs with vulnerable family members, including the elderly and young children, were particularly concerned about their well-being. Some HCWs had to stay away from their families as a protective measure, which affected their mental health. Isolation and discrimination from family members and peers added to their stress. HCWs with childcare responsibilities faced difficulties in balancing home life and work. However, the support and encouragement from family and friends were crucial coping resources for HCWs.

HEALTH SERVIES DOMIN

Increased workload and long working hours were major sources of stress for HCWs. The lack of mental health support for the public and the support staff in healthcare settings placed emotion burdens on HCWs. Assuming new responsibilities without adequate preparation and working in unsafe environments with unpredictable consequences added to their anxiety and stress. PPE-related issues such as shortage, discomfort, and poor quality were additional stress factors.

COMMUNITY AND WIDER SOCITY

HCWs felt rejected and stigmatized by society, often facing discriminatory behaviors and hatred. Some faced eviction from rented properties, leading to depression. The support received from co-workers was highly valued by HCWs.

Discussion

India was one of the nations hardest-hit by the COVID-19 pandemic. India’s dense population placed a massive burden on mortality and morbidity. The remarkable effect of COVID-19 had a grave psychological impact on the HCWs. Therefore, this mixed-methods review was undertaken to determine the impact of COVID-19 on HCWs’ mental health status in India and its attributing factors.

Compared to the global prevalence by Ghahramani et al,48 our review findings showed a lower prevalence of depression (32.96% vs. 36%) and anxiety (29.49% vs. 47%). Stress was the only exception, which had a higher prevalence in India (33.47% vs. 27%). According to our findings, the prevalence of depression and anxiety among HCWs is much higher in India than in the Asian subcontinent (China, South Korea, Saudi Arabia, Israel, Jordan, Palestine, Turkey, India, and Pakistan) and the Southeast-Asia region (Bangladesh, Pakistan, and Nepal) wherein the pooled prevalence was 27.2% (10 617/39 014), and 25.9% (6305/24 297) and 34.1% and 41.3%, respectively.49

The review also highlighted common themes identified in other studies worldwide,50 such as fear of contagion, issues with PPE, heavy workload, social stigma, and the complex dynamics between HCWs, family members, colleagues, media, and society. These findings demonstrate that the impact of COVID-19 on HCWs transcends geographical and temporal boundaries.

In India, PPE was a great concern for HCWs during the pandemic. Similarly, in Oman, they faced an excessive need for face masks and gowns which was tackled by the endowment fund dedicated to public healthcare services.51 Only one study included in the review compared the anxiety score between male and female HCWs which reported female HCWs had higher anxiety.25 This finding was similar to a study conducted among female HCWs during the pandemic in Oman wherein 27.9% had moderate to severe anxiety.52Another important stressor among the HCWs was the heavy workload which was causing fatigue and affecting their mental health due to the high number of cases admitted to the hospitals. An effective intervention to overcome such a challenge would be a healthcare system change. One of the exemplary models adopted in response to the pandemic in India was the Udupi-Manipal model which was a public-private partnership. One of the private hospitals was designated as a COVID-19 hospital to treat the overwhelming number of COVID-19 cases in the district.53 Similarly, the primary health care in Oman partnered with private establishments, in tracking, testing, managing the cases, and data management as well.54 However, studies on the role of the healthcare system in supporting the mental health of HCWs during the pandemic are lacking.

Recommendations for policy and practice

As HCWs continue to be the front-line workers in the face of the pandemic, they continue to be at significant risk of developing long-term psychological impacts. Implementing appropriate interventions to help HCWs cope with various mental health problems is the need of the hour. However, there were no studies on healthcare policies and interventional measures to meet the mental health needs of the HCWs during the pandemic. Due to the observed deficiency from this review, we recommend that there must be interventions and protocols at the institutional level, and policies at the governmental level to support HCWs’ mental health. Furthermore, adequate training in management and counseling services to equip the HCWs in providing care confidently can play a role in mitigating the psychological impact of the COVID-19 pandemic. The role of media should be above and beyond to spread community awareness to remove the stigma associated with COVID-19.

Strengths and limitations

In our mixed method analysis, integrating the quantitative and qualitative data using the social determinants of health framework provided a comprehensive insight into the factors related to individuals, family, peers, community, health services, and wider society that influence the mental health of HCWs during the pandemic. There is no evidence of publication bias in the included studies in the three outcomes assessed.

Due to the I2 in the data from the included studies, we were unable to perform a sub-group analysis. Another limitation of this review was that outcomes like insomnia, fear, quality of life, psychological impact, and post-traumatic stress disorder were not measured because we found that the most reported mental health outcome among the HCWs in India was anxiety, stress, and depression.

Conclusion

This review emphasizes the significant prevalence of depression, anxiety, and stress among HCWs in India. Integrating quantitative and qualitative data explained the psychological impact of the COVID-19 pandemic on the mental health of HCWs. We recommend multi-prong and multi-level approaches as a way forward to protect the HCWs and preserve their service.

Disclosure

The authors declared no conflicts of interest. We acknowledge the funding agency Scheme for Promotion of Academic and Research Collaboration (SPARC), Department of Education, Govt. of India for supporting to collaborate with experts from UCL and the UCL-AIIMS collaboration grant.

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