Vaccines | Free Full-Text | Anxiety Levels among Healthcare Workers during the COVID-19 Pandemic and Attitudes towards COVID-19 Vaccines
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1. Introduction
Infectious diseases, including SARS-CoV-2, have been and continue to be a major social problem, but more importantly, a health problem—both physically and mentally. Even if we do not become infected, we are nevertheless exposed to the psychological effects of the COVID-19 pandemic. The emergence of severe infectious diseases causes increased anxiety and fear throughout society, as seen by earlier MERS, H1N1, and SARS epidemics. The increased number of infections and deaths caused by infections have instilled a shared fear of death, infected people, and the disease itself. These circumstances have contributed to the elevated levels of anxiety and fear [1].
The psychological impact of the COVID-19 pandemic on individual, group, and societal health is a multidimensional topic. It is the focus of current in-depth research efforts. The psychological impact of the COVID-19 epidemic on the health of individuals, groups, and society is complicated and multifaceted. It is the focus of ongoing in-depth scientific investigations. What is essential is that, given the pandemic’s potential long-term psychological impact, a comprehensive assessment of the event will not be feasible until many years have passed. However, some authors are already formulating terms that refer to psychological problems related to COVID-19, such as pandemic stressors, COVID-19-related psychological stressors, or post-COVID-19 stress disorder [2].
Without a doubt, the COVID-19 pandemic had a negative impact on the well-being of individuals, groups, and society. Despite variations among particular diagnostic units and studied populations, available epidemiological evidence indicates that around 30% of people experienced mental disorders during the pandemic, and over 50% reported psychological distress [2]. During the pandemic, individuals universally experienced a range of difficult emotions, such as anxiety, danger, frustration, or anger. All these emotions lead to a decline in well-being and life satisfaction, potentially negatively impacting the quality of life and leading to mental health issues. Research shows that anxiety, which is the most common negative emotion, can significantly limit social and cognitive functioning, and increase clinical symptoms of social anxiety, phobia, and depression. The main source of anxiety during the pandemic was the disease and its consequences [3,4,5]. Moreover, the pandemic situation fostered social tensions and conflicts and increased the risk of individually harmful behaviours such as substance abuse, self-harm, suicide, aggression, and violence. Dr David Murphy points out that anxiety and danger are the key issues that society has to face during the pandemic [6]. The significant aspect is the fact that society had to deal with the psychological effects of the pandemic much longer than with the pandemic itself. The fear associated with contracting COVID-19 passes, but the fear caused by pandemic stressors remains [2,3,4,5,7].
Some social groups were more exposed to the psychosocial effects of the pandemic than others, for example, people who contracted the disease, people with chronic somatic diseases, as well as young people who are particularly vulnerable to destabilization, isolation, and the need for lifestyle changes. The latest research indicates that anxiety or sadness experienced by young people was the result of consequences and imposed restrictions rather than the illness itself, while in older adults, negative emotions were caused by health-related worries. During the pandemic, healthcare personnel faced heightened stress and chronic anxiety. They put not just their own lives and health at risk while carrying out their duty, but also the lives of others they care about. Healthcare personnel face daily challenges such as concern of infecting their families, a lack of adequate personal protective equipment, and work stress [2,3,5,7,8,9,10,11,12,13].
Considerations to date reveal how devastating the psychological implications of the pandemic are for the social, economic, and healthcare systems. This obviously implies the need for the introduction of preventive and therapeutic measures at the individual and institutional levels, as well as at the level of government agencies—now and in the future [2]. There are numerous recommendations for implementing possible activities at each level stated, but vaccination is the common action for all of them. Vaccines serve a highly vital role in health, particularly in protecting against infectious diseases such as COVID-19. Despite the fact that vaccinations are proven to be successful, there are still differing perspectives and theories about this approach. Opinions differ not only among the general public but even among doctors [2]. The pandemic has proven to be a particular challenge for healthcare workers, not only in the professional but also individual sense. Undoubtedly, direct contact with sick patients, the fight against the pandemic, and observing the epidemiological situation influenced the attitudes of this group towards COVID-19 and vaccinations [14]. Unfortunately, a substantial proportion of healthcare workers show a general lack of intention to get vaccinated, and similar tendencies for vaccine hesitancy were noticed among healthcare workers during the COVID-19 vaccination campaign. Vaccine hesitancy among healthcare workers in Europe has become a source of significant concern in recent years, and it stems from scepticism, lack of confidence, and worries regarding vaccine effectiveness and side effects [15,16]. The study intended to examine the severity of anxiety among healthcare workers during the COVID-19 pandemic, identify any potential links between current anxiety and vaccination attitudes, and investigate whether these variables interact. The study will complement the data concerning the attitudes of Polish healthcare workers towards COVID-19 vaccinations, and also fill the gaps in knowledge about the influence of anxiety on attitudes affecting the environment of healthcare workers. Previous research has provided limited data on the motivational impact of negative emotions on protective actions in COVID-19 prevention.
3. Data and Method
3.1. Study Design
The cross-sectional study was conducted in 2022 in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
3.2. Study Participants
The convenience purposive sampling method was used and the study was led among nurses and doctors employed in healthcare facilities of the Provincial Hospital in Mielec in the Podkarpackie voivodeship in Poland. The inclusion criteria for the research were the participant’s consent to completing the survey, professional activity, i.e., current employment as a nurse or a doctor, and having at least one year of work experience as a healthcare worker. The exclusion criterion was having less than one year of work experience. After obtaining the consent to participate in the study from the subjects, 400 surveys were distributed and 385 responses were received, which means a return rate of 97%. A total of 385 participants who correctly completed the survey were included in the analysis.
3.3. Instruments
The Trait Anxiety Scale SL-C and a survey were utilized in the investigation.
The survey contains explicit instructions on how to complete it. It includes open-ended, single- and multiple-choice questions that allow obtaining cadastral, epidemiological, and qualitative information. The survey consists of a general and a detailed part. The general section includes demographic data, such as age, gender, work experience, education, and workplace. The detailed section includes questions about anxiety levels, causes of anxiety, the influence of various factors on anxiety levels, the pandemic’s impact on mental health, the frequency of negative feelings during the pandemic, the use of anxiety-coping strategies during the COVID-19 pandemic, and questions about COVID-19 vaccinations and attitudes towards vaccinations.
The Trait Anxiety Scale SL-C is a tool for measuring the intensity of anxiety as a personality trait, which is understood as an individual’s tendency to perceive and predict future events in the range of dangers or threatening situations, which is manifested through specific symptoms at the emotional, cognitive, somatic, and behavioural level. The SL-C scale is built of 15 items and the answers are given on the 4-point scale from never to often. Every answer given is scored as follows: never—0, rarely—1, sometimes—2, often—3, except for items 9 and 11, where the score was as follows: never—3, rarely—2, sometimes—1, and often—0. The results of the SL-C scale are the sum of all obtained points. The scores range from 0 (lowest degree of anxiety traits) to 45 (highest intensity of anxiety traits).
3.4. Data Collection
The prepared research tool was verified, i.e., checked to what extent it measured the phenomenon that we wanted to understand. A pilot study was conducted on a small sample of people to verify and standardize the survey, ensuring that all questions were clear and understandable to respondents, that they were understood in accordance with the researcher’s intention, and that they provided the information the researcher desired. The researcher explained the purpose and meaning of the study to each surveyor and informed them that participation was completely voluntary. Envelopes with information about the study, the informed consent form, and the survey were distributed among all respondents who were asked to return the envelopes after completing them. Doctors and nurses who work in outpatient and surgery departments completed the survey. When the subjects responded to the survey questions, they had no objections. Taking into account refusals and withdrawals from the study, 400 surveys were given during the test phase, with 385 responses, resulting in a 97% return rate. A total of 385 forms (100%) were considered for statistical analysis. The retest took place after an average of one month. In the retest phase, 105 completed surveys were returned. The reduced number of retest participants was largely due to professional absence lasting over two weeks. Due to the high absence level of doctors, this group was not included in the study.
3.5. Sample
The study had 385 participants, including 67% women and 33% men. The average age of the patients was SD 48.41 ± 6.76 years.
3.6. Ethical Considerations
The study was approved by the Team for Scientific Research Ethics at the Bioethics Committee at Collegium Masoviense University of Health Sciences in Zyrardow and the Institute of Healthcare of the State University of Technology and Economics in Jarosław, no. 197/2022. Participation in the study was voluntary and anonymous and respondents were informed of their right to refuse or withdraw from the study at any time. Each participant was informed of the study’s purpose and deadline.
3.7. Data Analysis
The study’s results were statistically summarized and imported into the statistical programme Statistica (version 14.0, TIBCO Software Inc., Palo Alto, CA, USA). Descriptive statistics were used to determine the percentages and 95% confidence interval (CI). Statistical characteristics of continuous variables were presented in the form of arithmetic means, standard deviations, and medians. Statistical characteristics of step and qualitative variables were presented in the form of numerical and percentage distributions using the Student’s t-test or Mann–Whitney U test. A correlation was determined using Pearson’s test, while χ2 was used for comparison between groups. Significance was assessed at p < 0.05. The chi-square test was used to assess the diversity of opinions on vaccination safety in groups. The repeatability of responses to individual questions was assessed using Kappa Cohen statistics. Missing data were excluded from all analyses.
5. Discussion
The COVID-19 pandemic is an exceptional experience for healthcare workers who are in constant contact with this virus and infected patients. The introduction of preventive medicine and a significant improvement in sanitary and epidemiological activities can reduce the threat of infectious diseases. Despite scientific and medical consensus on the benefits of vaccination, concerns about vaccine hesitancy are growing. It has a great influence on the attitudes of healthcare workers towards COVID-19 vaccinations, and this study allowed us to learn about them [14,15,17].
This research was conducted on a group of nurses and doctors. After considering various reasons, 85% of respondents decided to get vaccinated against COVID-19. In Solecka’s research, as many as 90% of doctors were vaccinated with 2 doses of the vaccine, and all medical professionals achieved an exemplary result of over 80% [18]. In Cyprus, only 7% of 436 nurses and midwives were hesitant to be vaccinated against COVID-19, while according to a study conducted in France, 23% of 1965 nurses and doctors were hesitant. These numbers suggest very different perceptions among healthcare workers in various locations about the general concerns or concerns about vaccine safety and effectiveness [15]. However, the statistics were not equally optimistic everywhere. The initial percentage of vaccinated healthcare workers in Georgia was only 18%. The situation was better in Italy, where, according to the statement of the Public Health Committee of the Polish Academy of Sciences on vaccinations against COVID-19, 67% of medical workers declared the willingness to get vaccinated after the vaccine was introduced to the market [18,19]. However, studies conducted since March 2022 show that the attitude of Italian medical workers has improved and 91.5% of doctors and nurses received an additional dose of the vaccine [20]. Despite the large number of vaccinated personnel, the vast majority, up to 80%, believe that vaccination is not required to execute the duties of a doctor or nurse, and 50% consider that mandating vaccination obligations on healthcare workers violates human rights. This allegation contradicts various statements, including those made on the Ministry of Health website, which argue that mandating vaccination among healthcare workers is the only way to protect them, citing other EU countries, such as France, Greece, Latvia, and Italy. However, research conducted in these countries shows that local medics, despite being vaccinated, do not agree with the statements regarding compulsory vaccinations, and some of them decide to get vaccinated only because of the possibility of sanctions [21]. Perception of risk, trust, emotions, beliefs, worldviews, controversies, and significant events such as epidemics significantly impact healthcare workers’ attitudes and their perceptions about vaccinations [15].
Collective responsibility appears to be one of the most important motivators for medics who desire to work safely. However, respondents justified their decision to get vaccinated with reasons such as fear of severe illness, protecting their families, or believing that this was the only way to end the COVID-19 pandemic. These arguments seem to be justified, because, as shown by Johnson et al.’s research, the risk of illness and severe symptoms is almost four times higher in unvaccinated people [22]. Cosby noticed that being motivated by collective responsibility is more common among medical workers with a rather negative attitude towards vaccinations [23]. A slightly different approach was observed in a hospital in Munich, where surveyed healthcare workers stated that their motivation was mainly to avoid receiving medication in the treatment of infection or that the overall benefits outweighed the risks associated with vaccination [24]. According to Lou et al., trust is the most important factor that influences the decision to get vaccinated. Due to a lack of trust, the popularization of vaccinations is significantly hampered [25]. Research by Ciesiek-Ślizowska et al. shows a similar tendency [26]. This research also seems to confirm this conclusion, as the surveyed workers express considerable distrust resulting from the rapid introduction of COVID-19 vaccines to the market. Most unvaccinated medics are hesitant to get vaccinated due to the short duration of the study, as shown by Ledda et al.’s research [27].
Many researchers raise the issue of the harmfulness of vaccinations against COVID-19. In our research, 71% of respondents agree that the introduced vaccines are not dangerous, and some of them believe that side effects are inevitable, just as in the case of any other vaccine. Augustynowicz and Jackowska agree with the respondents’ opinion, adding that as the number of vaccinated people increases, the possibility of virus transmission decreases [28]. Opposing attitudes, which are consistent with the opinions of the remaining group of respondents, present numerous arguments related to the harmfulness of the introduced vaccine. These arguments were gathered and described in detail in the research by Ciesek-Ślizowska et al. [26]. Research led by Casuccio and Giuseppe La Torre in China showed that subsequent side effects observed in co-workers and subjects themselves have a significant impact on the negative attitude towards vaccinations. This may considerably contribute to the reluctance to receive booster doses. The most commonly reported side effects were mild or moderate and included headaches and fever [29]. General practitioners participating in the European multi-country study raised worries about insufficient information on vaccine safety and the possibility of overexposure [15].
Working during the COVID-19 pandemic was a difficult situation for healthcare workers, causing negative emotions such as stress or anxiety. Our research shows that 68% of respondents experienced anxiety during the COVID-19 pandemic. Similar results (79%) were obtained by Juszczak [30], which confirms that the pandemic negatively influenced the private lives of medical personnel, causing anxiety of varying intensity. Stress and anxiety are negative emotions that are an inherent part of the COVID-19 pandemic and can vary in intensity. Our research shows that anxiety was experienced in a mild, moderate, or severe form. However, in the research led by Proszek, the respondents reported severe stress and anxiety [31]. Almost half of the respondents experienced anxiety related to the pandemic several times a month, similar to the research by Grzelak and Szwarc, where 60% of the respondents sometimes experienced anxiety [32]. Our research shows that the level of anxiety experienced during the pandemic depends mostly on gender, and, to a lesser extent, on age. Similar results were obtained by Dymecka, who also showed that gender and age influence the level of anxiety [33]. However, in Wilczyńska’s research, no significant relationship was reported between the level of experienced anxiety during the pandemic and age [34]. Our research shows that the main cause of anxiety experienced during the COVID-19 pandemic is fear for the health of family members (72%) and fear for one’s health (60%). Also, Juszczak points out similar causes of anxiety—negative emotions such as fear for one’s health, fear for family members’ health, as well as fear for patients’ health and life [30]. Proszek mentions fear of infection as the main cause of anxiety [31]. Similarly, according to Bluszcz and Matachowska, the main stress factors during the pandemic are fear of getting sick and infecting family members [35]. As shown in our research, ways of coping with anxiety differ slightly from the level of feeling it. In the research conducted by Grzelak and Szwarc, the way of coping with anxiety was not influenced by any of the following factors: age, education, professional experience, or workplace [32]. Medical personnel working during the COVID-19 pandemic are a group that is at high risk of developing mental disorders [36]. A small number of respondents, only 11%, expressed willingness to receive psychological help. Similar results were obtained by Wasik and Koweszko. Their research shows that only 9% of respondents received psychological help during the pandemic [37]. For many years, there has been evidence of a positive impact of physical activity on mental health. Research conducted by a group of scientists from Gothenburg, published in November 2021, shows that physical activity significantly reduces the level of anxiety [38]. Also, according to our research, over half of the respondents (88%) claim that physical activity reduces their anxiety. Among many ways of coping with worry and anxiety, respondents most often chose spending time with family (73%), listening to music (55%), and sport (50%). However, Juszczak showed in her work that the most frequently chosen ways of coping with anxiety and stress are active methods [30].
Our results show that anxiety experienced during the COVID-19 pandemic was positively correlated with attitudes towards vaccinations and was consistent with previous research. Szmyd et al. showed that fear of getting infected with COVID-19 and fear of infecting family members were correlated with the willingness to get vaccinated [39]. Giuliani et al. found that willingness to get vaccinated is highest among people who believe that they may become infected with COVID-19 and become seriously ill [40]. In this context, the results indicating that fear of side effects is a negative correlate of willingness to be vaccinated also seem interesting [39,41]. Similarly, Jach et al. showed that attitudes towards COVID-19 vaccinations were positively related to fear of COVID-19, social distancing, perceived level of susceptibility to illnesses, avoiding germs, attitudes towards science, and knowledge about vaccines. Attitudes towards COVID-19 vaccines were also negatively related to the general tendency toward conspiracy beliefs, including beliefs about COVID-19 being a hoax [42]. The fear of COVID-19 can play a crucial role in shaping public messages about the COVID-19 vaccine. Too low a level of fear of COVID-19 may lead to a lower level of preventive behaviours and readiness to get vaccinated. From a different perspective, trust in science, scientists, and political leaders is crucial for effective large-scale preventive actions, including vaccination programs. [42,43].
It is also important to mention that there is evidence that advice from healthcare workers impacts patients’ decisions about vaccination. The role of healthcare workers has been identified as an appropriate category of determinants of vaccine hesitancy, as healthcare workers can provide their patients with personalized information and recommendations and have a positive impact on vaccine uptake [44,45]. In a study conducted by Charmasson et al., 65.2% of patients talked to a healthcare worker about COVID-19 vaccines, and 55% of patients were recommended to be vaccinated by their healthcare professional. The majority of the conversations were with a general practitioner (48.9%), and according to 52.5% of participants, the discussion had a positive impact [44]. These findings complement the results of a large study conducted by Nguyen et al. that shows that recommending COVID-19 vaccines by healthcare professionals influenced patients’ perception of the effectiveness and safety of COVID-19 vaccines. Nguyen et al. also found that recommendations of healthcare professionals had an objective effect on vaccination absorption. These results indicate that conversations with healthcare professionals may influence patients [46]. Lasagna et al. showed that during the first oncological visit, only 30% of doctors usually propose a vaccination at the first visit, 41% usually do not discuss vaccinations during the first visit, and 29% recommend vaccinations only to specific categories of patients. According to 56% of respondents, patients are more aware of the benefits of vaccines, while 36% stated that patients were concerned about receiving too many vaccines [45]. In our research, 60% of healthcare professionals did not share their views with patients, nor did they encourage or discourage them from getting vaccinated. A total of 55% of respondents who were vaccinated against COVID-19 encouraged their patients to get vaccinated. A total of 40% of vaccinated respondents encourage their families and friends to get vaccinated. They declared that 55% of their immediate family had been vaccinated.
To summarize, the pandemic had a significant impact not only on physical but also on mental health, resulting in a variety of physical and mental burdens. The COVID-19 pandemic, which has the characteristics of a catastrophic disaster, created a difficult situation that caused fear among medical personnel. However, the conducted research shows that despite differing opinions about vaccinations themselves, there is a large percentage of vaccinated healthcare workers, which has significantly reduced the sense of fear and anxiety. Moreover, a positive attitude of doctors and nurses towards vaccinations increases engagement in the vaccination process and has a measurable impact on the promotion of vaccinations not only among their patients but also in society.
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