Risk Factors of Posttraumatic Stress Symptoms among Healthcare Workers during Covid-19 Pandemic in Regional General Hospital of Baubau City,
Southeast Sulawesi
1Wa Ode NadziyranUrufia, 2Wahiduddin, 3Syamsiar S. Russeng, 2M. Nadjib Bustan,
2Ridwan Amiruddin, 4Agus BintaraBirawida
1Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
2Department of Epidemiology, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
3Department of Occupational Safety and Health, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
4Department of Environmental Health, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
ABSTRACT
The COVID-19 pandemic can cause posttraumatic stress symptoms for health workers. This study aims to determine the risk factors for posttraumatic stress in health workers at the Baubau City Hospital, Southeast Sulawesi during the COVID-19 pandemic. The research design used a cross sectional study. A total of 227 health workers with symptoms of posttraumatic stress participated in the study. Data was collected using an anonymous online self-report questionnaire. The research took place between 26 September 2020-19 January 2021 at the Baubau City Hospital. The study used The COVID-19-PTSD Questionnaire, a modified Indonesian version, to assess symptoms of posttraumatic stress in health workers. The results showed 24.23% of health workers with severe symptoms of posttraumatic stress and 75.77% of health workers with mild symptoms of posttraumatic stress. The results of the multivariate analysis showed that the risk factors associated with severe symptoms of posttraumatic stress were not working or being isolated (p-value = 0.040, OR = 16.464 (95% CI = 1,141-237,667)), feeling avoided by family members and friends (p- value = 0.023, OR = 3.287 (95% CI = 1.180- 9.152)) and a high level of fear of COVID-19 (p-value = 0.001, OR = 14.605 (95% CI = 2.899- 73.581)). Health workers with a high level of fear of COVID-19, not currently working or being isolated, and feel avoided by family members and friends because work is prone to experiencing severe symptoms of posttraumatic stress. Psychological intervention and support from family members and friends may be helpful.
Keywords: symptoms, stress, trauma, health workers, COVID-19, avoidance, isolation, fear
INTRODUCTION
COVID-19 is a respiratory disease caused by SARS-Cov-2 (The Severe Acute Respiratory Syndrome Coronavirus 2). The COVID-19 outbreak was first reported in Wuhan City, Hubei Province, China at the end of 2019 until an increase in COVID-19 cases was so fast and wide that the World Health Organization designated COVID-19 as a global health emergency or Public Health Emergency of International Concern (PHEIC) on January 30, 202041.
The COVID-19 pandemic was then determined by the World Health Organization on March 11, 2020 after the reported increase in COVID-19 cases that occurred in several countries other than China, which spread throughout the world41. On August 16, 2020, 215 countries in the world reported 21,294,854 cases of COVID-19 and 761,779 deaths, in ASEAN 3,040,168 cases and 59,875 deaths42. COVID-19 cases in Indonesia reached 139,549 cases and 6,150 deaths24. The Southeast Sulawesi COVID-19 Task Force reported 1,202 cases of COVID-19 in Southeast Sulawesi and 18 deaths. The city of Baubau is the second highest area of COVID-19 cases in Southeast Sulawesi with 221 cases30.
The existence of cases of COVID-19 that continues to increase can cause the workload of health workers to increase more than normal, they are at high risk of contracting while caring for patients 40and there is a risk of health workers dying from being infected with COVID-1934can trigger symptoms of post-traumatic stress.During the 2003 SARS outbreak, the H7N9 epidemic, the COVID-19 outbreak in Wuhan and during this pandemic, some studies show that age28,37,43,45
, gender4,5,12,16,18,23,33,35,37,37 44.45
,marital status4,28,45, education level20.45, employment4,36,37, work experience4,37,45, family members who are suspect or confirmed to suffer from COVID-1914.45, friends or coworker who suspect or confirmed suffering from COVID- 1914.43, work placement32,43,45, place of stay4.45,feelings ofavoidance of family members and friends2.2245,comorbid45,and fear ofCOVID-193.11 can contribute to post-traumatic stress symptoms in health workers.
The lack of health personnel in reaching psychological services, the lack of mental health interventions and evaluations for health workers, and the impact of post-traumatic stress symptoms that are not immediately addressed can affect the performance of health workers in providing services. To overcome this, this research is expected to help prevent and overcome the symptoms of post-traumatic stress in health workers by analyzing risk factors related to symptoms of post-traumatic stress during the COVID-19 pandemic among health workers who work at the General Hospital of Baubau City as referral hospital for COVID-19 patients in Baubau City, Southeast Sulawesi.
METHODS
This research was conducted at Baubau City General Hospital, Southeast Sulawesi during the COVID-19 pandemic. The study was conducted over 10 months between March 21, 2020 and January 19, 2021.Research design: this study uses cross-sectional study design.During the COVID-19 pandemic 377 health workers were asked to participate in this study. They work as doctors, nurses, midwives and medical technicians at Baubau City General Hospital and their education criteria are at least 3 diplomas. Sample population size is determined using N = Zα2P (1 − P) / d2 (N-1)+(Zα2P(1 − P)), where α = 0.05, Zα = 1.96, d = 0.05, and p = 0.5. The total number of participants who completed the questionnaire and showed posttraumatic stress symptom as many as 277 participants. The amount has exceeded the minimum sample size selected non randomly.
Acharacteristic questionnaire of anonymous respondents. The Indonesian version of The Modified COVID-19-PTSD Questionnaire was used in research to assess posttraumatic stress symptoms in health workers. The COVID-19-PTSD Questionnaire has a 19-item and 5-point scale (0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit; 4 = extremely) with sensitivity of 0.91 and specificity of 0.92, a cut-off score of 26 indicates posttraumatic stress disorder9. The Indonesian version of The Modified COVID-19-PTSD Questionnaire has Cronbach's alpha 0.897. In the Indonesian version of The Modified COVID-19-PTSD Questionnaire, a total score of ≥ 26 indicates severe symptoms and a score of 1-25 indicates mild symptoms. The Indonesian version of The Fear of COVID-19 Scale (The FCV-19s) is used to assess the fear of COVID-19 in HCWs health workers with Cronbach's alpha 0.811. The Fear of COVID-19 Scale hasinternal consistency (α = 0.82) and test–retest reliability (ICC = 0.72),7- item and five Likert scales (1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4
= agree; 5 = strongly agree) and ranges from 7 to 351. In the Indonesian version, a total score of
> 21.8 indicates a high level of fear of COVID-19, a score of 11.9-21.8 indicates a moderate level of fear of COVID-19, and a score of < 11.9 indicates a low level of fear of COVID-19.
All questionnaires used in the survey were administered via mobile devices to 377 health workers who worked and did not work or were being isolated during the COVID-19 pandemic period at Baubau City General Hospital between September 26th,2020 - December 16th,2020. A total of 236 out of 377 health workers completed the questionnaire. Among 236 health workers, 227 health workers showed symptoms of posttraumatic stress and 9 health workers showed no symptoms of posttraumatic stress. A total of 227 health workers with posttraumatic stress symptom became the focus in this study (Figure 1).This univariate analysis illustrates the distribution and percentage of each variable. Bivariate analysis uses chi-square analysis and multivariate analysis using logistic regression. Stata 16 software package is used with 95%
confidence interval (α = 0.05). This study used a 10% OR change to build the model. A potential confounder is added to the model.
Figure 1. Summary of survey progress 55 HCWs showed
severe PTSS
172 HCWs showed mild PTSS 227 HCWs
showed PTSS
9 HCWs non PTSS
377Hcws
236 HCWs completed questionnaires
3 HCWs partially filled out the questionneires
138 HCWs didn’t completequestionna
ires
RESULTS
Characteristics of Respondents
A total of 377 health workers with a minimum of 3 diploma educations were asked to participate in the study, consisting of 36 doctors (9.5%), 230 nurses (61%), 51 midwives (13.5%), 60 medical technicians (16%). From 236 health workers (62.59%) completed the survey, 9 health workers (3.8%) without symptoms of post-traumatic stress was not included in the research criteria so that only 277 health workers (96.2%) with the symptoms of post-traumatic stress studied (Fig. 1). A total of 277 respondents with post-traumatic stress symptoms completed the survey, 23 (10.13%) is a doctor, 138 (60.79%) are nurses, 40 (17.62%) are midwives, and 26 (11.45%) is a medical technician. The majority of respondents were women (77.53%), aged 30- 49 years (49.34%), married (56.39%), had a D3-S1 education level (93.39%), worked as a nurse (60.79%), had less than 2 years of work experience (28.19%), do not have family members who are suspect or confirmed to suffer from COVID-19 (90.75%), have friends and workmates who suspect or confirmed suffering from COVID-19 (51.10%), stay at home with family members (72.25%), do not treat suspect patients or confirmed suffering from COVID-19 (49.78%) , were unavoidable by family members and friends (64.76%), had no comorbid (97.36%), and had moderate COVID-19 fear levels (66.96%) (Table 1).
Dimensions of post-traumatic stress symptoms and related variables
The dimensions of post-traumatic stress symptoms that stood out in health workers were anxious arousal (95.59%; 1.56 ±1.23), negative affect (89.87%; 1.27 ± 1.16) and avoidance (87.22%;
0.96 ± 1.05). Gender is associated with symptoms of intrusion (p = 0.000) and avoidance (p = 0.013). Meanwhile, fear of COVID-19 is associated with symptoms of intrusion (p = 0.003), avoidance (p = 0.000), anhedonia (p = 0.002), anxious arousal (p = 0.000), and dysphoric arousal (p = 0.000) (Table 2).
Severity of post-traumatic stress symptoms and related variables
Bivariate analysis shows that health workers with current work placement (p = 0.041) and fear of COVID-19 (p = 0.000) are more likely to experience symptoms of severe posttraumatic stress (Table 3). Work, housing, and work experience were the key variables in this study (Figure 2).
Risk factors for post-traumatic stress symptoms
Multivariate analysis shows that it does not work or is being isolated (OR = 16,464; 95% CI = 1,141-237,667; p = 0.040), avoided by family members and friends (OR = 3,287; 95% CI = 1,180-9,152; p = 0.023), and has a high level of fear of COVID-19 (OR = 14,605; 95% CI = 2,899-73,581; p = 0.001) is associated with symptoms of severe posttraumatic stress. A risk factor that greatly affects the symptoms of severe posttraumatic stress is not working or being isolated, with OR = 16,464. 6-10 years of work experience is a protective factor against severe posttraumatic stress symptoms (OR = 0.315; 95% CI = 0.099-0.997; p = 0.049) (Table 4).
Table 1. Characteristics of respondents Characteristics of
respondents No. %
Age group (year)
19-29 111 48,90
30-49 112 49,34
≥ 50 4 1,76
Sex
Male 176 77,53
Female 51 22,47
Marital status
Single 93 40,97
Married 128 56,39
Divorced 6 2,64
Education Level Diploma 3 – Bachelor degree
212 93,39
Master degree and higher level
15 6,61
Occupation
Doctor 23 10,13
Nurse 138 60,79
Midwife 40 17,62
Medical technician 26 11,45
Work experience
< 2 years 64 28,19
2-5 years 62 27,31
6-10 years 47 20,70
> 10 years 54 23,79
Family members suspected or confirmed COVID-19
Yes 21 9,25
No 166 90,75
Friends or relatives suspected or confirmed COVID-19
Yes 116 51,10
No 111 48,90
Residence
Living in the inn/hotel, etc 164 72,25 Living in the home with
family members 63 27,75
Current work placement
Not treating suspected or confirmed COVID-19 patients
113 49,78
Treating suspected or confirmed COVID-19 patients
110 48,46
Off work or in isolation 4 1,76
Feel of family members and friends Avoidance
Don’t avoid 147 64,76
Unsure 46 20,26
Avoid 34 14,98
Comorbid
Yes 6 2,64
No 221 97,36
Fear of COVID-19
Low 46 20,26
Medium 152 66,96
High 29 12,78
Table 3. Percentage dimensions of post-traumatic stress symptoms
Variables
Dimension of posttraumatic stress symptom
INT AV NA AN EB AA DA
No. (%) P No. (%) p No. (%) p No. (%) p No. (%) P No. (%) p No. (%) p
Age group (year)
19-29 94(84.68) 0.358 85(76.58) 0.361 96(86.49) 0.229 86(77.48) 0.841 24(21.62) 0.207 107(96.40) 0.743 73(65.77) 0.188
30-49 101(90.18) 89(79.46) 104(92.86) 83(74.11) 36(32.14) 106(94.64) 61(54.46)
≥ 50 3(75.00) 2(50) 4(100) 3(75) 1(25) 4(100) 3(75)
Sex
Male 37(72.5) 0.000 33(64.71) 0.013 44(86.27) 0.334 38(74.51) 0.811 12(23.53) 0.541 48(94.12) 0.559 33(64.71) 0.470
Female 161(91.48) 143(81.25) 160(90.91) 134(76.14) 49(27.84) 169(96.02) 104(59.09)
Marital status
Single 77(82.80) 70(75.27) 82(88.17) 71(76.34) 23(24.73) 90(96.77) 58(62.37)
Married 116(90.63) 0.218 101(78.91) 0.768 117(91.41) 0.635 97(75.78) 0.866 36(28.13) 0.800 121(94.53) 0.629 75(58.59) 0.809
Divorced 5(83.33) 5(83.33) 5(83.33) 4(66.67) 2(33.33) 6(100) 4(66.67)
Education Level Diploma 3 – Bachelor
degree 186(87.74)
0.386
166(78.30)
0.297
189(89.15)
0.178
162(76.42)
0.394
56(26.42)
0.559
202(95.28)
0.390
127(59.91)
0.605 Master degree and higher
level 12(80) 10(66.67) 15(100) 10(66.67) 5(33.33) 15(100) 10(66.67)
Occupation
Doctor 19(82.61)
0.742
13(56.52)
0.067
22(95.65)
0.193
15(65.22)
0.326
5(21.74)
0.793
22(95.65)
0.825
14(60.87)
0.514
Nurse 121(87.68) 112(81.16) 127(92.03) 107(77.54) 39(28.26) 133(96.38) 82(59.42)
Midwife 34(85) 30(75) 33(82.50) 28(70) 9(22.50) 38(95) 22(55)
Medical technician 24(92.31) 21(80.77) 22(84.62) 22(84.62) 8(30.77) 24(92.31) 19(73.08)
Work experience
< 2 years 54(84.38)
0.711
51(79.69)
0.762
56(87.50)
0.258
53(82.81)
0.119
18(28.13)
0.962
63(98.44)
0.362
38(59.38)
0.218
2-5 years 55(88.71) 49(79.03) 56(90.32) 50(80.65) 17(27.42) 59(95.16) 44(70.97)
6-10 years 40(85.11) 37(78.72) 40(85.11) 31(65.96) 13(27.66) 43(91.49) 26(55.32)
> 10 years 49(90.74) 39(72.22) 52(96.30) 38(70.37) 13(24.07) 52(96.30) 29(53.70)
Family members suspected or confirmed COVID-19
Yes 19(90.48)
0.639 17(80.95)
0.694 20(95.24)
0.392 17(80.95)
0.561 5(23.81)
0.740 20(95.24)
0.933 14(66.67)
0.535
No 179(86.89) 159(77.18) 184(89.32) 155(75.24) 56(27.18) 197(95.63) 123(59.71)
Friends or relatives suspected or confirmed COVID-19
Yes 105(90.52)
0.129 96(82.76)
0.054 108(93.10)
0.099 86(74.14)
0.557 30(25.86)
0.726 109(93.97)
0.221 68(58.62)
0.586
No 93(83.78) 80(72.07) 96(86.49) 86(77.48) 31(27.93) 108(97.30) 69(62.16)
Residence
Living in the inn/hotel, etc 53(84.13)
0.386
51(80.95)
0.444
53(84.13)
0.076
50(79.37)
0.433
16(25.40)
0.756
59(93.65)
0.376
40(63.49)
0.549 Living in the home with
family members 145(88.41) 125(76.22) 151(92.07) 122(74.39) 45(27.44) 158(96.34) 97(59.15)
Current work placement Not treating suspected or confirmed COVID-19 patients
102(90.27)
0.247
90(79.65) 105(92.92)
0.213
86(76.11)
0.503
28(24.78)
0.765
108(95.58)
0.910
71(62.83)
0.161 Treating suspected or
confirmed COVID-19 patients
92(83.64) 82(74.55) 95(86.36) 82(74.55) 32(29.09) 105(95.45) 62(56.36)
Off work or in isolation 4(100) 4(100) 4(100) 4(100) 1(25) 4(100) 4(100)
Feel of family members and friends Avoidance
Don’t avoid 128(87.07) 114(77.55) 131(89.12) 107(72.79) 44(29.93) 140(95.24) 90(61.22)
Unsure 41(89.13) 0.875 34(73.91) 0.670 42(91.30) 0.878 40(86.96) 0.139 11(23.91) 0.305 45(97.83) 0.682 28(60.87) 0.845
Avoid 29(85.29) 28(82.35) 31(91.18) 25(73.53) 6(17.65) 32(94.12) 19(55.88)
Comorbid
Yes 5(83.33)
0.772 4(66.67)
0.518 6(100)
0.405 4(66.67)
0.598 3(50)
0.195 6(100)
0.594 4(66.67)
0.749
No 193(87.33) 172(77.83) 198(89.59) 168(76.02) 58(26.24) 211(95.48) 133(60.18)
Fear of COVID-19
Low 20(68.97) 16(55.17) 23(79.31) 16(55.17) 5(17.24) 23(79.31) 11(37.93)
Medium 134(88.16) 0.003 116(76.32) 0.000 138(90.79) 0.114 114(75) 0.002 45(29.61) 0.341 148(97.37) 0.000 85(55.92) 0.000
High 44(5.65) 44(95.65) 43(93.48) 42(91.30) 11(23.91) 46(100) 41(89.13)
Total (%) 198(8.22) 176(77.53) 204(89.87) 172(75.77) 61(26.87) 217(95,59) 137(60,35)
Mean ±SD 0.96 ± 1.05 1.06 ± 1.15 1.27 ± 1.16 0.94 ± 1.05 0.26 ± 0.63 1.56 ± 1.23 0.77 ± 0.97
Note:
INT = intrusion, AV = avoidance, NA = negative affect, AN = anhedonia, EB = externalizing behavior, AA = anxious arousal, DA = dysphoric arousal Mean and SD values of score of The Indonesian version of The Modified COVID-19-PTSD Questionnaire
Five points scale (0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit; 4 = extremely)
Table 4. Association of variables with posttraumatic stress symptom among HCWs identified by Bivariate logistic regression analysis
Variables
Severity of posttraumatic stress
p-value
Mild Severe
No. % No. %
Age group (year)
19-29 81 72.97 30 27.03
0.621
30-49 88 78.57 24 21.43
≥ 50 3 75.00 1 25.00
Sex
Male 132 75 44 25 0.615
Female 40 78.43 11 21.57
Marital status
Single 72 77.42 21 22.58
0.799
Married 96 75 32 25
Divorced 4 66.67 2 33.33
Education Level Diploma 3 – Bachelor
degree 161 75.94 51 24.06
0.820 Master degree and higher
level 11 73.33 4 26.67
Occupation
Doctor 18 78.26 5 21.74
0.155
Nurse 108 78.26 30 21.74
Midwife 31 77.50 9 22.50
Medical technician 15 57.69 11 42.31 Work experience
< 2 years 46 71.88 18 28.13
0.205
2-5 years 43 69.35 19 30.65
6-10 years 40 85.11 7 14.89
> 10 years 43 79.63 11 20.37
Family members suspected or confirmed COVID-19
Yes 13 61.90 8 38.10 0.120
No 159 77.18 47 22.82
Friends or relatives suspected or confirmed COVID-19
Yes 87 75 29 25
0.782
No 85 76.58 26 23.42
Residence
Living in the inn/hotel,
etc 52 82.54 11 17.46
0.140 Living in the home with
family members 120 73.17 44 26.83
Current work placement
Not treating suspected or confirmed COVID-19 patients
84 74.34 29 25.66
0.041 Treating suspected or
confirmed COVID-19 patients
87 79.09 23 20.91
Off work or in isolation 1 25 3 75
Feel of family members and friends avoidance
Don’t avoid 117 79.59 30 20.41
0.187
Unsure 32 69.57 14 30.43
Avoid 23 67.65 11 32.35
Comorbid
Yes 4 66.67 2 33.33
0.598
No 168 76.02 53 23.98
Fear of COVID-19
Low 27 93.10 2 6.90
0.000
Medium 122 80.26 30 19.74
High 23 50 23 50
Total 55 24.23 172 75.77
Figure2. Modeling scheme Feel of family members
and friends avoidance
Fear of COVID-19 Current work
placement Residence
Occupation
Work experience
Family members suspected or confirmed COVID-19
Severe symptom of posttraumatic
stress
Description:
direct effect confounding
Table 5. Risk factors for posttraumatic stress symptom Among HCWs identified by Multivariate logistic regression analysis
Variable P OR 95% CI
Occupation
Doctor Ref Ref Ref
Nurse 0.941 1.048 0.301-3.645
Midwife 0.803 0.822 0.176-3.844
Medical technician 0.134 3.053 0.709-13.142 Work experience
< 2 years Ref Ref Ref
2-5 years 0.786 0.875 0.333-2.298
6-10 years 0.049 0.315 0.099-0.997
> 10 years 0.180 0.491 0.174-1.388
Family members suspected or confirmed COVID- 19
No Ref Ref Ref
Yes 0.085 2.854 0.864-9.431
Current work placement
Not treating suspected or confirmed COVID- 19 patients
Ref Ref Ref
Treating suspected or confirmed COVID-19 patients
0.991 1.005 0.385-2.625
Off work or in
isolation 0.040 16.464 1.141-237.667
Residence Living in the
inn/hotel, etc Ref Ref Ref
Living in the home
with family members 0.051 3.027 0.996-9.200 Feel of family
members and friends Avoidance
Don’t avoid Ref Ref Ref
Unsure 0.496 1.374 0.550-3.430
Avoid 0.023 3.287 1.180-9.152
Fear of COVID-19
Low Ref Ref Ref
Medium 0.113 3.505 0.745-16.496
High 0.001 14.605 2.899-73.581
DISCUSSION
Post-traumatic stress disorder is a profound public health burden21. Post-traumatic stress disorder becomes a public health problem that can affect individuals in every sector of society and be of concern to children and adults7. Especially for health workers who are a group that is at risk of experiencing symptoms of post-traumatic stress. In survivors, SARS-CoV-2 as a pathogenic agent can cause a full cascade of stress responses, SARS-CoV-2 and its receptor angiotensin-converting enzyme 2 (ACE2) can have an impact on the endocrine stress system i.e.
hypothalamic-pituitary-adrenal (HPA) axis, excessive or chronic activation of the endocrine stress axis or HPA axis can trigger and contribute to stress conditions in humans such as post- traumatic stress disorder31. Other studies show that during SARSoutbreaks, SARS survivors who are health workers have stress levels similar to those of non-health workers, but health workers significantly show ahighposttraumatic symptom level of17.
A cross-sectional survey conducted on health workers at Baubau City General Hospital showed that 55 (24.23%) and 172 (75.77%) Health workers are reported to experience severe symptoms and mild symptoms of posttraumatic stress. The dominant dimension of posttraumatic stress symptoms experienced by health workers is anxious arousal (95.59%), negative affect (89.87%) and avoidance (87.22%).
This study shows that health workers who are not working or are being isolated are very likely to experience severe symptoms of posttraumatic stress compared to those who work not treating suspek patients or confirmed COVID-19. Other studies report that health workers who are isolated or quarantined due to infection are at high risk of experiencing posttraumatic stress symptoms10,32,43. On the other hand, isolation is done to provide appropriate treatment for patients in order to recover from the disease and limit the reach of patients with healthy people in order to prevent the spread of infectious diseases, but psychological problems such as posttraumatic stress disorder can arise and require special attention during the isolation period of13. In addition, the condition of isolated individuals causes daily activities to be disrupted, the response from the surrounding community, isolated, parting with family members at home becomes a factor that causes the occurrence of emotional mental disorders26. Unlike patients from the general public, health workers who are isolated or quarantined are more at risk of severe symptoms of posttraumatic stress27.
This study also shows that feelings of avoidance of family members and friends are associated with severe symptoms of posttraumatic stress. Other research shows that more than a quarter of people believe that health workers should have restrictions on their freedom as health workers are not allowed to be in the general public, isolated from society and separated from their families, and more than a third of people state that they will avoid health workers for fear of contracting COVID-1939. This is in line with previous research that shows that health workers are considered as a source of disease transmission so often get avoidance and stigmatization in society2.15.
Other results showed that covid-19 fears were significantly associated with posttraumatic
In addition, health workers who have a high level of FEAR of COVID-19 are more at risk of having severe symptoms of posttraumatic stress than those with low levels of COVID-19 fear.
Fear is part of the body's normal "fight or flight" response that helps us avoid potential dangers25.
The "fight or flight" response can cause the brain to stimulate the adrenal glands to produce 38 stress hormones. Other studies have shown that SARS-related fears are associated with posttraumatic stress symptoms in health workers who are recovering from SARS infection, they are reported to experience symptoms of post-traumatic stress intrusion and are more concentric to health problems and discrimination11. They are afraid if he infects others especially to family members rather than fear if he is infected3.11.
The study showed gender had a significant association with symptoms of intrusion and avoidance of posttraumatic stress and the majority experienced by women. Women in dealing with things tend to be detailed and if faced with a problem, they put more emphasis on feelings so that some of the information received can suppress their feelings as a result they are more prone to psychological problems than men6.8. On the other hand, women have ovarian hormone levels that tend to fluctuate during the menstrual cycle so that changes in emotional stimulus occur, the presence of an increase in intrusive flashbacks can underlie specific susceptibility in women in experiencing psychological disorders19.29.
Other results showed that 6-10 work experience became a protective factor against severe symptoms of posttraumatic stress in health workers. Other studies show that the limited skills, knowledge and self-regulation skills of health workers who have less than 3 years of work experience are at risk of post-traumatic stress disorder compared to those with 3-5 years of work experience37years.
Research limitations
The use of online questionnaires makes it difficult for researchers to control respondents when filling out questionnaires so that the answers given by respondents do not necessarily describe the actual state of the respondent. Some respondents were less familiar with using online questionnaires. Lack of interest in health workers to participate in surveys.
CONCLUSION
The fear level of COVID-19 is high, not working or being isolated and feeling avoided by family members and friends because their work as health workers can cause severe symptoms of posttraumatic stress. Not working or being isolated are the most influential risk factors compared to other risk factors. Psychological interventions and the support of family members and friends may be helpful.
ACKNOWLEDGMENTS
Authors would like to thank the director of the General Hospital of Baubau City and all healthcare workers who participated and helped author in this research project.
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