Impact of brief psychological intervention on reducing the psychological symptoms after COVID-19 infection among healthcare workers (HCWs) in Nepal

Devkota N. et al. Impact of brief psychological intervention on reducing


METHODS
The group-based pre-test and post-test interventional design were carried out with 380 HCWs who had been diagnosed and recovered from the COVID-19 infection.The inclusion criteria for the HCWs were adults previously diagnosed as COVID-19 positive according to their presenting symptoms and their nasopharyngeal swab.Participants were involved in the study at least a month after the diagnosis of COVID-19 infection.The study period was from November 2020 to January 2021.The study site was a tertiary level Hospital in Kathmandu.A purposive sampling technique was used.Formal ethical approval was obtained from the Institutional Review Committee (IRC) from the Nepalese Army Institute of Health Sciences (NAIHS) and the data collection site.The phone number of the possible participants who met the inclusion criteria was obtained from the data collection site.Verbal informed consent was provided by all participants before their enrollment via individual phone calls.The objectives of the study were explained.Participants were allowed to terminate the survey at any time if they desired.The anonymity of the participants was maintained through self-administered questionnaires without mentioning their names.Confidentiality was maintained as their responses were used for study purposes only.The brief (total of 3.20 hours) psychosocial support protocol (Identification and management of stress among HCWs) was implemented via an online Zoom platform.Groups were formed by asking for their convenient time either off-duty hours or on the day of duty off.The group session was planned accordingly.However, an in-person session was provided to a few interested participants by maintaining physical distance, who were of the view that an in-person intervention session was more effective than the online one.

Tools:
The self-administered questionnaire was developed and distributed to participants with other two tools.These tools were Nepalese validated versions of the structured self-report tools i.e.Questionnaire to assess depression, anxiety and stress, which was Depression, Anxiety and Stress Scale -21 (DASS-21).The DASS-21 is a set of 3 self-report scales designed to measure the emotional states of depression, anxiety and stress.Scores for depression, designed and provided.However, none of the published studies was found in the Nepalese context to see the effectiveness of such a program.Therefore, to fill the gap these small attempts were made to see the effectiveness of the designed brief psychosocial intervention protocol in reducing psychological symptoms.anxiety and stress scale were calculated by summing the scores for the relevant items.The DASS-21 has been validated and used in the Nepalese population to identify the symptoms of Depression, Anxiety, and Stress [13-15] .Cronbach's alpha coefficient for DASS-21 is ranging from 0.78-0.91 [16, 17].
A short, easily administered self-report questionnaire, a Nepalese-validated version of the Impact of Event Scale-Revised (IES-R) [18] has 22 questions.The tool, not diagnostic for PTSD [18,19] is an appropriate instrument to measure the subjective response to a specific traumatic event in the senior population, especially in the response sets of intrusion (intrusive thoughts, nightmares, intrusive feelings and imagery, dissociative-like re-experiencing), avoidance (numbing of responsiveness, avoidance of feelings, situations, and ideas), and hyperarousal (anger, irritability, hypervigilance, difficulty concentrating, heightened startle), as well as total subjective stress IES-R score.The IES-R revised the original IES-R, recognized as one of the earliest self-report tools developed to assess post-traumatic stress, to add a third cluster of symptoms, hyperarousal, to intrusion and avoidance subscales.IES-R is the acronym for the test assessment purpose: I -Impact, E -of Event, S -Scale R -Revised.The IES-R is a measure of the symptomatic status of PTSD after specific traumatic events [20].According to Kvestad et al. [18] , the IES-R questionnaire measures the degree of distress related to a traumatic event in the past 7 days on a Likert scale and provides a total score (range 0-88), and three subscale scores; Avoidance (range 0-32), Intrusion (range 0-32), and Hyperarousal (range 0-24).This study used the formally Nepalese-translated version of the IES-R scale.The internal consistency reliability of the Nepalese translated version for the total scale was found at 0.87 and ranged from 0.50 to 0.80 in the subscales.It has been highlighted that a score of 24 or more is an indication of PTSD and should be a clinical concern [18, 21] , above 33 is an indication of a probable PTSD diagnosis [18, 22] and these cut-offs have shown good psychometric properties when validated against a diagnostic interview [18] .Our study used a total score of 24 as it is seen as a matter of clinical concern.The study planned to use Nepalese-translated and validated versions of DASS-21 and IES-R.Permission from authors who have translated and validated these tools in the context of Nepal was obtained.Permission was also obtained from UNICEF to use the intervention protocol (i.e."Identification and management of stress among HCWs during a pandemic") in research.Then, facilitation training was provided to the data collector (a clinical psychologist, who has been work-

Table 1: Intervention Protocol (Facilitator's Guide)
ing in the same hospital for many years) by the protocol developer before starting the data collection.Training Methods as recommended by the protocol developer: The total duration to complete the session is 3.20 hours.The trainer can be a Psychiatrist or a Clinical psychologist who has already completed the facilitation training from the expert of this protocol developer.The total number of participants in the training can be around 20 participants or less in each group.Equal gender distribution and health staff of similar levels should be considered in each group.These recommendations were followed while collecting the data.

Data collection and intervention procedures
Pre-test and post-test designs were used to deliver DASS-21 and IES-R before and after the introduction of the intervention program for the participants in the group.The pre-test is the measurement of baseline levels of symptoms of depression, anxiety, stress and PTSD which was done before the intervention.The post-test involves the measurement of the dependent variable after the intervention has been carried out on the participant group.The purpose of the post-test is to determine any variations in the level of symptoms felt by the participant group after the intervention has occurred.Therefore, a post-test was done after 2 weeks (i.e. on the 14th day) of the intervention.[(I) Pre-test, (II) intervention and (III) post-test are the 3 major steps that were applied in this study].
I. Pre-test: DASS-21 and IES-R were used to identify the level of depression, anxiety and stress of the selected HCWs on the same day, before starting the intervention.

II. Intervention:
Three hours and 20 minutes of intervention were provided to all the selected HCWs by using the PowerPoint slides (PPTs) derived from the same intervention protocol (i.e."Identification and management of stress among HCWs during a pandemic").These PPTs were made by the protocol developers to use the same content and format by each trainer after the completion of the facilitation training to maintain implementation fidelity.At the end of the training, the research participants were notified about the post-test date i.e. after two weeks (on the 14th day) from the training day and the procedure of the post-test i.e. via an online platform.

III. Post-test:
The same DASS-21 tool was used to reassess the level of depression, anxiety and stress.Likewise, the same IES-R was used to reassess the improvement of post-traumatic stress symptoms after two weeks (on the 14th day) of the intervention among selected HCWs, who were involved in the pre-test and who participated in the intervention session.The link (google form) was forwarded to their Email/ Viber / Facebook messenger (based on their availability) and requested to complete the form as soon as possible.However, 12% of HCWs were not responding well to the post-test questionnaires.Two participants just filled in a few sociodemographic-related information and submitted it.

Data Analysis Procedures:
The collected data was reviewed, organized, coded, entered and analyzed by using Statistical Package for Social Sciences-26.Some post-test data had a lot of missing information which was excluded while doing the main analysis.The pre-test was completed by the participants and the post-test was not submitted by around 12% of participants which was also excluded while doing the main analysis.As highlighted by the previous study [23] , the most common approach to the missing data is to simply omit those cases with the missing data and analyze the remaining data.This approach is known as the complete case (or available case) analysis or list-wise deletion.According to the author, list-wise deletion is the most frequently used method in handling missing data and thus has become the default option for analysis in most statistical software packages.This study further explained that some researchers insist that it may introduce bias in the estimation of the parameters [23] .Data were analyzed by using descriptive statistical methods to describe participants' demographic variables (mean, standard deviation, frequency, and frequency percentage indexes).On the inferential statistics, a paired sample t-test was used.Then the findings were presented in the tables.Table 2 demonstrated that about 11% (N=37) of participants had the symptoms of depression, about 31% (N=107) had symptoms of anxiety and about 3% (N=9) had stress before the innervation whereas all three symptoms were found to be reduced within a period of 2 weeks.Depression reduced from about 11% (N=37) to about 7% (N=24), Anxiety reduced from about 31% (N=107) to about 26% (N=89) and stress reduced from about 3% (N=9) to about 2% (N=7) after the intervention.

DISCUSSION
A number of studies done in different parts of the world including Nepal have found increased mental health problems among HCWs during the pandemic crises.Studies also demonstrated that mental health problems among HCWs negatively impact the quality of the health care delivered by them [22,24].However, this study would be one of the few and earliest studies, if any, to see the impact of brief psychological intervention to reduce the mental health problems (i.e.anxiety, depression, stress and post-traumatic stress symptoms) of the COVID-19 pandemic among HCWs who were previously diagnosed as COVID-19 positive in the context of Nepal.A Systematic review [25] reported that as of 8 May 2020, a total of 152 888 HCWs have been infected with COVID-19 and 1413 deaths of HCWs were reported due to infection.Infections were mainly in women (71.60%,N=14 058) and nurses (38.60%,N=10 706), but deaths were mainly in men (70.8%,N=550) and doctors (51.40%,N=525).Later on, the next review study done by Chutiyami et al. [26] reported that the overall infection rate among healthcare workers ranged from 3.90% to 11%.Another study highlighted that worldwide trends of COVID-19 resulted in over 333 thousand deaths till that time (i.e.till May 2020) where higher incidences of COVID-19 infection and mortality in HCWs are well documented Rothan & Byrareddy; Sheraton et al. [27,28].In this crisis situation, individual caretaker workloads were increased either due to high-risk exposure developing symptoms or testing positive and the resulting quarantine as highlighted in the previous research [28,29].These factors may also result in significant stress for HCWs in Nepal as highlighted by Sheraton et al. [28].Other significant factors, according to the studies done by Neto et al. & Lai et al. [29,30] were depletion of personal protective equipment, extensive media coverage, lack of specific medications and inadequate support feelings that can contribute to the mental burden of these health professionals.Similar problems might be experienced by these HCWs in Nepal.As coronavirus cases increased and deaths surged in Italy, the media during this period was constantly highlighting the morbidity and mortality rates of COVID-19, focusing particularly on index cases and affected HCWs over there.Many HCWs were traumatized either directly by eyewitnesses of the infection of colleagues or patients admitted to the hospital or vicariously as a consequence of extensive media coverage.Despite media coverage, as HCWs, they also knew the fact that COVID-19 is transmissible from human to human as highlighted by Li et al.& Rothe et al. [30,31] and they were aware that the pandemic is associated with high morbidity and potential fatality that might intensify the perception of personal danger as highlighted by Wang, Tang and Wie [32].At the beginning of the pandemic in Nepal, there were no mortality or severe forms of COVID-19 cases [17].However, few studies were conducted in Nepal to screen the mental health consequences of the HCWs.A study done in Nepal between April 26 and May 12, 2020 [14] revealed a considerable propor-Table 3 clearly showed that nearly all i.e. about 99% (N=343) of participants who had experienced COVID-19 infection had symptoms of PTSD before intervention.It was found that there was a reduction of the symptoms from PTSD to either clinical concerns or Normal after the intervention.In total, these symptoms were reduced from about 99% (N=343) to about 95% (N=329) after the intervention.
To compare the mean of the IES-R and DASS-21 before and after the intervention, a paired-sample t-test was used.The results of the paired sample t-test showed a significant difference between the means for the IES-R before the intervention (M=47.94,SD=14.53); and after the intervention (M=43.63,SD=15.35);(t = 5.003 and p=.000).The study also found a significant difference between the DASS-21 mean before the intervention (M=14.11,SD=11.74) and after intervention (M=12.28,SD=10.81);(t = 2.97 and p = .003).In Nepal, the first case of COVID-19 was reported on January 23, 2020, by a 32-year-old Nepalese man who returned from Wuhan, China [33].Two months after the first case, the second case was diagnosed through domestic testing on March 23 in a returnee from France [33,34].The first mortality due to COVID-19 in Nepal was reported only in May 2020.As of January 22, 2021, 268,948 COVID-19-positive cases were reported, with 263,546 recovered, and 1,986 death cases [33,35].During this period many HCWs in Nepal experienced COVID-19 infections.Therefore, by considering these factors our study targeted HCWs who tested positive.However, the reported symptoms of anxiety, depression and stress in our study were lower than in the previous studies, as our study found that about 11%, 31% and about 3% of participants had symptoms of depression, anxiety, and stress respectively.Higher prevalence in previous studies can be due to the time of the data collection when uncertainty and mismanagement of the healthcare system were heightened at the beginning of the COVID-19 era and those studies were conducted in that period of uncertainty when everybody was facing symptoms of acute stress.Next, it might be due to the selection of the assessment scale.The DASS-21 scale has certain limitations that can lead to subscale overlap and interaction.There might be the possibility of bias due to cultural factors in the questionnaire.A study [11] done after two previous studies [14,17] with paramedic trainees, who were doing round-o'clock duty with HCWs in a hospital found almost similar findings to our study regarding the symptoms of depression i.e. 12%.
Alarmingly, in this study, 98.50% had symptoms of PTSD.It seems that nearly every HCW who participated in the study and experienced COVID-19 infection had symptoms of PTSD.It is due to the time of the study where on January 22, 2021, 1,986 death cases were reported [33,35].Therefore, HCWs might have had traumatic experiences [36,37].Bo et al. [36,37]  A longitudinal study would be needed to establish the exact prevalence but it is very evident from the existing literature that mental health problems were raised among the HCWs during the pandemic era and hence, intervention protocols should be there to address these issues.A systematic review suggested that the presence of good mental health support in a safe working environment afforded a greater sense of control and agency to HCWs and helped improve their resilience during the pandemic [39].Many previous studies have already found that emotional support, the teaching of self-care strategies, and psychological interventions are essential to reduce any kind of mental health problems that arise during the period of pandemic or crisis.Therefore, we also designed the intervention protocol and successfully implemented it to support the HCWs in Nepal.Despite having many limitations of the pre-post design with no control group as discussed in the limitation section, by considering the crisis situation a quick and feasible research design was implemented to see the impact of brief intervention.Our study revealed that the anxiety, depression, stress and PTSD symptoms score identified by DASS-21 and IES-R tools respectively, before and after a brief psychological intervention were found statistically significant where, the paired sample t-test showed a significant difference between the means for the IES-R scale's findings before the intervention (M=47.94,SD=14.53); and after the intervention (M=43.63,SD=15.35);(t = 5.003 and p=.000).Similarly, the paired sample t-test showed a significant difference between the means for DASS-21 scale's findings before the intervention (M=14.11,SD=11.74) and after intervention (M=12.28,SD=10.81);(t = 2.97 and p = .003).This means that it was found that there was a reduction in symptoms after the interventions.

CONCLUSION
The brief online psychosocial intervention protocol developed by a team of psychiatrists and clinical psychologists to help identify the stress and manage stress during the COVID-19 pandemic, and intervention led by a trained clinical psychologist is found to be effective in reducing the psychological symptoms specifically, depression, anxiety, stress and PTSD symptoms of HCWs who were previously diagnosed as COVID-19 positive and recovered from it.Therefore, on the basis of the findings, it can be concluded that the accurate provision of a group-based brief psychosocial intervention protocol developed for HCWs is considered an effective program to reduce anxiety, depression, stress and PTSD symptoms of HCWs in the context of Nepal.
Our study evokes the need for further research with longitudinal study designs to see the progress of these symptoms in HCWs who were previously diagnosed as COVID-19 positive to establish the impact of this intervention protocol.

LIMITATIONS
There are a few limitations to this study: a) Participants were selected from only one hospital in Nepal.Therefore, the findings from this study cannot be generalized to all HCWs in Nepal.b) Given the ongoing quarantine during the time of the study, an online survey would have introduced the element of selection bias.c) The main outcome of this study was measured by a self-rating scale with the liability of response bias and less reliable than more objective measurements.d) Use of the Original version of the cut-off score to calcu late DASS-21 findings is also a limitation of the study: Nepali version of the DASS-21, 5 items from the depression subscale and 4 items from the stress subscale loaded to Factor 1 (Depression).Two items from the depression subscale, three from anxiety and two from stress loaded to Factor 2 (Stress).The third factor (Anxiety) consisted of only four items, all from the anxiety subscale [40].The authors concluded that the Nepali version of the DASS-21 is a reliable and valid instrument with which to assess negative emotional states but may not adequately distinguish between depression, anxiety and stress in this setting.Confirmatory factor analysis could not support the original three-factor solution of the DASS-21 and the cut-off score was not determined according to the factor analysis results from the Nepalese sample.

CONFLICT OF INTEREST
There are no conflicts of interest.[41] have documented the problem of pre-post design with no control group is "response shift bias".In the literature, it is also mentioned that designs not including a control condition do not warrant any statement about the cause of the findings, whether due to response shift or subject bias.Thus, the outcomes observed in such studies cannot be reliably attributed to the specific intervention.g) This research design is less reliable than randomized controlled trials (RCTs) since the results obtained in this research cannot be consistently linked to the particular intervention.h) The duration to see the effect is too short to have any clinically meaningful impact on the mental health of the study population.
Self &Participants) State the Objectives of the Session Section 1: Allow to Ventilate, Acknowledge, Universalize, Validate and Empathize on the problems expressed by the HCWs Activity-1.1:Ventilate Activity-1.2:Acknowledge, Universalize, Validate and Empathize SECTION II: TO IDENTIFY AND MANAGE ONE'S STRESS DURING A CRISIS Activity-2.1: pair and share part A Ask participants individually to share their s ymptoms of stress Discussion Activity-2.2:Strive for balance Structure of the session Time (Mins)

Table 3 . Pre-Post status of PTSD symptoms according to the IES-R ScaleTable 4 . IES-R and DASS-21 score before and after the Intervention
Original Research Article J Psychiatrists' Association of Nepal Vol. 12 No. 2 2023 18 Devkota N. et al.Impact of brief psychological intervention on reducing d) It was a cross-sectional study, so interpretation for causality cannot be established.e) This study used a pre-post design.A weakness of a one-group pre-post design is that other factors besides the intervention may impact the outcome.f) Several existing studies (Howard & Dailey, 1979; Howard, Ralph, Gulanick, Maxwell, Nance, & Gerber, 1979; Pohl, 1982; Sprangers & Hoogstraten, 1988; Rockwell & Kohn, 1989; Rohs & Langone, 1997)