Paramedics are health care professionals who oversee the prehospital procedure from the time of an unexpected occurrence or disease until the patient arrives at the hospital. They must make rapid and precise selections because every minute counts during this procedure. Therefore, to increase the quality of care during disasters, individual and occupational mental health risk factors in paramedics must be addressed. World Health Organization reported that adverse working conditions pose a risk to mental health; globally, an estimated 12 billion working days are lost each year due to depression and anxiety, resulting in productivity losses of 1 trillion USD annually; and urgent measures to protect mental health are needed.1 Traumatic experiences due to disasters at work are one of the most important factors that increase the burden of mental illness. Exposure to COVID-19 is classified as a traumatic event because it transcends the normal human experience.Reference Benfante, Di Tella and Romeo2 The magnitude of the psychological impact due to the traumatic effect of the COVID-19 pandemic varies based on several factors, including biological characteristics (age, sex, chronic disease, etc.) and socioeconomic and cultural characteristics (such as the work environment and social support of individuals, the significance attributed to the event, and the level of psychological resilience).Reference Benfante, Di Tella and Romeo2‒Reference Kang, Ma and Chen5
The prevalence and negative consequences of infectious diseases, which continue to exist with major epidemics, will increase with climate change. Studies have shown that mental problems such as exhaustion, PTSD (post-traumatic stress disorder), depression, anxiety, and sleep disorders increased during the pandemic compared to before the pandemic as a result of the stress experienced by paramedics during the pandemic.Reference Jonsson6‒Reference Almutairi, Al-Rashdi and Almutairi7 Factors such as lack of personal protective equipment (PPE), changes in working hours, changing hospital practices, increased workload, lack of social support, uncertainty in managing a new disease, stigmatization, discrimination, selection of patients from different points, and community noncompliance with health and safety guidelines negatively affect the mental health of health care workers and increase the level of stress triggers in various mental illnesses.Reference Marczewski, Piegza and Gospodarczyk8‒Reference Baykal and Tütüncü9 The current study aims to provide evidence-based recommendations for disaster preparedness strategies by investigating the prevalence of PTSD among paramedics as well as the individual and occupational predictors of PTSD in terms of future pandemic preparation.
Methods
This cross-sectional study was conducted in Istanbul, Turkey’s largest metropolis with a population of around 20 million people. 460 paramedics participated in this study, which used a random sampling procedure with a 95% confidence level. The response rate was 95.6%. Study approval was obtained from the X University Ethics Committee (February 20, 2020, 2020-20845-33).
The “Sociodemographic Information Form” consisting of paramedics’ individual (age, sex, marital status, alcohol consumption, history of psychiatric treatment, general health status, self-care practices, and impact of work on private life, number of children) and working environment factors (crisis management skill, working hours, traffic density, and the adequacy of equipment and supplies) which was developed by researchers in the current study; “Life Events Checklist” for identifying stressful life events;Reference Weathers, Blake and Schnurr10 and “Post-Traumatic Stress Disorder Checklist,” a valid and reliable measurement tool for screening PTSD,Reference Weathers, Litz and Keane11 were used to improve occupational health and safety measures based on the mental health of paramedics during disasters. Because the skewness and kurtosis indices of the PTSD score were between −0.820 and 0.084, parametric analyses were performed. After bivariate analyses, including t tests, analyses of variance, and the Pearson correlation test, multiple regression analysis (enter) was used to determine the independent effect of each independent variable on the PTSD scores and the magnitude of those effects, as well as to control for confounding variables.
Results
The mean age of the 440 participants was 29.9±7.34 years, with 49.5% being female. Of the paramedics, 44% were married and around 35% had at least 1 child. Furthermore, 8.9% had undergone psychiatric treatment, 6.4% had a family history of mental illness, and 2.3% had attempted suicide. We observed that approximately 1 in 2 paramedics were exposed to COVID-19, had an accident while traveling, and were exposed to fire and explosions, physical assault, and life-threatening injuries (Table 1).
Table 1. Distribution of traumatic experiences according to the life events checklist
non-respondents are not included in the table as column
The prevalence of PTSD was 59.8% in the 11th month of the COVID-19 pandemic. The mean PTSD score was 38.6±22.1. Paramedics had substantially lower scores on the change in mood and cognitive subdimensions (P < 0.05), with high scores on the “hyperarousal and hyperreactivity,” “avoidance,” and “intrusive thinking” subdimensions.
In bivariate analysis, there was no significant relationship between the total PTSD score and economic situation, smoking status, intervention in medical emergencies, falls and blunt traumas, occupational accidents, years of employment, or desire to change the place of work (P > 0.05). Sex, age, marital status, number of children, educational background, general health status, history of psychiatric disorders, exposure to violence, working hours, alcohol use, intervention to gunshot wounds and suicide, traffic density, housing structures of multistory buildings without elevators and with narrow stairs, inability to allocate enough time for each patient in case of multiple patients, inadequacy of equipment/materials, the level of knowledge on ambulance services usage, inadequate penalties for crimes committed against health care workers, the risk of exposure to infectious diseases, lack of crisis intervention skills, and the impact of the work on personal life were significantly related to PTSD scores (P < 0.05).
Factors underlying the development of PTSD were determined by applying multiple regression analysis to variables with a significant association. Being female, being young, consuming alcohol, having a history of receiving psychiatric treatment, practicing no self-care measure, and having a poor health status independently increased the PTSD score and explained 25% of the development of PTSD (P < 0.05) (Table 2). The number of children, marital status, and impact of work on personal life were confounding variables (P>0.05).
Table 2. Results of multiple regression analysis on individual characteristics explaining the PTSD score
R = 0.497; R 2 = 0.247; Durbin–Watson = 1.814.
Previous traumatic experiences accounted for approximately 40% of the PTSD score (Table 3). Being subjected to or interfering in a weapon assault or sexual assault, intervening in a violent death, and inflicting harm or death on another person independently contributed to explaining PTSD scores (P < 0.05). Other traumatic experiences did not predict the PTSD score (P > 0.05). Factors related to the working environment accounted for approximately 27% of the PTSD score (Table 4). Lack of crisis management skills, long working hours, traffic density, and lack of equipment/supplies independently predicted the PTSD score (P < 0.05).
Table 3. Results of multiple regression analysis of occupational exposures explaining the PTSD score
R = 0.630; R 2 = 0.397; Durbin–Watson = 1.936.
Table 4. Results of multiple regression analysis of work environment factors explaining the PTSD score
R = 0.520; R 2 square = 0.270; Durbin–Watson = 1.955.
Discussion and Conclusion
These analyses highlight important gaps in the health and safety services and practices of paramedics before, during, and after disasters, which require immediate attention. Of the paramedics, 59.8% were found to be at risk for PTSD, and the prevalence of PTSD among paramedics increased 3-fold in the 11th month of the pandemic compared with that in previous studies. In studies conducted in the early stages of the pandemic, it was reported that prolonged contact with patients with COVID-19, having a relative or coworker who had COVID-19, insufficient knowledge on transmission prevention, a lack of work experience, and inadequate PPE increased the prevalence of PTSD from 26% to 55%.Reference Yin, Sun and Liu12 Consistent with other studies, young age, female sex, alcohol use, history of receiving psychiatric treatment, a poor general health status, long working hours, and a lack of equipment/materials were found to be risk factors for PTSD in our study.Reference Ehrlich, McKenney and Elkbuli13‒Reference Walton, Murray and Christian15
Approximately 40% of the predicted PTSD scores were associated with severe traumatic experiences, such as being subjected to/intervening in assaults with a weapon, being subjected to/intervening in sexual assault, intervening in a violent death, and causing injury/death to another person. It was reported that emergency department workers should be monitored for PTSD caused by cumulative exposure, emphasizing that PTSD should be considered an occupational disease.Reference McFarlane and Bryant16‒Reference Gallagher and McGilloway17 Another important finding of this study is that crisis management skills and self-care are important protective factors against PTSD. Because crisis management includes the basic elements of trauma-informed care, it enables the paramedic to understand the reactions of the patient and his/her family/environment and react appropriately while increasing her/his resilience using self-care methods. The literature shows that emergency service workers have inadequate crisis management skills.Reference Mojica-Crespo and Morales-Crespo18 Analytical studies would help better understand the underlying causal nature of the relationships among the study variables.
The results of the present study should be interpreted considering several limitations. First, as this study involved a cross-sectional survey, it may be impossible to draw conclusions about the nature of the putative causal relationship between mental health and individual and occupational factors. Second, private ambulance services were excluded to control for sample selection bias arising from the engagement of state’s paramedics with patients on their free days. Third, data were self-reported and may thus have been subject to recall bias and misclassification because disease reporting was not validated against medical records.
Despite the study’s limitations, identifying risk and protective factors for mental health in disaster settings can directly assist in identifying essential interventions and setting priorities to protect and improve the mental health of front-line paramedics working during disasters. Based on the findings, the following recommendations are given within the scope of occupational health and safety services:
Training and Education
Add courses on crisis management skills and trauma-informed approaches to pre- and post-graduation training programs.
Resilience Building
Design and implement a comprehensive self-care plan that incorporates physical, emotional, social, intellectual (professional knowledge and growth-promoting activities), and spiritual dimensions to increase resilience.
Workplace Regulations and Support
Regulate paramedics’ working hours, provide adequate personal protective equipment (PPE), and reorganize work schedules.
Peer Support and Supervision
To control the pervasive and severe impact of traumatic stress reactions and to prevent re-traumatization through the implementation of group or individual psychological first aid, psychoeducation, and supportive mechanisms such as trauma-informed peer support and supervision systems.
Surveillance System and Management of Mental Health Conditions
To implement regular screening programs to identify paramedics at risk for PTSD, particularly those exposed to severe traumatic events, younger age, women, individuals with a history of psychiatric treatment, and those in poor and inadequate concern for their health. It is also advised that paramedics undergoing treatment for mental disorders not be assigned to severe traumatic events, and access to quality mental health services should be ensured.
These recommendations aim to create a supportive environment and provide necessary resources to enhance the mental well-being of paramedics facing the challenges of disaster response. In conclusion, while disasters are expected to increase because of climate change and inadequate infrastructure, developing occupational health and safety programs for paramedics working on the front lines of disasters will protect their right to health and improve the quality of health services provided to society during disasters.
Acknowledgments
The authors are thankful to the Istanbul Provincial Health Directorate for granting their approval to conduct this research and to Istanbul Bilgi University.
Competing interest
The authors have no conflicts of interest to declare.
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