Influence of the continuing COVID-19 epidemic on sleep quality and psychological status of healthcare workers in private institutions

Abstract

BACKGROUND

On January 22, 2020, Macao reported its first case of coronavirus disease 2019 (COVID-19) infection. By August 2021, the situation had escalated into a crisis of community transmission. In response, the government launched a recruitment campaign seeking assistance and services of healthcare workers (HCWs) from the private sector throughout Macao. These participants faced concerns about their own health and that of their families, as well as the responsibility of maintaining public health and wellness. This study aims to determine whether the ongoing epidemic has caused them physical and psychological distress.

AIM

To examine the influence of COVID-19 on the sleep quality and psychological status of HCWs in private institutions in Macao during the pandemic.

METHODS

Data were collected from December 2020 to January 2022. Two consecutive surveys were conducted. The Pittsburgh Sleep Quality Index (PSQI) scale, Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) were employed as investigation tools.

RESULTS

In the first-stage survey, 32% of HCWs experienced a sleep disorder, compared to 28.45% in the second-stage survey. A total of 31.25% of HCWs in the first-stage survey and 28.03% in the second had varying degrees of anxiety. A total of 50.00% of HCWs in the first-stage survey and 50.63% in the second experienced varying degrees of depression. No difference in PSQI scores, SAS scores, or SDS scores were observed between the two surveys, indicating that the COVID-19 epidemic influenced the sleep quality and psychological status of HCWs. The negative influence persisted over both periods but did not increase remarkably for more than a year. However, a positive correlation was observed between the PSQI, SAS, and SDS scores (r = 0.428-0.775, P < 0.01), indicating that when one of these states deteriorated, the other two tended to deteriorate as well.

CONCLUSION

The sleep quality, anxiety, and depression of HCWs in private institution in Macao were affected by the COVID-19 epidemic. While these factors did not deteriorate significantly, the negative effects persisted for a year and remained noteworthy.

Key Words: COVID-19; Healthcare workers; Sleep quality; Anxiety; Depression; Psychological status

Core Tip: This study highlights the impact of coronavirus disease 2019 on the sleep quality and psychological status of healthcare workers in private institutions in Macao during the pandemic. Their sleep quality, anxiety, and depression were negatively affected for a year, with two surveys conducted a year apart revealing a strong correlation between anxiety and depression. These findings offer valuable insights for various industries and serve as a reference for studies in other regions.

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic is a global human catastrophe, more destructive and far-reaching than major earthquakes or intense storms. In December 2019, China reported the emergence and spread of COVID-19 in Wuhan City, Hubei Province, after which the virus spread rapidly to all provinces in China and other countries. On January 30, 2020, the second meeting of the Emergency Committee, convened under the International Health Regulations (2005), declared the outbreak of novel coronavirus 2019 a public health emergency of international concern[1]. The same classification was given to the severe acute respiratory syndrome (SARS) that emerged in 2003[2]. At that time, many scholars investigated the sleep quality and psychological status of healthcare workers (HCWs) in the areas where the cases occurred[3-5] to determine whether the SARS outbreak had any adverse effects on them, such as sleep disturbance or psychological distress. SARS and COVID-19 are both novel coronaviruses, with infected individuals primarily presenting respiratory symptoms. However, COVID-19 is more transmissible, invades both lungs, and triggers a more significant increase in inflammatory cytokines[6]. The incidence and prevalence of novel coronavirus 2019 cases are continuously increasing[7]. The impact on patients and HCWs has been so significant that national and regional studies have been conducted on the sleep and psychological status of HCWs[8-11]. Macao is a special administrative region of the People’s Republic of China located in southern China. In 2003, Macao was spared from the SARS pandemic in Asia. However, the COVID-19 outbreak was more contagious, and the first confirmed case in Macao was reported on January 22, 2020, with a cumulative total of 79 confirmed cases as of December 2021[12].

The Macao SAR government conducted three citywide nucleic acid testing programs to trace and intercept the transmission chain. Compared to most densely populated countries/territories, Macao has experienced lower prevalence and mortality from COVID-19[13]. This success can be attributed to effective epidemic prevention policies in Macao as well as to the support of HCWs. Throughout the pandemic, medical staff in Macao have faced numerous challenges and taken on unprecedented and demanding responsibilities. Medical staff in private institutions (PIs) in Macao have also volunteered in various roles for anti-epidemic efforts, increasing their exposure to frontline responsibilities. The literature has mainly studied the psychological status of HCWs from the onset to the peak of the epidemic, focusing on their psychological support. However, research on their experiences after the peak period is limited. Historical evidence from previous outbreaks indicates that psychological issues often emerge later. During an outbreak, HCWs may prioritize patient care, leaving little time to attend to their mental health. Thus, posttraumatic stress disorder often arises late in the pandemic[14-16]. Such events can disrupt people’s basic needs, leading to a variety of acute and chronic reactions[17]. HCWs at high risk of contracting SARS appeared not only to experience chronic stress but also exhibited higher levels of depression and anxiety, with negative psychological impacts persisting after one year[18].

Several studies have examined the sleep quality, anxiety, and depression of HCWs during the COVID-19 pandemic[19-22]. In Macao, HCWs in PIs account for 42.46% of the healthcare system, which includes 677 private healthcare establishments[23]. However, research focusing specifically on this region and this group, particularly on private HCWs in Macao is lacking. At the same time, understanding the situation of HCWs in PIs in Macao, as they often face challenges such as inadequate medical materials and equipment and financial difficulties more acutely than those in public units is worthwhile. The purpose of this study was to investigate the status and changes in sleep quality, anxiety, and depression in this group. A survey conducted in Italy from 2020 to 2021 found that the percentage of HCWs scoring above the cutoff for anxiety and depression, among other conditions, increased[24]. A one-year longitudinal study in Singapore showed significant improvement in anxiety but notable worsening of depression in frontline HCWs over the same period[25]. Our survey also aimed to determine whether the ongoing COVID-19 epidemic will have any influence on HCWs in PIs in Macao.

MATERIALS AND METHODS

Participants

Our survey was developed and administered to 4392 HCWs from private hospitals and private clinics in Macao[23]. This cross-sectional study was conducted from December 2020 to January 2021 (first stage) and from November 2021 to January 2022 (second stage). Given that the first confirmed case in Macao occurred in January 2020, we timed the survey to coincide with the first and second years following the outbreak, intending to follow up on the situation regularly and continuously to monitor the relevant changes in this group.

Data collection procedure

Data were collected mainly using an online survey distributed through the wenjuan.com software (https://www.wenjuan.com). To promote the survey, we sent the network links to civil medical and psychological associations, and both digital and paper versions were delivered to PIs.

Measures

The questionnaire collected data on both personal data and mental health status. Personal data included sex, age, occupation, occupation role, and working seniority. Psychometric tools used in this study included the Pittsburgh Sleep Quality Index (PSQI) scale, Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS). The PSQI has internal uniformity and a reliability coefficient (Cronbach’s alpha) of 0.83 for its seven components[26]. The overall PSQI total score correlation coefficient for test-retest reliability was r = 0.85. Individual items on PSQI scales were scored out of 3, with the minimum score being 0 and the maximum score being 3, where lower values indicated better sleep quality. Except for use of sleep, medications are defined as poor quality in this component with a score of ≥ 1, and other components are defined as poor quality in this dimension with a score of ≥ 2[27]. The total PSQI score ranges from 0 to 21. For all components, a higher score represented lower quality sleep. A total score ≤ 7 is regarded as normal, and a score of > 7 is considered to suggest the presence of sleep disorders.

The SAS is a 20-item self-report measure designed to assess levels of psychological and somatic symptoms of anxiety and has been widely used[26]. Each item is scored on a Likert-type scale from 1 to 4. Total raw scores range from 20 to 80 points. This raw score is converted to a standard score using a provided conversion formula. According to this standard score, four levels of anxiety are differentiated: A standard score of < 50 indicates the absence of anxiety, ≥ 50 signifies mild anxiety, ≥ 60 denotes moderate anxiety, and ≥ 70 indicates severe anxiety. The Chinese version of the scale had a Cronbach’s alpha equal to 0.85[28].

The SDS is used to assess people’s depression, with 20 items rated on a scale of 1-4 and a cumulative score range of 20 to 80[26]. The higher the total raw score, the more severe the depression. The cumulative scores were divided by 80 to obtain the depression index or converted to a standard score using a provided conversion formula. An index score of < 0.5 indicates the absence of depression (standard score < 49), 0.50 to 0.59 indicates mild depression (standard score from 50 to 59), 0.60 to 0.69 indicates moderate to severe depression (standard score from 60 to 69) and ≥ 0.7 indicates severe depression (standard score ≥ 70). The Chinese version of the scale had a Cronbach’s alpha equal to 0.88[28].

Statistical analysis

In this study, IBM SPSS Statistics version 23.0 was used for data analysis. Categorical variables were analyzed using descriptive statistics, while continuous variables are expressed as mean ± SD. Pearson’s χ² test was used to analyze the differences in rates of sleep disorder, anxiety, and depression between the two stages. The Mann-Whitney test (Z test) was used for comparisons between groups. Pearson correlation coefficients were used to identify the variables that correlated with sleep quality, anxiety, and depression. Data with fewer than five cases were excluded from the analysis, and a significance level of P < 0.05 was considered statistically significant.

RESULTS

Study group

In the first stage, 320 questionnaires were collected, with a sample size of 7.29%, and 224 valid questionnaires were retained. In the second stage, 274 questionnaires were collected, with a sample size of 6.24%, and 239 valid questionnaires were retained. See Tables 1 and 2 for further details.

Table 1 Sociodemographic data from the participants (first stage, n = 224).

Variable		Frequency	Percent (%)
Sex	Male	114	50.89
	Female	110	49.11
Age (year)	21-30	93	41.52
	31-40	85	37.95
	41-50	28	12.50
	51-60	12	5.36
	61-70	4	1.79
	71-75	2	0.89
Occupation	TCM doctor	111	49.55
	Doctor	44	19.64
	Nurse	22	9.82
	Diagnostic and therapeutic technician	18	8.04
	Others1	10	4.46
	Administrative staff	8	3.57
	Unemployed	6	2.68
	Logisticians	5	2.23
Occupation role	Employees (regular income)	126	56.25
	Employees (no regular income)	39	17.41
	Owners (employees)	28	12.50
	Owners (no employees)	20	8.93
	Unemployed	6	2.68
	Owners and employees	5	2.23
Working seniority (year)	0-10	148	66.07
	11-20	60	26.79
	21-30	12	5.36
	31-40	3	1.34
	41-50	1	0.45

¹Others included 3 dentists, 3 therapists, 2 pharmacists, 1 nucleic acid sampler, and 1 TCM and Western Medical Doctor.

Table 2 Sociodemographic data from the participants (second stage, n = 239).

Variable		Frequency	Percent (%)
Sex	Male	126	52.72
	Female	113	47.28
Age (year)	18-20	4	1.67
	21-30	93	39.91
	31-40	87	36.40
	41-50	35	14.64
	51-60	14	5.86
	61-70	5	2.09
	71-83	1	0.42
Occupation	TCM doctor	118	49.37
	Doctor	47	19.67
	Nurse	23	9.62
	Others1	20	8.37
	Administrative staff	14	5.86
	Unemployed	7	2.93
	Logisticians	6	2.51
	Diagnostic and therapeutic technician	4	1.67
Occupation role	Employees (regular income)	131	54.81
	Employees (no regular income)	44	18.41
	Owners (employees)	31	12.97
	Owners (no employees)	21	8.79
	Unemployed	7	2.93
	Owners and employees	5	2.09
Working seniority (year)	0-10	169	70.71
	11-20	46	19.25
	21-30	13	5.44
	31-40	8	3.35
	41-50	3	1.26

¹Others included 7 dentists, 3 therapists, and 10 pharmacists.

PSQI scale

There were 152 people (67.86%) in the first stage and 171 people (71.55%) in the second stage who were classified as “normal”, 72 people (32.14%) in the first stage and 68 (28.45%) people in the second stage who were classified as “sleep disorder”. The analysis in Table 3 shows no significant difference in the presence or absence of sleep disturbance between the first and second surveys (P = 0.338 > 0.05). The comparison of the mean ± SD in Table 4 also indicates no significant difference between the two surveys.

Table 3 Comparison of the difference in the rates of sleep disorder between the two stages.

Stage	Normal, n (%)	Sleep disorder, n (%)	χ2	P value
1st stage	152 (67.86)	72 (32.14)	0.747	0.388
2nd stage	171 (71.55)	68 (28.45)

Table 4 Total Pittsburgh Sleep Quality Index scores and 7-component scores.

Item	1st stage scores, mean ± SD	2nd stage scores, mean ± SD	Z	P value
PSQI total scores	6.46 ± 2.89	6.27 ± 2.79	-0.625	0.532
Subjective sleep quality	1.24 ± 0.67	1.29 ± 2.73	-1.060	0.289
Sleep latency	1.02 ± 0.80	0.85 ± 0.74	-2.191	0.028a
Sleep duration	1.07 ± 0.85	1.03 ± 1.03	-1.089	0.276
Habitual sleep efficiency	0.22 ± 0.53	0.38 ± 0.87	-1.378	0.168
Sleep disturbances	1.11 ± 0.62	0.97 ± 0.56	-2.367	0.018a
Use of sleep medications	0.16 ± 0.52	0.20 ± 0.48	-1.957	0.050
Daytime dysfunction	1.65 ± 0.80	1.53 ± 0.77	-1.678	0.093

^aP < 0.05.

PSQI: Pittsburgh Sleep Quality Index.

SAS and SDS

The standard score of the SAS in this study showed that 154 individuals (68.75%) had “absence of anxiety”, 48 individuals (21.43%) had “mild anxiety”, 22 individuals (9.82%) had “moderate anxiety”, and no one had “severe anxiety” in the first survey. In the second survey, 172 individuals (71.97%) reported “absence of anxiety”, 46 individuals (19.25%) had “mild anxiety”, 18 individuals (7.53%) had “moderate anxiety”, and 3 individuals (1.26%) experienced “severe anxiety”.

The standard score of the SDS showed that 112 individuals (50.00%) had “absence of depression”, 68 individuals (30.36%) had “mild depression”, 39 individuals (17.41%) had “moderate to severe depression”, and 5 individuals (2.23%) had “major depression” in the first survey. In the second survey, 118 individuals (49.37%) reported “absence of depression”, 67 individuals (28.03%) had “mild depression”, 48 individuals (20.08%) experienced “moderate to severe depression”, and 6 individuals (2.51%) had “major depression”. The analysis in Table 5 indicates no significant difference in the presence or absence of anxiety and depression between the first and second surveys (P = 0.449 > 0.05, P = 0.893 > 0.05). The comparison of the mean ± SD in Table 6 also indicates that there was no significant difference between them.

Table 5 Comparison of the difference in the rates of anxiety and depression between the two stages.

Item	Stage	Normal, n (%)	Abnormal, n (%)	χ2	P value
Anxiety	1st stage	154 (68.75)	70 (31.25)	0.574	0.449
	2nd stage	172 (71.97)	67 (28.03)
Depression	1st stage	112 (50.00)	112 (50.00)	0.018	0.893
	2nd stage	118 (49.37)	121 (50.63)

Table 6 Self-Rating Anxiety Scale and Self-Rating Depression Scale standard scores.

Item	1st stage scores (mean ± SD)	2nd stage scores (mean ± SD)	Z	P value
SAS standard scores	43.78 ± 9.99	44.33 ± 9.78	-0.335	0.738
SDS standard scores	48.20 ± 11.69	49.01 ± 11.18	-0.688	0.492

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

The correlations of PSQI scores, SAS scores, and SDS scores

Significant positive correlations (r = 0.428-0.775, P < 0.01) were observed between the sleep quality, anxiety, and depression scores in the two stages, with strong correlations for anxiety and depression (r = 0.775, 0.735; P < 0.01), as shown in Tables 7 and 8.

Table 7 Correlations of Pittsburgh Sleep Quality Index scores, Self-Rating Anxiety Scale scores, and Self-Rating Depression Scale scores (first stage).

	PSQI total scores	SAS standard scores	SDS standard scores
PSQI total scores	1
SAS standard scores	0.461b	1
SDS standard scores	0.428b	0.775b	1

^bP < 0.01.

PSQI: Pittsburgh Sleep Quality Index; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Table 8 Correlations of Pittsburgh Sleep Quality Index scores, Self-Rating Anxiety Scale scores, and Self-Rating Depression Scale scores (Second Stage).

	PSQI total scores	SAS standard scores	SDS standard scores
PSQI total scores	1
SAS standard scores	0.593b	1
SDS standard scores	0.470b	0.735b	1

^bP < 0.01.

PSQI: Pittsburgh Sleep Quality Index; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

DISCUSSION

A systematic study found that the prevalence of insomnia among HCWs was 38.9%[20]. In this study, 32.14% of HCWs in the first stage and 28.45% of HCWs in the second stage were classified as having sleep disorders. The mean score was lower than the critical value of seven, indicating that sleep quality was generally normal; however, some HCWs still experienced poor sleep quality. In addition, no significant difference was found between the results of the two stages in PSQI total scores. However, in “sleep latency” and “sleep disturbances”, the scores of the second stage were lower than that of the first stage. “Sleep disorders” are the most common sleep problem among nurses[29]. In the second stage, HCWs reported an improvement, taking less time to fall asleep and experiencing fewer sleep disturbances. This may be because HCWs were tired from the heavy workload and intensity of the anti-epidemic efforts, allowing them to fall asleep quickly and sleep more deeply due to fatigue. No significant differences were observed between the first-stage PSQI total scores of this study and the results of the COVID-19 epidemic on HCWs’ sleep quality survey conducted by Wei et al[30] (6.45 ± 3.67) and Amra et al[31] (6.9 ± 3.1), reflecting that the results of sleep quality of HCWs in these studies were similar. Although the results of our study align with those from HCWs in other regions, the scores were significantly higher than those of the general population and other professionals in China[32,33], suggesting that the epidemic had a significant impact on the sleep quality of HCWs.

HCWs are more susceptible to infection, facing a high risk that can lead to both physical and mental health issues[34]. In our survey, 31.25% of HCWs reported mild to moderate anxiety in the first stage, and 28.03% reported mild to severe anxiety. At the same time, 50% of HCWs experienced mild to major depression in the first stage, and 50.62% experienced mild to major depression, indicating that some HCWs still had psychological problems, and half of them had depression. The SAS and SDS scores during the two stages of this study are higher than the results of the COVID-19 epidemic on HCWs’ anxiety and depression symptom survey conducted by Zhou et al[35] (40.36 ± 10.85) and Xiao et al[36] (42. 57 ± 11. 29), with statistically significant differences observed. However, comparing the results of the SAS and SDS, no significant differences were observed in the scores between the two stages, meaning that the psychological status of HCWs in PIs in Macao remained unchanged as the COVID-19 epidemic continued. At the same time, comparing the results of the SAS and SDS, no significant differences were observed in the scores between the two stages, meaning that although the psychological status of HCWs did not change remarkably as the COVID-19 epidemic continued, it still had a negative effect on them. This negative effect has persisted for over a year, and it remains uncertain whether it will continue or extend for an even longer period. A survey in China showed that HCWs without experience in public health emergency procedures exhibit worse mental health performance[37]. PIs operate on self-financing. More than 20% of the staff in this study are proprietors, and most of them have employed staff, while 17.41% to 18.41% of the employees are employed on a non-fixed monthly salary. The owners were under pressure to pay rent and staff salaries, while employees experienced stress from reduced income due to fewer consultations. Even if they participated in the frontline work, many did so as volunteers, often without pay. These factors may negatively impact their emotional well-being. HCWs with financial difficulties were at the highest risk for developing anxiety, depression, and stress[38]. However, few cases existed at the beginning of the epidemic in Macao, and no frontline HCWs were infected. Moreover, the effective treatment provided by Chinese medicine, along with the development and use of vaccines, instilled confidence in HCWs to confront these challenges. Therefore, the problems they faced at work and in their personal lives were not overwhelmingly negative. A study found that, over time, HCWs had adapted psychologically to manage the pandemic[39]. During the period of our investigation, the absence of widespread infections in Macao contributed to the lack of significant change in the psychological state of HCWs in our study.

The correlation between the sleep quality, anxiety, and depression scores of the two surveys is significantly positive. Anxiety and depression are strongly correlated. The results suggest that when one of these states deteriorates, the other two deteriorate as well. Although these two surveys are approximately one year apart, the results are consistent, which indicates a strong relationship between them. Nearly half of the HCWs (50.00%/49.37%) had different grades of depressive status (mild depression, moderate to severe depression, and severe depression), indicating a high prevalence of depressive status in this group. Depression and sleep disturbance are often causal, with depression leading to sleep disturbance and the latter in turn exacerbating depression[40]. A revelation shows that 90% of individuals with symptoms of depression have sleep disturbances[41]. Hertenstein also suggests that insomnia is an important risk factor for the development of depression and anxiety[42]. A survey in Italy also stressed the importance of proper sleep hygiene to help limit anxiety of HCWs[43]. As both caregivers and patients, HCWs are at risk of infection in both their living and working environments[44] and experience greater psychological stress than the general population. HCWs are responsible for protecting and improving public health and wellness, as well as facing the pressures of livelihood. Long-time working reduces rest and sleep time of HCWs. The high intensity of tasks may lead to the development of distressing psychological problems. Sleep quality, anxiety, and depression are closely related, and both physical and psychological support should be considered. In this study, physical and psychological measurements were carried out on HCWs from PIs in Macao during the COVID-19 epidemic from December 2020 to January 2022. The results provided a more accurate and objective understanding of changes in their sleep quality, anxiety, and depression status, while also exploring the underlying causes of these conditions. We analyzed the factors influencing sleep quality, anxiety, and depression status, which can help inform targeted intervention for this specific group. However, this study has some limitations. First, since the survey was primarily conducted online, many older HCWs in Macao were unable to participate, resulting in a low response rate despite our efforts to provide a paper questionnaire. Second, our sample was limited to volunteers and relied on self-assessment, which may introduce biases in the results. One year has passed since the second-stage survey and Macao’s epidemic prevention policy has changed from “Zero-COVID” to “coexisting with the virus” in December 2022. Therefore, conducting another survey to obtain new data is worthwhile. The next survey should include a random sampling component to ensure generalizability. Third, apart from the reasons mentioned in this study, other reasons affect sleep quality, anxiety, and depression status that need to be explored and discovered. The results of this survey only reflect the sleep quality, anxiety, and depression of HCWs in PIs in Macao during the survey period. However, different aspects and levels of the physical and psychological impact of the epidemic on HCWs exists. Qian et al[45] summarized several causes of psychological problems among HCWs, including insufficient knowledge of COVID-19, relative lack of epidemic prevention materials, the sacrifice of a considerable number of HCWs, insufficient ability to recognize relevant information, and susceptibility. Despite a deeper understanding of the disease, improved epidemic prevention materials and equipment, and the availability of vaccines leading to a significant reduction in deaths, the epidemic continues to pose challenges. Issues such as virus mutation, anti-epidemic fatigue, economic depression, and the post-COVID-19 condition persistently impact HCWs and may lead to ongoing or worsening physical and mental health problems. HCWs, personnel departments, civil medical associations, and psychological associations, as well as the government health bureau should pay attention to these issues. This includes incorporating the preservation and promotion of the physical and mental health of HCWs into professional training and enhancing their awareness and professional skills in relation to public health emergencies. Such measures can help mitigate sleep disorders, anxiety, and depression when facing similar challenges in the future. Finally, although two surveys on this specific group were conducted in this cross-sectional study, the problem of economic depression did not improve as the epidemic persisted. Long-term follow-up is necessary; however, due to limitations in time and manpower, this was not feasible in this study. Given the potential impact of “post-COVID-19 syndrome” (long COVID) on HCWs and their consultations with patients, regular follow-ups on their status are recommended. Such monitoring will facilitate early detection of problems, allow for prompt support for relevant personnel, and enable timely guidance and adjustments, all of which are crucial for maintaining their physical and mental health.

CONCLUSION

The sleep quality, anxiety, and depression of HCWs in PIs in Macao were affected by the COVID-19 epidemic. While there was no significant deterioration in these areas, the negative effects persisted for a year and are noteworthy. Therefore, regular follow-ups are recommended as a standard measure to identify ongoing issues, provide appropriate support, and extend the survey to all HCWs.

ACKNOWLEDGEMENTS

We would like to thank the researchers who contributed to this study and express our gratitude to the healthcare workers who participated in completing the questionnaire.