The World Health Organization (WHO) declared an outbreak of COVID-19 as a public health emergency of international concern on 30 January 2020 (1). Around 60 million people have been affected by COVID-19, with nearly three hundred thousand deaths recorded at the time of writing this proposal. The majority of infected people have completely recovered from the condition. Currently, the virus is affecting more than 200 countries and territories globally. The situation in Sri Lanka is fluctuating with more than a thousand positives and 11 deaths currently (2). Public health measures are critical to controlling the spread of illnesses (3). Sri Lanka is a country with a well-established preventive health system reaching to the grass-root level, headed by a medical doctor and supported by public health field officers such as public health inspectors and public health midwives (4). Public health officers play a crucial role in preventing and controlling crises, especially in an infectious disease outbreak. Public health officials at the field level are mainly involved in operational issues and directly engaged with the public (5). Previous experiences during pandemics showed high levels of stress, anxiety, and low mood for Healthcare workers (6). There is a significant mental health impact of new infectious disease on health care works was explained, and it requires appropriate interventions. A large study done in Toronto in 2003 during the SARS outbreak found that significant levels of psychiatric morbidity among 60% of the staff and almost 30% had emotional distress (7). The psychological distress on employee’s outcomes shows the negative impact on organizations from previous studies. When healthcare workers work with extreme psychological pressures during a pandemic, it adversely affects the well-being of the individual, the healthcare system, and patient care (8). The experience during the SARS outbreak showed a significant association between workers’ resignations and reduced workers’ performance (9). Early interventions will benefit affected health staff with specialized psychological support, general welfare support, and strategies to reduce workplace stressors. Individual perceptions of the event may mediate the psychological impact of activities related to an infection outbreak, and altruism may lessen the negative impact. Early staff training and adequate staff support will be mandatory components to reduce psychological adversities of COVID-19 on health care workers (10). The role played by public health field officers is often ignored even during COVID 19 pandemic. Therefore, it is of great importance to be concerned about the health and prevent related diseases with a view to a better life. There are several advancements in the management of psychological aspects to improve their quality of life. There are no published studies on the epidemiology of common psychological problems such as depression, anxiety, and stress among public health field officers in Sri Lanka. This data is vital to plan a programme for the prevention and control of such problems. We must also have a better understanding of the associated factors or risk factors of common psychological problems or issues (depression, anxiety, and stress) among public health field officers.
The policymakers are not aware of the burden of these common psychological problems among public health inspectors during the COVID 19 pandemic. The main reason for this is the lack of scientific information on the subject while it is an obstacle to organize services in our country. It is foreseen that such data will be of use to Health Administrators, Psychiatrists, Community Physicians, and others involved in the care of public health field officers. Therefore, it is decided to conduct this study to provide some vital baseline epidemiological information on depression, anxiety, and stress among public health field officers during COVID 19 pandemic to plan current and future preventive strategies. By keeping all these in mind, we try to estimate the prevalence and associated factors of depression, anxiety, and stress among public health inspectors during COVID 19 in the Western Province.
1.3.1. General Objectives
To estimate the prevalence and associated factors of depression, anxiety and stress among Public Health Inspectors (PHII) and Supervisory Public Health Inspectors (SPHII) during COVID 19 in the Western Province
1.3.2. Specific Objectives
- To estimate the prevalence of depression, anxiety and stress among Public Health Inspectors (PHII) and Supervisory Public Health Inspectors (SPHII) during COVID 19 in the Western Province
- To describe the selected associated factors of depression, anxiety and stress among Public Health Inspectors (PHII) and Supervisory Public Health Inspectors (SPHII) during COVID 19 in the Western Province
2.1. Study Design
A descriptive cross-sectional study will be carried out.
2.2. Study Setting
This study will be done in the Western Province of Sri Lanka
2.3. Study Period
The study will be conducted three months following ethical approval.
2.4. Study Population
The study population will be all Public Health Inspectors (PHII) and Supervisory Public Health Inspectors (SPHII) working in the Western Province
Inclusion criteria: Public Health Inspectors (PHII) and Supervisory Public Health Inspectors (SPHII) are working in the Western Province during the COVID-19 epidemic.
2.5. Sample Size Calculation
The minimum sample size required estimating the expected prevalence of depression/anxiety/stress among public health inspectors with a predetermined level of precision and confidence was calculated. The sample size for the prevalence study was calculated using the following formula (Lwanga & Lameshow 1991).
n = Z21-α/2. P (1-P)/d2
n = sample size
Z1-α/2 = Z score corresponding to alpha error of 5% = 1.96
P = Anticipated population proportion of the prevalence of depression or anxiety or stress in public health inspectors in Sri Lanka.
As the prevalence of depression, anxiety, or stress in public health inspectors is not available in the literature, to get a maximum sample size, it was assumed to be 50%.
d = Absolute precision required on either side of the proportion. Considering the feasibility and accuracy of the estimation, it was decided to have 5% as the desired precision level as higher precision (5%) gives a narrower confidence interval.
n = Z2 P (1-P)/d2
n = 1.96 x 0.5 x 0.5 /0.05 x 0.05
n = 384
To compensate for the non-response rate, the sample size was increased by 5% (Lwanga & Lameshow 1991).
384×105/100 = 403
2.6. Sampling Technique
Multistage Stratified Sampling
- The first stage – the number of total participants for each district will be allocated according to the population proportion to staff size (SPHII/PHII) in each district
- The second stage – Once the total participants for each district are allocated, participants will be randomly allocated from the sampling frame of Employment Register at RDHS office (SPHII/PHII).
2.7. Study Instruments
A self-administered questionnaire will be used to assess depression, anxiety, and stress among public health inspectors. The study instrument is prepared in three sections
Section 1: A pre-tested self-administered questionnaire (SAQ) to collect information on demographic and socio-economic factors
Section 2: The validated DASS-21 Sinhala to assess depression/anxiety/stress among public health inspectors.
Section 3: A pre-tested self-administered questionnaire to collect information on factors associated with depression/anxiety/stress public health inspectors.
Section 1 & 3 of the questionnaire will be developed in English and translated to Sinhala and Tamil. Back translation will be done by a person who is thorough in both languages to assess the questionnaire’s correctness.
Section 2 of the questionnaire, DASS-21 Sinhala version, which is validated for Sri Lanka, will be used to estimate the prevalence of psychological problems (Depression, Anxiety, and Stress). DASS-21 was also translated to Tamil.
The DASS-21 was translated to Sinhala, culturally adapted, and back-translated. A Panel comprising of multidisciplinary experts in psychiatry and Psychology assessed the judgmental validity (Face, Content & Consensual validity). The criterion validity was assessed against a consultant psychiatrist’s diagnosis. The ROC curves plotted for the different cut off values of the total scores of depression, anxiety, and stress, respectively (11).
Depression – cut off ≥17
Anxiety – cut off ≥16
Stress – cut off ≥20
Scores for each subscale were able to detect the depression, anxiety, and stress with a sensitivity of 97%, specificity of 98% at the optimal cut off level of each subscale (11).
All Public Health Inspectors (PHII) and Supervisory Public Health Inspectors (SPHII) working in the Western Province are conversant in Sinhala (both reading and writing) according to a preliminary survey. Therefore, Sinhala versions of the questionnaires will be used for the study.
2.7.1. Pretesting of Questionnaire
Pre-testing of sections 1 and 3 of the study instruments will be done among 15 eligible participants selected from another province (e.g., North Western) to establish the applicability and acceptability before the proper study. On the findings of the pre-testing, modifications will be made to the questionnaires
2.7.2. Definition of Variables
Structure of the family
- Nuclear family – The family unit consists of two generations, mother and father (1st generation) and the children (2nd generation). They are economically independent and self-supporting. (Power, Robinson, and Popowicz, 1986 as cited in De Silva, 2006)
- Extended family – The typical extended family was considered any family consisting of three generations, grandparents, parents, and children. Even family units with two generations are also considered as extended families when aunts, uncles, and cousins live in the same household and the typical nuclear family. (Power, Robinson, and Popowicz, 1986 as cited in De Silva, 2006)
2.8. Data collection
Two research assistants, who are social science graduates, will be selected as field investigators (FI) for the study. They will be trained for two days by the principal investigator (PI). In the training of FIs, an overview of the research, importance of the study, assessing eligibility using the selection criteria, consent, and confidentiality issues, and administering a self-administered questionnaire to the participants will be emphasized. Each item in the instrument will be discussed along with the protocol guide. The PI will regularly supervise data collection.
2.9. Data Analysis
Data will be manually checked and cleaned by the PIs before entering the database. The PIs will code the response to each variable. Data will be entered in EpiData 3.1software and imported to SPSS software package to analyze. The data quality will be assured by calculating response rates, Kappa coefficient to assess the agreement between data collectors.
Descriptive analysis will be carried out to determine the proportions of depression, anxiety, and stress. A Chi-square test will be done to determine the factors with any mental health problems. (Groups will be divided as the participants with and without mental health problems i.e., depression/anxiety and stress).
2.10. Ethical Issues and Clearance
Ethics approval will be obtained from the Ethics Review Committee of the Sri Lanka Medical Association. Further, authorization to conduct the study will be obtained from the review committee of the Provincial Director of Health Services.
Informed written consent will be obtained before the commencement of data collection after providing detailed information about the study and clarifying their doubts (IS and Consent form).
All participants will be informed that participation is voluntary and that there are strong presumption confidentiality and data anonymity.
Data will be stored with restricted access only to the principal investigator. The computerized data will be password protected and will only be available to the investigator. Hard copies of the questionnaires will be destroyed after two years of research by the PI.
Study findings will be presented and published in a relevant symposium or a journal to promote conducting this form of research in other areas. At the same time, the information will be disseminated to relevant authorities for necessary future actions.
Participants will be given adequate time to read, understand the information leaflets, and discuss participation with trusted others (partners and family members) before giving written consent. If requested, further clarifications will be provided by the researcher. All participants will be informed that they can stop at any time and withdraw from the research up to 1 week after data collection (after which, the analysis will have begun, and data cannot be untangled).
The personal information of participants (i.e., name, address, contact number, etc.) will be obtained, after explaining to them that they need to be referred for psychiatric advice if they are found to have any psychological problems detected by using DASS-21. All the personal details provided by the participants will be treated as strictly confidential. If participants show a need for any medical or psychological support (i.e., having higher cut off values for above-described depression, anxiety, and stress of DASS-21) will be referred to the nearest state health care institution where a psychiatry unit is available.
The public health inspectors’ will be benefited by being able to identify their need for improvement in the well-being.
2.11. Administrative Requirements
Permission will be obtained from the Provincial Director of Health Services and all Regional Directors of Health Services.
- WHO. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020 [Internet]. [cited 2020 12 May]. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020
- Worldometer. Coronavirus Cases [Internet]. Worldometer. 2020 [cited 2020 6 June]. p. 1–22. Available from: https://www.worldometers.info/coronavirus/coronavirus-cases/#daily-cases
- WHO. Q &A on coronaviruses (COVID-19) [Internet]. [cited 2020 6 June]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses
- Perera DS. Primary Health Care Reforms in Sri Lanka: Aiming at Preserving Universal Access to Health. 2015;
- Strauss R, Muchl R, Kunze M, Hrabcik H. The role of public health officers in preparedness planning and management of health crises. Euro surveillance [Internet]. 2008 13 March [cited 2020 6 June];13(11):11–2.
- Available from: https://www.eurosurveillance.org/content/10.2807/ese.13.11.08071-en
- Goulia P, Mantas C, Dimitroula D, Mantis D, Hyphantis T. General hospital staff worries, perceived sufficiency of information, and associated psychological distress during the A/H1N1 influenza pandemic. BMC Infect Dis. 2010 Nov 9;10:322.
- Sim K, Chua HC. The psychological impact of SARS: A matter of heart and mind. Vol. 170, CMAJ. Canadian Medical Association; 2004. p. 811–2.
- Patel RS, Bachu R, Adikey A, Malik M, Shah M. Factors related to physician burnout and its consequences: A review. Vol. 8, Behavioral Sciences. MDPI Multidisciplinary Digital Publishing Institute; 2018.
- Giles-Corti B, Donovan RJ. Survey of Stress Reactions Among Health Care Workers Involved With the SARS Outbreak. Soc Sci Med [Internet]. 2002 Jun [cited 2018 4 March];54(12):1793–812. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12113436
- Ellepola A, R.P.S.S R. Foreseeable psychological impact of COVID 19 in Sri Lanka. 2020;(April).
- Dheerasinghe D.S.A.F., Fonseka P., Kathriarachchi S, Seneviratne H.R. Validation of Sinhala version of the depression anxiety stress scales-21 for middle-aged Sri Lankan women. Ceylon Medical Journal, 2017, Volume 62, Supplement 1, 139