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INTRODUCTION
Since the emergence of the COVID-19 pandemic, several studies have assessed its effects on health professionals’ mental and physical health. In general, these studies have shown high levels of mental burden among health workers and females with higher averages of stress, anxiety, and depression than males1-6. Despite this, most studies have focused their analysis on elucidating the professional aspects that have any impact on the mental burden of health professionals independently of gender1-4,7. However, there is a gap in studies that investigate specifically among female workers how much their stress is influenced by personal, domestic, economic, and family variables related to gender roles in each society.
Gausman & Langer8 highlighted the importance that the studies on pandemics include in their analysis which they named “gender lens”, to understand how women and men are exposed differently to the social and psychological consequences of a pandemic. They also emphasized that these studies should be carried out in global, national, and local contexts, as well as in different social and professional spheres due to disparities in gender equality aspects around the world.
Regarding health professionals, it is important to note that in recent decades, the proportion of female workers in the health workforce has increased. In addition, currently, there is a higher proportion of female workers in the health workforce than in the general workforce9. Therefore, it is essential to identify the factors related to high levels of stress perception among female workers in different health professions to contribute to the development of policies and strategies for facing this issue.
In several countries, physiotherapists (PTs) play a decisive role in the treatment of patients with COVID-19, working in intensive care units, hospital wards, and rehabilitation after hospital discharge10-15. However, some publications have assessed the levels of stress among PTs during this pandemic2,13,16 and to the best of our knowledge, no study was published focusing specifically on female PTs.
Thus, this study aimed to analyze which psychosocial demands, sociodemographic, and clinical factors were associated with high levels of perceived stress among Brazilian female physiotherapists during the COVID-19 pandemic.
METHODS
Study design
This cross-sectional study17 included a post hoc subgroup analysis of female physiotherapists who participated in a web-based questionnaire survey published in 20222.
Study location and period
The data collection was performed from May to June 2020, during the period of social distancing in Brazil, by an online survey.
Study population and eligibility criteria
All female PTs registered in Regional Physical Therapy Council-15 (CREFITO-15), who were practicing physiotherapy in Espírito Santo (ES) state, Brazil, at the period of the data collection, received the questionnaire and agreed with the informed consent term, were included. The PTs who did not complete the questionnaire were excluded from the study. It is worth mentioning that registration on CREFITO-15 is mandatory for all PTs who work in the Espírito Santo state.
To calculate the sample, it was considered the number of PTs registered on CREFITO-15 in May 2020, 4,173 PTs (3,266 females and 907 males). Using this number, a confidence level of 0.95 with a margin of error of 5% and a proportion of 50%, the sample size was estimated at 352 participants for the analysis of PTs (both sexes), and 275 (78.3% of the total sample) for the analysis focusing specifically on female PTs, which was the target population of this post-hoc subgroup analysis. So, the estimated sample size was 275 (confidence level of 0.95 and 5% margin of error).
Data collection
For data collection, the Regional Physical Therapy Council of the 15th Region (CREFITO-15) sent e-mails to all physiotherapists registered and practicing physiotherapy in the Espirito Santo state. The e-mails included an invitation to participate in the survey and a link to a questionnaire available in Survey Monkey Software.
The self-reported questionnaire was structured in four sections: 1) sociodemographic and professional characteristics, 2) clinical characteristics and information related to COVID-19 pandemic, 3) psychosocial demands, and 4) Perceived Stress Scale (PSS-10).
The dependent variable was the perceived stress measured by the Perceived Stress Scale (PSS-10)18, a widely used instrument for measuring perceived stress19-22. PSS-10 consists of 10 items (four positive and six negatives), which must be answered on a Likert scale of frequency, ranging from Never (0) to Always (4). The final score ranges from 0 to 40 and was obtained from the sum of the scores of the questions, and the four questions with a positive connotation had their quotation reversed. High stress was defined as a score equal to or above the 80th percentile (score greater than or equal to 27 points), according to a previous study23.
The exposure variables were the factors related to the effects of COVID-19 on the participants’ concerns related to psychosocial demands and measured by the question: “In the past 7 days, how much did the factors below affect you psychologically?” a. housework; b. care/relationship with children; c. relationship with the partner; d. professional overload; e. concern about financial issues; f. concern about being infected by SARS-CoV-2; g. concern about close people/family members being infected by SARS-CoV-2; h. restriction of leisure/social interaction; and i. loneliness. The options for response to these questions were: not at all, slightly, moderately, a lot and extremely2.
The adjustment variables were: age group in years (22 to 34; 35 to 69); marital status (with partner - married / in a stable relationship; no partner - single; separated / divorced; widowed; others); children (yes or no); income (up to 5 minimum wage; above 5 minimum wage); working in person as a physiotherapist (yes or no); distancing (question: “Do you consider that you are adequately practicing the measures of” social distancing “due to the outbreak of COVID-19?”, yes or no); COVID-19 diagnosis (“Have you ever been diagnosed with COVID-19?”, yes or no).
Data analysis
Stata software (version 12.0) was used for data analysis. Descriptive analysis of all variables was performed using absolute and relative frequency distribution. In the bivariate analysis, the proportion of high levels of stress perception and the respective 95% confidence intervals (95% CI) were calculated according to the independent variables. Unadjusted and adjusted odds ratios (OR), with their respective 95% CI, were estimated through logistic regression. In the multiple analysis, a full model was fitted with all the independent variables included in the study24. A significance level of 5% was adopted.
RESULTS
A total of 522 questionnaires were initiated and 417 were completed, yielding a completion rate of 79,88%, among which 339 were completed by PTs who identified themselves as belonging to the female sex, being included in this sample.
Therefore, the sample consisted of 339 PTs. Among them, 69% were between 18 and 35 years old, 54.87% had a partner, 53.98% did not have children, 67.5% reported having a monthly income less than 5 minimum wage, 64.3% reported working as PTs during the period of data collection (table 1).
Table 1 : Factors related to high perceived stress levels among Brazilian physiotherapists
| Variables | Total | Bivariate analysis | Multivariate analysis | |
|---|---|---|---|---|
| n (%) | % (IC95%) | OR (IC95%) | OR (IC95%) | |
| Age group (years) | ||||
| 18 to 34 | 182 (53.69) | 21.98 (16.52; 28.62) | 1.64 (0.93; 2.89) | 1.55 (0.71; 3.36) |
| 35 to 69 | 157 (46.31) | 14.65 (9.91; 21.13) | 1.00 | 1.00 |
| Marital status | ||||
| With a partner | 186 (54.87) | 15.05 (10.58; 20.98) | 1.00 | 1.00 |
| Without a partner | 153 (45.13) | 22.88 (16.87; 30.25) | 1.67 (0.96; 2.90) | 1.67 (0.78; 3.55) |
| Children | ||||
| No | 183 (53.98) | 21.31 (15.95; 27.88) | 1.49 (0.85; 2.61) | 1.10 (0.45; 2.67) |
| Yes | 156 (46.02) | 15.38 (10.50; 21.98) | 1.00 | 1.00 |
| Family income | ||||
| Up to 5 minimum wage | 229 (67.55) | 18.78 (14.21; 24.40) | 1.04 (0.58; 1.87) | 1.58 (0.78; 3.20) |
| > 5 minimum wage | 110 (32.45) | 18.18 (12.00; 26.59) | 1.00 | 1.00 |
| Working in person-care as a physiotherapist | ||||
| No | 121 (35.69) | 23.14 (16.44; 31.55) | 1.57 (0.90; 2.75) | 1.89 (0.97; 3.67) |
| Yes | 218 (64.31) | 16.06 (11.73; 21.58) | 1.00 | 1.00 |
| Adequately practicing the measures of social distancing | ||||
| No | 44 (12.98) | 25.00 (14.29; 39.99) | 1.56 (0.74; 3.28) | 1.19 (0.50; 2.80) |
| Yes | 295 (87.02) | 17.63 (13.67; 22.43) | 1.00 | 1.00 |
| Confirmed diagnosis of COVID-19 | ||||
| No | 315 (92.92) | 17.78 (13.92; 22.42) | 1.00 | 1.00 |
| Yes | 24 (7.08) | 29.17 (14.31; 50.38) | 1.90 (0.75; 4.81) | 1.75 (0.57; 5.36) |
| Housework | ||||
| Not at all/slightly/moderately | 257 (75.81) | 13.62 (9.92; 18.41) | 1.00 | 1.00 |
| Very/extremely | 82 (24.19) | 34.15 (24.64; 45.12) | 3.29 (1.84; 5.87) | 2.76 (1.40; 5.46) |
| Care/relationship with children | ||||
| Not at all/slightly/moderately | 287 (84.66) | 18.12 (14.06; 23.03) | 1.00 | 1.00 |
| Very/extremely | 52 (15.34) | 21.15 (12.02; 34.50) | 1.21 (0.58; 2.52) | 0.53 (0.19; 1.52) |
| Relationship with the partner | ||||
| Not at all/slightly/moderately | 285 (84.07) | 14.74 (11.06; 19.37) | 1.00 | 1.00 |
| Very/extremely | 54 (15.93) | 38.89 (26.77; 52.55) | 3.68 (1.95; 6.97) | 4.06 (1.79; 9.21) |
| Professional overload | ||||
| Not at all/slightly/moderately | 225 (66.37) | 16.00 (11.75; 21.42) | 1.00 | 1.00 |
| Very/extremely | 114 (33.63) | 23.68 (16.72; 32.41) | 1.63 (0.93; 2.85) | 1.32 (0.69; 2.55) |
| Concern about financial issues | ||||
| Not at all/slightly/ moderately | 165 (48.67) | 11.52 (7.44; 17.39) | 1.00 | 1.00 |
| Very/extremely | 174 (51.33) | 25.29 (19.35; 32.32) | 2.60 (1.45; 4.68) | 2.24 (1.15; 4.35) |
| Concern about being infected | ||||
| Not at all/slightly/moderately | 129 (38.05) | 11.63 (7.11; 18.46) | 1.00 | 1.00 |
| Very/extremely | 210 (61.95) | 22.86 (17.65; 29.06) | 2.25 (1.20; 4.22) | 1.06 (0.47; 2.38) |
| Concern about close people/family members being infected | ||||
| Not at all/slightly/moderately | 58 (17.11) | 6.90 (2.58; 17.16) | 1.00 | 1.00 |
| Very/extremely | 281 (82.89) | 21.00 (16.61; 26.18) | 3.59 (1.25; 10.31) | 1.73 (0.48; 6.19) |
| Restriction of leisure/social interaction | ||||
| Not at all/slightly/ moderately | 125 (36.87) | 12.00 (7.34; 19.02) | 1.00 | 1.00 |
| Very/extremely | 214 (63.13) | 22.43 (17.31; 28.54) | 2.12 (1.13; 3.97) | 1.42 (0.68; 2.96) |
| Loneliness | ||||
| Not at all/slightly/ moderately | 246 (72.57) | 14.23 (10.37; 19.20) | 1.00 | 1.00 |
| Very/extremely | 93 (27.43) | 30.11 (21.60; 40.25) | 2.60 (1.47; 4.59) | 1.40 (0.71; 2.76) |
OR- odds ratio; CI = confidence interval; COVID-19 = coronavirus disease 2019.
Participants who reported having a lot or extreme concern with housework (OR = 2.76; 95% CI: 1.40; 5.46), with their relationship with the partner (OR = 4.06; CI 95 %: 1.79; 9.21) and with financial issues (OR = 2.24; 95% CI: 1.15; 4.35) were more likely to report high perceived stress levels (table 1).
DISCUSSION
After multivariate analysis, PTs’ high levels of perceived stress remained associated with the following psychosocial demands: feeling high or extreme concern about housework, high or extreme concern about the relationship with their partner, and high or extreme concern about financial issues. Sociodemographic and clinical factors were not associated with high levels of perceived stress among these Brazilian female PTs during the pandemic.
Some sociodemographic factors included in the current study (like age1,2,16, marital status1,16, and family income2) were previously associated with stress in health professionals during the COVID-19 pandemic, which differs from our results. However, none of these studies analyzed the association of these variables specifically with high-stress perception levels, defined as scores equal to or above the 80th percentile of the PSS-1023. To the best of our knowledge, this is the first study about the factors associated with high levels of perceived stress levels in female PTs during the pandemic, which is relevant since scores equal to or above the 80th percentile of the PSS-10, which have been considered significant indicators of pathology23.
The effects of biological, physiological, sociocultural elements on the prevalence of stress in women have been discussed since before the pandemic25-26. The three psychosocial demands associated to high perceived stress levels in present study seems to be related to the socio-cultural elements that comprise gender and may be determinants in the health-disease process, although sometimes ignored by biomedical research27. The different social roles assigned to men and women may explain differences in the impacts of the pandemic between the sexes8,27,28.
A multi-country study, including data from the United States, Canada, Denmark, Brazil, and Spain, evidenced that during the COVID-19 pandemic, women spent more time on tasks such as household chores and childcare than men29. These challenges for female workers have also been reported in others studies30-31. Although it has not been investigated specifically in female health workers the association between household chores and stress, it was reported that the scientific productivity of female academics has been disproportionately affected due to increasing challenges as family responsibilities, domestic labor, childcare, and others, during the pandemic31. Moreover, the prementioned multi-country study showed that the women reported lower happiness, to the extent they spent more time on housework31. The disparities in time use by gender during the pandemic can explain the association between extreme concern about housework and perceived stress observed in the present study since participants who reported a high or extreme concern about housework were more likely to report high perceived stress levels.
Marital status did not predict the high stress perceived levels in this study, which corroborates a study conducted with nurses in Saudi Arabia32 but diverges from studies conducted with physicians1 and PTs16, in which married individuals reported lower levels of perceived stress than non-married ones16,32. However, in the current study, participants who reported a high or extreme level of concern about their relationship with their partner were more likely to report a high level of perceived stress. Although we did not find any study analyzing this psychosocial demand among health professionals, an Austrian study with the general population showed that the lockdown was a challenge, especially for couples with poor relationships. In that study, relationship per se was not a risk or a protective factor for mental health during COVID-19. However, the relationship quality was. A poor relationship was a risk factor, while a good relationship was a protective factor, compared to no relationship33. Indeed, an increase in family stress and domestic violence occurred during the COVID-19 pandemic34.
In this study, a high and extreme concern with financial issues was associated with a higher perceived stress. Gausman & Langer8 reported that financial uncertainties can have the effect of increasing psychological suffering for women. Moreover, economic inequalities experienced by women in the labor market have been pointed as one of the factors of psychological overload and increasing the predisposition to the development of depressive symptoms, anxiety, and stress33,35. According to Barbosa, Costa, and Heckscher36, in Brazil, women, compared to men, had a greater deterioration in working conditions, with loss of occupation, due to the COVID-19 pandemic. These facts should be considered in the formulation of public policies to minimize the economic impact of this pandemic.
The results highlight the importance of studying gender differences in research that assesses the effects of the COVID-19 pandemic on mental health. In addition, the results show the need to adopt measures to address the mental suffering of health professionals during the pandemic and public policies that minimize the impact of gender and professional inequalities historically present in several countries.
This study had three main limitations. The first limitation was the convenience sample, which precludes the generalization of the results. The second limitation was the cross-sectional design, which limits the results to a single point in time; therefore, it does not show the dynamics of changes in the level of perceived stress during the pandemic. Finally, the third limitation was the assessment of stress using a self-report questionnaire, which is less reliable than a professional assessment. Although, the questionnaire PSS-10 is a validated and largely used tool for stress screening.
CONCLUSION
In this sample of Brazilian female physiotherapists, during the COVID-19 pandemic, the psychosocial demands associated with high levels of perceived stress were high or extreme concern about housework, or about the relationship with the partner, or financial issues. The sociodemographic and clinical factors were not associated with high levels of stress perception in this population.
