Pollock Alex, Campbell Pauline, Cheyne Joshua, Cowie Julie, Davis Bridget, McCallum Jacqueline, McGill Kris, Elders Andrew, Hagen Suzanne, McClurg Doreen, Torrens Claire, Maxwell Margaret
Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK.
Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, Edinburgh, UK.
Cochrane Database Syst Rev. 2020 Nov 5;11(11):CD013779. doi: 10.1002/14651858.CD013779.
Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. The World Health Organization (WHO) has warned about the potential negative impact of the COVID-19 crisis on the mental well-being of health and social care professionals. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.
Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.
On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions.
We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions.
Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together.
We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies). Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout. Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings. We are moderately confident that the following two factors were barriers to intervention implementation: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention. We are moderately confident that the following three factors were facilitators of intervention implementation: interventions that could be adapted for local needs; having effective communication, both formally and socially; and having positive, safe and supportive learning environments for frontline workers. We are moderately confident that the knowledge or beliefs, or both, that people have about an intervention can act as either barriers or facilitators to implementation of the intervention.
AUTHORS' CONCLUSIONS: There is a lack of both quantitative and qualitative evidence from studies carried out during or after disease epidemics and pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers. Alternative sources of evidence (e.g. from other healthcare crises, and general evidence about interventions that support mental well-being) could therefore be used to inform decision making. When selecting interventions aimed at supporting frontline workers' mental health, organisational, social, personal, and psychological factors may all be important. Research to determine the effectiveness of interventions is a high priority. The COVID-19 pandemic provides unique opportunities for robust evaluation of interventions. Future studies must be developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice, and with appropriate length of follow-up. Factors that may act as barriers and facilitators to implementation of interventions should be considered during the planning of future research and when selecting interventions to deliver within local settings.
疾病流行的证据表明，医护人员面临出现短期和长期心理健康问题的风险。世界卫生组织（WHO）已就2019冠状病毒病危机对卫生和社会护理专业人员心理健康的潜在负面影响发出警告。心理健康问题的症状通常包括抑郁、焦虑、压力以及其他认知和社会问题；这些问题会影响工作场所的功能。在疾病流行期间，可通过工作场所干预、支持基本日常需求的干预、心理支持干预、药物干预或这些干预措施中任何一种或全部的组合，来支持一线卫生和社会护理专业人员（本综述中的“一线工作者”）的心理健康和恢复力（应对压力负面影响的能力）。
目的1：评估旨在支持一线卫生和社会护理专业人员在疾病爆发、流行或大流行期间及之后恢复力和心理健康的干预措施的效果。目的2：确定可能影响旨在支持一线卫生和社会护理专业人员在疾病爆发、流行或大流行期间及之后恢复力和心理健康的干预措施实施的障碍和促进因素。
2020年5月28日，我们检索了Cochrane系统评价数据库、CENTRAL、MEDLINE、Embase、科学引文索引、心理学文摘数据库、护理学与健康照护领域数据库、全球医学索引数据库以及WHO信息共享机构知识库。我们还检索了正在进行的试验注册库和谷歌学术。我们检索了2002年以后的所有文献，无语言限制。
我们纳入了从2002年起参与者为在传染病爆发期间处于一线工作的卫生和社会护理专业人员的研究，这些传染病爆发被WHO归类为流行病或大流行。对于目的1，我们纳入了来自随机试验、非随机试验、前后对照研究和中断时间序列研究的定量证据，这些研究调查了与无干预、标准护理、安慰剂或注意力控制干预或其他积极干预相比，任何支持心理健康或恢复力的干预措施的效果。对于目的2，我们纳入了描述干预措施实施障碍和促进因素的研究的定性证据。本综述的关键结局是总体心理健康和恢复力。其他结局包括焦虑、抑郁或压力的心理症状；倦怠；其他心理健康障碍；工作场所人员配备；以及干预措施引起的不良事件。
两位综述作者独立将选择标准应用于摘要和全文，并通过讨论解决分歧。一位综述作者系统地提取数据，由另一位综述作者进行交叉核对。对于目的1，我们使用Cochrane“偏倚风险”工具评估有效性研究的偏倚风险。对于目的2，我们使用批判性评价技能计划（CASP）定性研究工具（用于定性研究）或评估重要和相关数据的方法（WEIRD）工具（用于描述性研究）评估方法学局限性。如果有直接证据，我们计划对结局进行成对比较的荟萃分析。两位综述作者提取了与实施障碍和促进因素相关的证据，围绕实施研究综合框架的领域进行组织，并使用GRADE-CERQual方法评估对每个发现的信心。我们计划进行总体综合分析，将定量和定性结果结合起来。
我们纳入了16项报告在疾病爆发期间实施旨在支持一线工作者恢复力或心理健康的干预措施的研究（严重急性呼吸综合征（SARS）：2项；埃博拉：9项；中东呼吸综合征（MERS）：1项；2019冠状病毒病：4项）。所研究的干预措施包括工作场所干预，如培训、结构和沟通（6项研究）；心理支持干预，如咨询和心理服务（8项研究）；以及多方面干预（2项研究）。目的1：一项纳入整群随机试验的混合方法研究，调查基于工作的干预措施的效果，但提供了非常低确定性的证据，表明培训一线医护人员提供心理急救对倦怠测量指标的影响。目的2：我们将所有16项研究纳入定性证据综合分析；我们将7项分类为定性研究，9项分类为描述性研究。我们从研究中报告的多个障碍和促进因素中确定了17个关键发现。我们对任何发现都没有高度信心；我们对6个发现有中等信心，对11个发现有低至非常低的信心。我们有中等信心认为以下两个因素是干预措施实施的障碍：一线工作者或他们工作的组织没有充分意识到支持其心理健康所需的内容；以及缺乏干预措施所需的设备、工作人员时间或技能。我们有中等信心认为以下三个因素是干预措施实施的促进因素：可以根据当地需求进行调整的干预措施；拥有正式和社交方面的有效沟通；以及为一线工作者提供积极、安全和支持性的学习环境。我们有中等信心认为人们对干预措施的知识或信念，或两者兼而有之，可以成为干预措施实施的障碍或促进因素。
在疾病流行和大流行期间或之后进行的研究中，缺乏定量和定性证据，无法为选择有利于一线工作者恢复力和心理健康的干预措施提供参考。因此，可以使用其他证据来源（例如来自其他医疗保健危机的证据，以及关于支持心理健康的干预措施的一般证据）为决策提供信息。在选择旨在支持一线工作者心理健康的干预措施时，组织、社会、个人和心理因素可能都很重要。确定干预措施有效性的研究是当务之急。2019冠状病毒病大流行提供了对干预措施进行有力评估的独特机会。未来的研究必须进行适当严格的规划，包括研究方案的制定、同行评审和透明报告，遵循最佳实践的指导和标准，并进行适当长度的随访。在未来研究的规划过程中以及在选择在当地环境中实施的干预措施时，应考虑可能成为干预措施实施障碍和促进因素的因素。
