Generalized anxiety disorder and associated factors in primary health care workers in Minas Gerais,Brazil

Abstract

BACKGROUND:

The COVID-19 pandemic had direct and indirect impacts on public health, also affecting the mental health of the population.

OBJECTIVE:

To analyze symptoms of generalized anxiety disorder (GAD) and associated factors, in primary health care (PHC) professionals.

METHODS:

Cross-sectional and analytical study conducted with professionals who work in the Primary Health Care (PHC) of the Northern health macro-region of the state of Minas Gerais, Brazil. Data collection was carried out through an online, self-administered questionnaire, made available from August 27, 2021, to October 30, 2021 using the Google Forms tool. The questionnaire included sociodemographic questions as well as questions related to the history of anxiety and work during the pandemic. To assess anxiety symptoms, the General Anxiety Disorder-7 (GAD-7) instrument was used. Data treatment consisted of descriptive analysis of the variables, bivariate analysis followed by multivariate Poisson Regression with robust variance.

RESULTS:

702 health professionals participated in the study and the general prevalence of GAD was 32.2%. Current anxiety symptoms were self-reported by 37.6% of the participants. In the final model, the associated factors identified were: female sex (PR = 1.82; 95% CI = 1.17–2.84; p = 0.007), previous symptoms (PR = 1.58; 95% CI = 1.19–2.10; p = 0.002) and (PR = 2.68; 95% CI = 2.00–3.62; p < 0.001) current self-reported anxiety.

CONCLUSION:

The results show the need to implement actions in mental health promotion and anxiety prevention, through the dissemination of information about mental health care, health education activities, encouraging the adoption of healthy habits and professional monitoring when necessary.

Keywords

Anxiety health personnel primary health care COVID-19 pandemics mental disorders

1 Introduction

In Hubei Province, China, an outbreak of pneumonia caused by a new type of coronavirus was reported and associated with the local food market in December 2019 [1]. This disease is caused by SARS-CoV-2, received the name of COVID-19, and was declared a pandemic in March 2020 by the World Health Organization (WHO). It is a contagious disease that can be lethal, depending on the conditions of each infected patient [1, 2].

With the COVID-19 pandemic, health services had to reorganize their work processes due to the increasing number of positive cases of the disease, which require greater attention from health professionals. Additionally, the lack of hospital beds has been observed in countries with insufficient capacity for hospitalizations [3]. However, publications highlight the importance of strengthening Primary Health Care (PHC) in the fight against COVID-19 in the context of the pandemic [4, 5]. With its roles and work processes, PHC has been fundamental in health surveillance within its territories and in the monitoring and management of patients with mild and moderate symptoms. Furthermore, PHC acts as a care coordinator for cases that need to be referred to the tertiary level of care [4, 5].

The work overload of health professionals in response to COVID-19 has had several consequences on their health status. The manifestation of symptoms of physical and, mainly, mental stress is being widely reported to the scientific community [6–10]. Generalized Anxiety Disorder (GAD) is a disorder that can lead to a loss of quality of life and is among the ten leading causes of years lived with disability. Brazil has the highest prevalence of anxiety in the world [11]. In a systematic review, the findings on the prevalence of anxiety in health professionals showed results that ranged from 22.2% to 33.0% [12]. However, the prevalence of this disorder in this population is higher than in the general population [13].

To our knowledge, studies involving the assessment of the prevalence of anxiety symptoms in the different professional categories of PHC in Brazil are unknown, as well as their factors associated with the COVID-19 pandemic. Thus, the objective of this study is to analyze GAD symptoms, as well as their associated factors, in PHC health professionals.

2 Methods

A quantitative, descriptive, analytical, and cross-sectional study was conducted in the northern health macro-region of Minas Gerais (MG), Brazil. This region is composed of the Regional Health Superintendence (SRS) of Montes Claros, which comprises 54 cities, the Regional Health Management (GRS) of Januária, covering 25 cities, and the GRS of Pirapora, covering seven cities, presenting a total of 86 target municipalities for the present study.

The study participants were health professionals who work in PHC in the North health macro-region of Minas Gerais. The study universe, verified in August 2021 using TABNET system [14] developed by DATASUS to generate information from the Unified Health System databases, was composed of 8,968 professionals. The inclusion criteria adopted were: being a health professional in APS and working in one of the cities that compose the macro-region studied. Individuals who were on vacation or on service leave for any reason during the data collection period were excluded.

The sample size calculation was performed using the following statistical criteria: population size of 8,968, a confidence level of 95%, an estimated prevalence of 32% [15], a margin of error of 5%, and a correction for design effect (DEFF = 2). Based on these parameters, a minimum of 645 health professionals was required for the study.

Sampling was done using a convenience method, obtained through the snowball technique [16]. The responsible researcher contacted the SRS of Montes Claros and the other two GRS of the North macro-region to obtain the contacts of the respective PHC coordinators of the cities included in the research. Invitations were sent to the coordinators via email and social networks (WhatsApp and Instagram), and they sent the invitations with the link to access the questionnaire to health professionals in their respective cities for online data collection. The data collection took place from August 27, 2021, to October 30, 2021. The data collection process is described in Fig. 1.

Fig. 1

Flowchart of the data collection process. ^aPrimary health care.

The variables were measured using an online, self-administered questionnaire made available through the Google Forms® tool. The variables used for the characterization of study participants included sex, age group, marital status, income, performance level, professional category, region of activity, and whether they worked on the front line of COVID-19. The contagion of COVID-19 was measured by the question “Have you had COVID-19?". For the history of anxiety symptoms, the variables included previous and current anxiety symptoms, previous and current psychological and/or psychiatric follow-up, and previous and current use of anxiolytic medication. Work overload during the COVID-19 pandemic was measured using the response options “I worked less than usual”, “I worked the same way I used to”, “I worked more than usual and felt overwhelmed”.

The dependent variable of the study was the presence of GAD symptoms, measured by the General Anxiety Disorder-7 (GAD-7) instrument. The GAD-7 is a validated instrument, and widely used in studies. The questionnaire consists of seven questions that assess symptoms experienced by the respondent, including feeling nervous, anxious, or on edge; not being able to stop or control worrying; worrying too much about different things; trouble relaxing; being so restless that it is hard to sit still; becoming easily annoyed or irritable; and feeling afraid as if something awful might happen. The answer options for the questions included “Not at all,” “several days,” “more than half the days,” and “nearly every day” and were answered using a Likert scale with response values ranging from zero to three points [17].

The GAD-7 questionnaire produces scores ranging from 0 to 21 points, with a result of 0–4 classified as minimum anxiety, 5–9 as mild anxiety, 10–14 as moderate anxiety, and 15–21 as severe anxiety. A cut-off point of ≥10 was used in this study to assess the presence of anxiety symptoms. At this cut-off point, the scale has a sensitivity and specificity of 89% and 82%, respectively [17].

It is worth noting that the research team prepared a booklet with information related to mental health care for health professionals. The booklet was organized to provide participants with relevant guidelines on the topic of anxiety and common mental disorders. After completing the questionnaire, participants had access to the material.

The data obtained from the research were entered into the Statistical Package for the Social Sciences for Windows® (SPSS) program. Descriptive analysis of the variables was performed, as well as bivariate analysis (simple Poisson regression) to verify associations between independent variables and the outcome, and multiple analysis (Poisson regression with robust variance). For the multiple analysis, variables associated with a significance level equal to or less than 20% (p≤0.20) were included and the variables that showed an association at a level equal to or less than 5% (p≤0.05) were maintained in the final model. The multicollinearity was evaluated by the variance inflation factor (VIF) values and the goodness of fit of the model was evaluated by the deviance test.

This study was conducted in accordance with the Declaration of Helsinki of 1964 and its later amendments, with Resolution No. 466 of December 12, 2012 of the National Health Council of the Ministry of Health and the Circular Letter No. 1/2021 of the National Research Ethics Commission, which presents guidelines for conducting research in a virtual environment, including data security and privacy issues. The research was approved by the Institutional Research Ethics Committee (#4.838.846/CAAE n° 47795821.7.0000.5146).

3 Results

A total of 741 responses were recorded from August 27 to October 30, 2021, with 39 responses not meeting the inclusion criteria, as they were answered by professionals who were not in the health area, and, for this reason, were excluded. Thus, there were 702 valid responses of health professionals from 61 cities among the 86 in the macro-region of Minas Gerais, with the majority of participants being female (84.5%). The results also show that the majority were in the age group of 19 to 39 years (71.5%), with a mean of 35.31 years (standard deviation of σ 8.35), married (55.7%) and with income from 1 to 2 minimum salaries (55.4%) (Table 1).

Table 1
Characterization of health professionals in the northern macro-region of Minas Gerais (n = 702), 2021

Variables n %

Sex

Male 109 15.50

Female 593 84.50

Age range (years)

19 a 30 226 32.20

31 a 39 276 39.30

>40 200 28.50

Marital status

Single 259 37.10

Married 389 55.70

Widower 5 0.70

Divorced 46 6.60

Monthly income (minimum salary)

1 a 2 386 57.40

2 a 4 205 30.50

4 a 6 52 7.70

6 a 8 11 1.60

>de 8 19 2.80

Educational level of the position

Medium level 233 33.20

Technical level 85 12.10

Higher level 384 54.70

Work region

SRS^† Montes Claros 462 66.20

GRS^‡ Pirapora 66 9.50

GRS^‡ Januária 170 24.40

Professional category

Community health agent 222 31.60

Dentist 91 13.00

Nurse 168 23.90

Nurse technician 77 11.00

Other professions 144 20.50

Working on the frontline of COVID-19

No 166 24.20

Yes 520 75.80

Tested positive for COVID-19

No 520 74.10

Yes 182 25.90

Work during the pandemic

I worked less than usual 73 10.80

I worked the same way I was used to 219 32.50

I worked harder than usual and felt overwhelmed 382 56.70

Variables	n	%
Sex
Male	109	15.50
Female	593	84.50
Age range (years)
19 a 30	226	32.20
31 a 39	276	39.30
>40	200	28.50
Marital status
Single	259	37.10
Married	389	55.70
Widower	5	0.70
Divorced	46	6.60
Monthly income (minimum salary)
1 a 2	386	57.40
2 a 4	205	30.50
4 a 6	52	7.70
6 a 8	11	1.60
>de 8	19	2.80
Educational level of the position
Medium level	233	33.20
Technical level	85	12.10
Higher level	384	54.70
Work region
SRS^† Montes Claros	462	66.20
GRS^‡ Pirapora	66	9.50
GRS^‡ Januária	170	24.40
Professional category
Community health agent	222	31.60
Dentist	91	13.00
Nurse	168	23.90
Nurse technician	77	11.00
Other professions	144	20.50
Working on the frontline of COVID-19
No	166	24.20
Yes	520	75.80
Tested positive for COVID-19
No	520	74.10
Yes	182	25.90
Work during the pandemic
I worked less than usual	73	10.80
I worked the same way I was used to	219	32.50
I worked harder than usual and felt overwhelmed	382	56.70

^†Superintendência Regional de Saúde (Regional Health Superintendence). ^‡Gerência Regional de Saúde (Regional Health Management).

The overall prevalence of GAD was 32.2%. Table 2 shows the variables related to anxiety and the mental health history of professionals. 37.6% self-reported current anxiety symptoms and according to the GAD-7 34.8% had moderate symptoms. In terms of current follow-up with a mental health professional, 14.8% answered affirmatively, and 21.7% reported using anxiolytics.

Table 2

Anxiety and mental health history of health professionals in the North macro-region of Minas Gerais (n = 702), 2021

Variables	n	%
Anxiety level
Minimal	232	33.00
Mild	244	34.80
Moderate	120	17.10
Severe	106	15.10
Have you ever had symptoms of anxiety?
No	298	43.10
Yes	394	56.90
Are you currently experiencing symptoms of anxiety?
No	431	62.40
Yes	260	37.60
Have you ever had psychological or psychiatric follow-up?
No	441	63.40
Yes	255	36.60
Current psychological or psychiatric follow-up?
No	594	85.20
Yes	103	14.80
Have you ever used anxiolytics?
No	561	79.90
Yes	141	20.10
Current use of anxiolytics
No	531	78.30
Yes	147	21.70

Table 3 presents the prevalence, prevalence ratio (PR) and respective p value of the association between the outcome variable and the independent variables of the study. The following variables had a p-value <0.20 and were included in the multiple analysis: sex, age group, marital status, performance level, professional category, frontline work, presence of previous and current anxiety symptoms, previous and current psychological and/or psychiatric follow-up, previous and current use of anxiolytic, and work load during the pandemic.

Table 3

Bivariate analysis between anxiety (GAD-7) and independent variables in health professionals from the northern macro-region of Minas Gerais (n = 702), 2021

Variables	Anxiety				RP (IC95%)	p value
	No		Yes
	n	%	n	%
Sex
Male	93	85.30	16	14.70	1
Female	383	64.60	210	35.40	2.41(1.51–3.84)	0.000
Age range (years)
19 a 30	167	73.90	59	26.10	1
31 a 39	172	62.30	104	37.70	1.44(1.10–1.88)	0.007
>40	137	68.50	63	31.50	1.20(0.89–1.62)	0.220
Marital status
Single	186	71.80	73	28.20	1
Married	261	67.10	128	32.90	1.16(0.91–1.48)	0.207
Widower	3	60.00	2	40.00	1.41(0.47–4.22)	0.529
Divorced	25	54.30	21	45.70	1.62(1.11–2.34)	0.011
Monthly income (minimum salary)
1 a 2	255	66.10	131	33.90	1
2 a 4	141	68.80	64	31.20	0.92(0.71–1.17)	0.506
4 a 6	37	71.20	15	28.80	0.85(0.54–1.33)	0.478
6 a 8	7	63.60	4	36.40	1.07(0.48–2.37)	0.865
>de 8	14	73.70	5	26.30	0.77(0.36–1.66)	0.515
Educational level of the position
Medium level	169	72.50	64	27.50	1
Technical level	50	58.80	35	41.20	1.49(1.07–2.08)	0.016
Higher level	257	66.90	127	33.10	1.20(0.93–1.55)	0.150
Work region
SRS^† Montes Claros	310	67.10	152	32.90	1.14(0.87–1.49)	0.336
GRS^‡ Pirapora	43	65.20	23	34.80	1.20(0.80–1.81)	0.359
GRS^‡ Januária	121	71.20	49	28.80	1
Professional category
Community health agente	161	72.50	61	27.50	1.01(0.72–1.42)	0.934
Dentist	69	75.80	22	24.20	0.89(0.56–1.40)	0.622
Nurse	96	57.10	72	42.90	1.58(1.14–2.17)	0.005
Nurse technician	45	58.40	32	41.6	1.53(1.05–2.23)	0.026
Other professions	105	72.90	39	27.10	1
Working on the frontline of COVID-19
No	125	75.30	41	24.70	1
Yes	338	65.00	182	35.00	1.41(1.06–1.89)	0.019
Tested positive for COVID-19
No	357	68.70	163	31.30	1
Yes	119	65.40	63	34.60	1.10(0.87–1.39)	0.411
Have you ever had symptoms of anxiety?
No	252	84.60	46	15.40	1
Yes	216	54.80	178	45.20	2.97(2.19–3.90)	0.000
Are you currently experiencing symptoms of anxiety?
No	367	85.20	64	14.80	1
Yes	102	39.20	158	60.80	4.09(3.19–5.23)	0.000
Have you ever had psychological or psychiatric follow-up?
No	331	75.10	110	24.90	1
Yes	142	55.70	113	44.30	1.77(1.43–2.19)	0.000
Current psychological or psychiatric follow-up?
No	424	71.40	170	28.60	1
Yes	49	47.60	54	52.40	1.83(1.46–2.29)	0.000
Have you ever used anxiolytics?
No	410	73.10	151	26.90	1
Yes	66	46.80	75	53.20	1.97(1.60–2.42)	0.000
Current use of anxiolytics
No	390	73.40	141	26.60	1
Yes	66	44.90	81	55.10	2.07(1.69–2.54)	0.000
Work during the pandemic
I worked less than usual	56	76.70	17	23.30	1
I worked the same way I was used to	177	80.80	42	19.20	0.82(0.50–1.35)	0.444
I worked harder than usual and felt overwhelmed	223	58.40	159	41.60	1.78(1.15–2.75)	0.009
General prevalence	476	67.80	226	32.20	–	–

^†Superintendência Regional de Saúde (Regional Health Superintendence). ^‡Gerência Regional de Saúde (Regional Health Management).

In the multiple analysis, a statistically significant association was found between the variables of sex, profession, and presence of previous and current anxiety symptoms. The highest prevalence was found in female professionals (p = 0.008) and in those who reported previous or current symptoms of anxiety (p = 0.002 and p = 0.000). The variables included in the multiple analysis did not show multicollinearity, as the VIF values were below 10 and tolerances above 0.20 (Table 4).

Table 4

Multiple analysis between anxiety (GAD-7) and independent variables in health professionals from the northern macro-region of Minas Gerais (n = 702), 2021

Variables	RP (IC95%)	p value
Sex
Male	1
Female	1.82(1.17–2.84)	0.008
Have you ever had symptoms of anxiety?
No	1
Yes	1.58(1.19–2.10)	0.001
Are you currently experiencing symptoms of anxiety?
No	1
Yes	2.69(2.00–3.62)	0.000

4 Discussion

It is noteworthy that the prevalence of anxiety found in this study corroborates the results of a systematic review with meta-analysis that evaluated the impact of the COVID-19 pandemic on the mental health of healthcare professionals and the general public. The review found an overall prevalence of anxiety of 33.0% (28.0% – 38.0%) [18]. A similar study identified a prevalence of 24.0%, and when evaluating only articles that used the GAD-7, the same instrument used in this study, a prevalence of 36.9% in healthcare professionals was observed in subgroup analysis [19].

The findings of research carried out in Brazil with healthcare professionals from medium and high complexity services during the COVID-19 pandemic period identified anxiety ranging from 31.3% to 48.9% [20–23]. Studies analyzed in a systematic review [19] show a wide variation in the prevalence of anxiety among these professionals, ranging from 10.0% to 44.7%. This variation can be explained by the heterogeneity of the studies, the variety of instruments used in the research, and the fact that they were conducted in different places and times during the pandemic.

A study carried out in Spain [9] compared anxiety symptoms between healthcare professionals working in hospitals and PHC professionals, with prevalences of 35.0% and 37.0%, respectively. Additionally, the risk of developing anxiety was significantly higher in PHC professionals (32.0%) compared to hospital professionals (18.0%). In China, when evaluating anxiety in 33,706 hospital professionals, researchers found a general prevalence of anxiety of 24.4% [24], which is lower than that observed in the present investigation.

Although there is not a high level of evidence for the difference between the prevalence of anxiety in the two groups, Londoño-Ramírez et al. [9] explain the possibility that, as PHC is the first point of contact in the health system, the work overload, uncertainty and fear of being infected by COVID-19 or transmitting it to a family member may have been greater in this group.

Women presented 2.41 times more chances of having anxiety symptoms than men, remaining in the final model of the multiple analysis with an adjusted PR of 1.85. The scientific literature has shown that women are at a greater risk of developing symptoms of anxiety, with a 1.9 times greater risk, which persists even when associated with other variables such as income, ethnicity, and geographic location [25]. A possible explanation for the higher prevalence of anxiety in women is the social conditions in which they live, such as a double burden, social attribution of the female role of care, lack of family support, lack of autonomy, male chauvinism, and being more often victims of domestic violence. The pandemic is a scenario that can aggravate these social factors [23, 26].

The age group from 31 to 39 years old had the highest prevalence of GAD. This result differs from a study carried out in China [27] whose findings, converging with other studies, show that participants younger than 35 years old had a higher prevalence of anxiety symptoms. Another study [28] that assessed the impact of the pandemic on the psychological state of 1653 participants from 63 countries demonstrated a greater vulnerability to the manifestation of stress, depression, and anxiety in the age group of 18 to 35 years. A similar result was found in a systematic review with meta-analysis [29] that identified a higher prevalence of anxiety and depression in the younger population, particularly in the age group of 20–24 years. Due to school closures and broader social restrictions, the physical gathering of young individuals has been hindered, impacting their learning capabilities and limiting peer interaction. Additionally, young people are at a higher risk of unemployment during and after economic crises, such as the one caused by the COVID-19 pandemic, compared to older individuals. These factors are possible explanations for the higher prevalence of anxiety and other mental disorders in this group [30].

In relation to marital status, people who live without a partner may be at a greater risk of developing symptoms of anxiety, as loneliness is a factor that can lead to higher levels of anxiety, as pointed out by Ta et al. [31]. In this study, the category that presented the highest prevalence was divorced, and the other categories did not present a statistically significant difference in the prevalences.

Although no significant difference was found between anxiety symptoms and income, studies analyzed in a review [32] show that people who live with fewer financial resources are at a greater risk of presenting symptoms, as poverty is associated with stressful environmental factors [33], greater exposure to violence and crimes [34], greater difficulty in accessing healthcare services, and greater concern and uncertainty about the future and health crises, such as the COVID-19 pandemic, that can aggravate this situation [32].

Regarding education, the intermediate level of professional education presented a higher prevalence of anxiety compared to the technical and higher levels. However, higher levels of education generally increase access to information related to healthcare and provide more opportunities for making choices, setting goals, and aspirations in life, which can lead to the adoption of healthier habits [35]. It is noteworthy that among the technical professionals, the majority were nursing technicians, professionals who were at the frontline in the fight against COVID-19 with higher exposure to the virus, increased workload, lack of adequate resources, and concerns regarding contagion and transmission of the virus [36, 37]. These factors possibly contributed to the higher prevalence found in this group.

It is observed that higher income and education levels are protective socioeconomic factors regarding mental disorder symptoms in general, including access to treatment, as shown in a study [38] that analyzed 16,753 patients diagnosed with mental disorders in 25 countries. The study identified that few patients have adequate access to treatment, even in high-income countries, with greater inequality in treatment access for individuals with low levels of education and income.

Among the professions with the highest number of participants, the prevalence of anxiety in nursing professionals (nurses and nursing technicians) stands out, which was higher than other professional categories. Nursing professionals mostly worked on the frontline in the fight against COVID-19 and studies have shown high levels of anxiety in this professional category [21, 23].

Professionals who worked on the front line in the fight against COVID-19 showed a higher prevalence of anxiety symptoms in the bivariate analysis. This result is consistent with the findings of other studies [13, 39] that compared symptoms between frontline healthcare professionals and other healthcare professionals. Cai et al. [40] identified concerns about personal safety and that of their families, the lack of protective equipment, and increased work overload as variables associated with higher levels of anxiety. Although other studies [41, 42] have shown that patients who have had COVID-19 may have anxiety symptoms during the period of infection and afterward, this study found no significant difference between a previous history of COVID-19 and anxiety symptoms.

Participants who answered “yes” to the variables “previous and current anxiety symptoms,” “previous and current psychological and/or psychiatric follow-up,” and “previous and current use of anxiolytic medication” had a higher prevalence of anxiety symptoms. Having a history of anxiety diagnosis is a risk factor for the manifestation of anxiety symptoms [42].

It is observed that 37.6% of participants reported current symptoms of anxiety; however, the overall prevalence, assessed by the GAD-7, was 32.2%. In both cases, the number of professionals is greater than those who reported being in psychological or psychiatric care and using anxiolytics, which were 14.8% and 21.7%, respectively. This information shows that there is a significant number of healthcare workers who have symptoms of anxiety and have not sought professional help. This situation can lead to a worsening of anxiety.

The professionals who reported working more during the pandemic and feeling overwhelmed had a higher prevalence of anxiety symptoms. This association between work overload and the manifestation of psychological symptoms is well documented by other studies [9, 43].

Regarding the level of anxiety, it was observed that the majority (34.8%) of the participants had a moderate level of anxiety, which can be understood as the presence of mild anxiety symptoms that, even if not currently causing significant impairment in the patient’s life, puts them at risk for the development of more severe symptoms [44].

The limitations of this study should be taken into consideration. The use of a self-administered questionnaire may have led to response and memory biases. Additionally, the convenience sampling method used due to the COVID-19 pandemic may have limited the representativeness of the sample. Moreover, the online delivery of the survey may have excluded professionals who do not have internet access or are not proficient in using the internet.

It is noteworthy that this study is a pioneer in assessing anxiety symptoms among PHC professionals in Brazil. Seeking to understand the mental health conditions of health professionals, especially in PHC, in the context of the COVID-19 pandemic is essential to comprehend the impacts of the new disease on workers’ health. Additionally, efforts must be made to establish strategies that reduce these damages.

5 Conclusion

The prevalence of GAD was observed in 32.2% of the PHC professionals studied, with the majority experiencing a mild level of anxiety, placing them at risk of developing more severe symptoms. Female gender and self-reported previous and current anxiety symptoms were associated factors identified by the multiple analysis. A significant number of professionals reported experiencing anxiety symptoms but were not receiving professional care, highlighting the need to raise awareness among this population about the importance of mental health care.

Also noteworthy is the importance of developing actions to promote mental health and prevention of anxiety for PHC health professionals. Health education activities on the subject, implementation of listening spaces, encouraging the adoption of healthy habits, psychological and/or psychiatric support and follow-up when necessary are suggested.

Footnotes

Ethical approval

The study was approved by the State University of Montes Claros (#4.838.846/CAAE no 47795821.7.0000.5146).

Informed consent

All participants signed the informed consent form.

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgments

The authors thank the Minas Gerais Research Support Foundation (FAPEMIG), the National Council for Scientific and Technological Development (CNPQ), the Coordination for the Improvement of Higher Education Personnel (CAPES), the Health Regional Superintendence of Montes Claros, and the Health Regional Managements of Januária and Pirapora.

Funding

The authors report no funding.

References

Tsang

, Chan

LWC

, Cho

WCS

, Yu

ACS

, Yim

AKY

, Chan

AKC

, et al. An update on COVID-19 pandemic: The epidemiology, pathogenesis, prevention and treatment strategies. Expert Rev Anti Infect Ther 2021;19(7):877–88.

Rothan

, Byrareddy

. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun 2020;109:102433.

Kandel

, Chungong

, Omaar

, Xing

. Health security capacities in the context of the COVID-19 outbreak: An analysis of International Health Regulations annual report data from 182 countries. Lancet. 2020;395(10229):1047–1053.

Prado

NMBL

, Rossi

TRA

, Chaves

SCL

, Barros

, Magno

, Santos

HLPC

, et al. The international response of primary health care to COVID- Document analysis in selected countries. Cad Saúde Pública 2020;36(12):e00183820.

Dunlop

, Howe

, Li

, Allen

. The coronavirus outbreak: The central role of primary care in emergency preparedness and response. BJGP Open.bjgpopen20X 2020;4(1):101041.

Lamb

, Gnanapragasam

, Greenberg

, Bhundia

, Carr

, Hotopf

, et al. Psychosocial impact of the COVID-19 pandemic on UK healthcare workers and ancillary staff: Initial baseline data from a cohort study collected during the first wave of the pandemic. Occup Environ Med 2021;78(11):801–8.

Julio

, Lourenção

, Penha

JGM

, Oliveira

AMN

, Nascimento

, Oliveira

, et al. Anxiety, depression, and work engagement in Primary Health Care nursing professionals. Rev Rene 2021;22:e70762.

Young

, Kolcz

, O’Sullivan

, Ferrand

, Fried

, Robinson

. Health care workers’ mental health and quality of life during COVID- Results from a mid-pandemic, national survey. Psychiatr Serv 2021;72(2):122–8.

Londoño-Ramírez

, García-Pla

, Bernabeu-Juan

, Pérez-Martínez

, Rodríguez-Marín

, Hofstadt-Román

. Impact of COVID-19 on the anxiety perceived by healthcare professional: Differences between Primary Care and Hospital Care. Int J Environ Res Public Health 2021;18(6):3277.

10.

Styra

, Hawryluck

, Mc

Geer A

, Dimas

, Sheen

, Giacobbe

, et al. Surviving SARS and living through COVID- Healthcare worker mental health outcomes and insights for coping. PLoS One 2021;16(11):e0258893.

11.

World Health Organization. Depression and other common mental disorders: Global health estimates. World Health Organization; 2017.

12.

Fernandez

, Sikhosana

, Green

, Halcomb

, Middleton

, Alananzeh

, et al. Anxiety and depression among healthcare workers during the COVID-19 pandemic: A systematic umbrella review of the global evidence. BMJ Open 2021;11(9):e054528.

13.

Alshekaili

, Hassan

, Said

, Sulaimani

, Jayapal

, Al-Mawali

, et al. Factors associated with mental health outcomes across healthcare settings in Oman during COVID- Frontline versus non-frontline healthcare workers. BMJ Open 2020;10:e042030.

14.

Brazil Ministry of Health, Datasus - IT department of the Brazilian Unified Health System; [cited 2023 May 7]. Available from: http://www.datasus.gov.br

15.

Alves

, Pedrosa

, Coimbra

, Miranzi

, Hass

. Prevalência de transtornos mentais comuns entre profissionais de saúde. Revista Enfermagem UERJ 2015;23(1):64–9.

16.

Kennedy-Shaffer

, Qiu

, Hanage

. Snowball sampling study design for serosurveys early in disease outbreaks. Am J Epidemiol 2021;190(9):1918–27.

17.

Spitzer

, Kroenke

, Williams

, Lowe

. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166(10):1092–7.

18.

Luo

, Guo

, Yu

, Jiang

, Wang

. The psychological and mental impact of coronavirus disease (COVID19) on medical staff and general public – A systematic review and metaanalysis. Psychiatry Research 2020;291:113190.

19.

Pappa

, Ntella

, Giannakas

, Giannakoulis

, Papoutsi

, Katsaounou

. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun 2020;88:901–7.

20.

Dantas

, Filho

, Silva

, Silveira

, Dantas

, Meira

. Fatores associados à ansiedade em residentes multiprofissionais em saúde durante a pandemia por COVID-19. Rev Bras Enferm 2021;74(1):e20200961.

21.

Santos

KMR

, Galvão

MHR

, Gomes

, Souza

, Medeiros

, Barbosa

. Depressão e ansiedade em profissionais de enfermagem durante a pandemia da covid-19. Esc Anna Nery 2021;25(spe):e20200370.

22.

Civantos

, Bertelli

, Gonçalves

, Getzen

, Chang

, Long

, Rajasekaran

. Mental health among head and neck surgeons in Brazil during the COVID-19 pandemic: A national study. Am J Otolaryngol 2020;41(6):102694.

23.

Dal’Bosco

, Floriano

, Skupien

, Arcaro

, Martins

, Anselmo

. A saúde mental da enfermagem no enfrentamento da COVID-19 em um hospital universitário regional. Rev Bras Enferm 2020;73(2):e20200434.

24.

Lixia

, Xiaoming

, Lei

, Su

, Wo

, Xin

, Jianmei

, Qi

, Ming

, Li

. A cross-sectional study of the psychological status of 33,706 hospital workers at the late stage of the COVID-19 outbreak. J Affect Disord 2022;297:156–68.

25.

Remes

, Brayne

, van

der Linde R

, Lafortune

. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav 2016;6(7):e00497.

26.

Serafim

, Durães

RSS

, Rocca

CCA

, Gonçalves

, Saffi

, Cappellozza

, et al. Exploratory study on the psychological impact of COVID-19 on the general Brazilian population. PLoS ONE 2021;16(2):e0245868.

27.

Huang

, Zhao

. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Research 2020;288:112954.

28.

Varma

, Junge

, Meaklim

, Jackson

. Younger people are more vulnerable to stress, anxiety and depression during COVID-19 pandemic: A global cross-sectional survey. Prog Neuropsychopharmacol Biol Psychiatry 2021;109:110236.

29.

COVID-19 Mental Disorders Collaborators. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in due to the COVID-19 pandemic. Lancet. 2021;398(10312):1700–12.

30.

Bell

DNF

, Blanchflower

. Young people and the great recession. Oxf Rev Econ Policy 2011;27:241–67.

31.

, Gesselman

, Perry

, Fisher

, Garcia JR. Stress of singlehood: Marital status , domain-specific

stress

, and

anxiety in a national U

. S. Sample. Journal of Social and Clinical Psychology 2017;36(6):461–85.

32.

Ridley

, Rao

, Schilbach

, Patel

. Poverty, depression, and anxiety: Causal evidence and mechanisms. Science. 2020;370(6522);eaay0214.

33.

Dean

, Schilbach

, Schofield

The Economics of Poverty Traps. Eds. Univ. Chicago Press 2018;57–118 Poverty and Cognitive Function Barrett CB, Carter MR, Chavas JP.

34.

Marmot

. Social determinants of health inequalities. The Lancet. 2005;365(9464):1099–104.

35.

Costa

, Branco

, Vieira

, Souza

LDM

, Silva

. Prevalência de ansiedade e fatores associados em adultos. Jornal Brasileiro de Psiquiatria 2019;68(2):92–100.

36.

Sánchez-Sánchez

, García-Álvarez

JÁ

, García-Marín

, Gutierrez-Serrano

, Alférez

MJM

, Ramirez-Vargas

. Impact of the COVID-19 pandemic on the mental health of nurses and auxiliary nursing care technicians-a voluntary online survey. Int J Environ Res Public Health 2021;18(16):8310.

37.

Oliveira

FES de

, Costa

, Dias

, Martelli

Júnior H

, Martelli

DRB

. Prevalência de transtornos mentais em profissionais de saúde durante a pandemia da COVID- Revisão sistemática. J bras psiquiatr 2022;71(4):311–20.

38.

Evans-Lacko

, Aguilar-Gaxiola

, Al-Hamzawi

, Alonso

, Benjet

, Bruffaerts

, et al. Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: Results from the WHO World Mental Health (WMH) surveys. Psychol Med 2018;48(9):1560–71.

39.

Cai

, Feng

, Huang

, Wang

, Lu

, et al. The mental health of frontline and non-frontline medical workers during the coronavirus disease (COVID-19) outbreak in China: A case-control study. J Affect Disord 2020;275:210–5.

40.

Cai

, Tu

, Ma

, Chen

, Fu

, Jiang

et al. Psychological impact and coping strategies of frontline medical staff in hunan between January and March during the outbreak of coronavirus disease (COVID-19) in Hubei, China. Med Sci Monit 2020;26:e924171.

41.

Taquet

, Sierra

, Geddes

, Harisson

. Bidirectional associations between COVID-19 and psychiatric disorder: Retrospective cohort studies of 4 COVID-19 cases in the USA. Lancet Psychiatry 2020;8(2):130–40.

42.

Mazza

, De

Lorenzo R

, Conte

, Poletti

, Vai

, Bollettini

, et al. Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors. Brain Behav Immun 2020;89:594–600.

43.

Sinsky

, Brown

, Stillman

, Linzer

. COVID-related stress and work intentions in a sample of US health care workers. Mayo Clin Proc Innov Qual Outcomes 2021;5(6):1165–73.

44.

Craske

, Stein

. Anxiety. The Lancet. 2016;388(10063):3048–59.