Work ability and mental health at return to work after COVID-19: A descriptive study among healthcare workers

Abstract

BACKGROUND:

Healthcare workers (HCW) may experience anxiety and prolonged work schedules during pandemics. The mental health status after a COVID-19 infection and the work ability of HCW are interesting criteria in assessing their fitness to work at the return to work (RTW) medical visit.

OBJECTIVES:

To assess mental health and work ability after a COVID-19 infection among HCW at the RTW medical visit.

METHODS:

An observational cross-sectional and descriptive study was carried out among HCW of Charles Nicolle Hospital of Tunisia infected with COVID-19 from September to December 2020. Anxiety and depression were screened using the Hospital Anxiety and Depression Scale (HAD). The perceived ability to work at RTW was measured using the Work Ability Index (WAI).

RESULTS:

We included 531 HCW. The median age was 40 years. HCW belonged to surgical departments (36.9%) and were nurses (32.4%). The median delay to RTW was 15 days (IQR: 13–18). At the RTW medical visit, certain anxiety and depression were found in 36.5% and 33.3% of the patients respectively. The perceived work ability was evaluated as good to very good in 37.8% of cases. The delay to RTW increased proportionally with a better-perceived work ability (p = 0.007).

CONCLUSION:

Keywords

Mental health COVID-19 work ability healthcare worker

1 Introduction

COVID-19 infection control and return to work (RTW) are two health policies that must be balanced with potential shortages of healthcare workers (HCW). HCW, first-line fighters treating patients with COVID-19, are at a high risk of contamination and may endure mental health disorders. HCW may experience anxiety coexisting with prolonged work schedules. Assessing sources of stress allows decision-makers to develop appropriate ways to address these concerns and to provide specific support [1, 2]. The Department of Occupational Medicine of the Charles Nicolle Hospital of Tunisia arranged to comply with medical and legal recommendations since the early stages of the COVID-19 pandemic by scheduling medical visits for HCW to return to their work after a COVID-19 infection. Apart from the duration of isolation and the resolution of infection symptoms, several criteria should be considered in this medical evaluation. Thus, the mental health status after a COVID-19 infection and the work ability of the HCW were interesting criteria in assessing their fitness to work at the RTW medical visit. In this context, we aimed to evaluate the work ability after a COVID-19 infection among HCW of the Charles Nicolle Hospital and to assess the mental health problems at the RTW medical visit.

2 Methods

2.1 Study design

This was an observational cross-sectional and descriptive study.

2.2 Setting

The study included HCW of Charles Nicolle Hospital infected with COVID-19 from September to December 2020. They were examined at the Department of Occupational Medicine in an RTW medical visit. This visit was scheduled based on clinical assessment of symptoms and using the national protocol during this period [3 –5].

We have included all the HCW infected with COVID-19 during the period from September 8 to December 31, 2020, and who had their RTW medical visit in our department during or after this period. HCW who did not belong to our hospital (Nursing or medical students), and HCW who did not return to work (death; long-term sick leave) were not included. Cases with incomplete medical files and those who returned to work outside our hospital (medical trainees) were excluded from the study.

2.3 Variables

We consulted the medical files of the HCW infected with COVID-19 at the RTW medical visit. Data collection was based on a self-administered questionnaire including socio-demographic and professional characteristics (age, sex, marital status, professional category, professional seniority, and department) and medical data (habits, medical history, delay to RTW, and residual symptoms) and was completed by clinical data recorded during the medical visit.

2.4 Data sources/measurement

Anxiety and depression were screened using the Hospital Anxiety and Depression Scale (HAD) in its validated French version. The HAD Scale has 14 items. Each item is evaluated on a 4-point Likert scale, with values from 0 to 3. Both anxiety and depression are assessed by 7 questions to obtain two scores (total A and total D) with a maximum score of 21 points for each score. For each dimension, when the score is between 8 and 10, the state of anxiety or depression is doubtful. Above 10, the state of anxiety or depression is certain [6, 7].

The perceived ability to work was measured during the medical visit using the Work Ability Index (WAI) [8, 9]. We used its validated French version, composed of seven items.

According to the total score of the WAI questionnaire which reaches 49 points, the work ability is classified into four categories: poor (score between 7 and 27), moderate (between 28 and 36), good (between 37 and 43), and very good (between 44 and 49) [10].

2.5 Bias

The self-administration of the questionnaire could also generate reporting bias. Incomplete answers to the questionnaire were excluded.

2.6 Study size

A total of 531 complete responses to the questionnaire were collected.

2.7 Statistical methods

The characteristics of the participants are described as proportions for categorical variables, and means with standard deviations for continuous variables. Differences between groups were assessed by the Chi-square test and -Fisher’s exact test for categorical variables. The Student t-test was used for the analysis of continuous variables with normal distribution and the Mann–Whitney U test for the analysis of continuous variables with skewed distribution. The significance level was set at 0.05. A multivariate logistic regression model was established. The data were analyzed using Software Package for Statistics and Simulation (IBM SPSS version 25, IBM Corp, Armonk, NY).

2.8 Ethical considerations

At the time of our study, the approval of the Ethics Committee or the institutional review board was unfortunately not provided. This study, as an observation of the perceived work ability and the mental health among HCW, is exempt from Institutional Review Board approval [11] and met the following criteria: The information obtained is recorded by the investigator in such a manner that the identity of the Human Subjects cannot be readily ascertained, directly or indirectly through identifiers linked to the subjects.

2.9 Informed consent

Participants were informed of the objectives of the study. We obtained their oral consent. The anonymity of the respondents was respected.

3 Results

3.1 Socio-demographic and occupational characteristics

During our study period, 531 cases were included. The median age of our participants was 40 years (IQR: 31 -49 years) [extremes 24; 63 years]. Our population was composed of 407 women and 124 men (sex ratio of 0.3). Participants were married in 67.6% of cases. HCW were mainly nurses in 32.4% and health technicians in 24.5% of cases. They worked mainly in surgical departments (36.9%), followed by medical departments (36.3%). The median professional seniority of our population was 10 years (IQR: 4-21 years) [extremes 1; 37 years]. The socio-demographic and professional characteristics of our population are shown in Table 1.

Table 1
Socio-professional characteristics of the participants (N= 531)

Variables Frequency (Percentage %)

Age range, years

20–29 82(15.4)

30–39 183(34.5)

40–49 144(27.1)

50–59 110(20.7)

60–65 12(2.3)

Gender

Female 407(76.6)

Male 124(23.4)

Marital status

Single 147(27.7)

Married 359(67.6)

Divorced 25(4.7)

Job category

Nurse 172(32.4)

Healthcare technician 130(24.5)

Doctor 105(19.7)

Nurse aide 71(13.4)

Administrative agent 45(8.5)

Cleaning agent 8(1.5)

Workplace

Emergency and reanimation departments 50(9.5)

Medical departments 193(36.3)

Surgical departments 196(36.9)

Laboratories 39(7.3)

Administration 34(6.4)

General services 19(3.6)

Variables	Frequency (Percentage %)
Age range, years
20–29	82(15.4)
30–39	183(34.5)
40–49	144(27.1)
50–59	110(20.7)
60–65	12(2.3)
Gender
Female	407(76.6)
Male	124(23.4)
Marital status
Single	147(27.7)
Married	359(67.6)
Divorced	25(4.7)
Job category
Nurse	172(32.4)
Healthcare technician	130(24.5)
Doctor	105(19.7)
Nurse aide	71(13.4)
Administrative agent	45(8.5)
Cleaning agent	8(1.5)
Workplace
Emergency and reanimation departments	50(9.5)
Medical departments	193(36.3)
Surgical departments	196(36.9)
Laboratories	39(7.3)
Administration	34(6.4)
General services	19(3.6)

3.2 Medical characteristics of the population

Pathological medical history was reported by 89.6% of cases (n = 476) represented mainly by osteoarticular disorders (10.4%), asthma (9.9%), hypertension (9.8%), and diabetes (7.9%).

The median delay to RTW was 15 days (IQR: 13–18 days) with extremes ranging from 8 to 153 days. This delay was between 10 and 14 days in 38% of cases. Regarding residual symptoms at the RTW medical visit, 390 HCW (73.4%) reported at least one residual symptom and 141 (26.6%) were asymptomatic. Cough was reported as the only residual symptom by 39 HCW (7.3% of residual symptoms). Residual symptoms reported at the RTW medical visit are summarized in Table 2.

Table 2
Residual symptoms at the RTW medical visit (N= 531)

Residual symptom Frequency (Percentage %)

Fever 0

Cough 130(24.5)

Anosmia 60(11.3)

Agueusia 28(5.3)

Dyspnea 113(21.2)

Chest pain/palpitation 69(12.9)

Nausea/Vomiting 1(0.2)

Diarrhea 43(8.1)

Abdominal pain 10(1.9)

Asthenia/fatigue 94(17.7)

Arthomyalgia 49(9.2)

Headache 92(17.3)

Vertigo 25(4.7)

Low back pain 9(1.7)

Other symptoms (hearing loss, polyuropolydipsia Cutaneous symptoms, psychological distress...) 43(8.1)

Residual symptom	Frequency (Percentage %)
Fever	0
Cough	130(24.5)
Anosmia	60(11.3)
Agueusia	28(5.3)
Dyspnea	113(21.2)
Chest pain/palpitation	69(12.9)
Nausea/Vomiting	1(0.2)
Diarrhea	43(8.1)
Abdominal pain	10(1.9)
Asthenia/fatigue	94(17.7)
Arthomyalgia	49(9.2)
Headache	92(17.3)
Vertigo	25(4.7)
Low back pain	9(1.7)
Other symptoms (hearing loss, polyuropolydipsia Cutaneous symptoms, psychological distress...)	43(8.1)

3.3 Mental health assessment according to the HAD scale

Signs of psychological distress were spontaneously reported while interviewing 19 HCW (3.6%) at the RTW medical visit: anxiety (3 cases), depression (4 cases), anorexia (4 cases), memory problems (3 cases), concentration problems (1 case) and sleep disorders (4 cases). By assessing the HAD scale, the median scores of anxiety and depression were 8.25 (SD 4.80) and 9.06 (SD 4.70) respectively. A certain anxiety according to the HAD scale was found in 36.5% of the patients. Depression was present in 177 (33.3%) of the patients. The interpretation of the HAD scale is summarized in Table 3.

Table 3A
Depression and Anxiety according to HAD scale

Questionnaire items Mean±SD

Hospital Anxiety and Depression Scale (HAD)

Item 1: I feel tense or ‘wound up’ 1.50±0.93

Item 2: I still enjoy the things I used to enjoy 1.46±1.05

Item 3: I get a sort of frightened feeling as if something awful is about to happen 1.37±0.95

Item 4: I can laugh and see the funny side of things 1.43±0.78

Item 5: Worrying thoughts go through my mind 1.16±0.89

Item 6: I feel cheerful 1.05±0.95

Item 7: I can sit at ease and feel relaxed 1.09±0.93

Item 8: I feel as if I am slowed down 1.23±0.98

Item 9: I get a sort of frightened feeling like ‘butterflies’ in the stomach 1.22±0.95

Item 10: I have lost interest in my appearance 1.12±0.84

Item 11: I feel restless as I have to be on the move 1.21±0.87

Item 12: I look forward with enjoyment to things 1.15±1.04

Item 13: I get sudden feelings of panic 1.13±0.91

Item 14: I can enjoy a good book or radio or TV program 1.17±1.01

Total depression score 8.25±4.80

Total anxiety score 9.06±4.70

Total HAD 17.31±8.80

Questionnaire items	Mean±SD
Hospital Anxiety and Depression Scale (HAD)
Item 1: I feel tense or ‘wound up’	1.50±0.93
Item 2: I still enjoy the things I used to enjoy	1.46±1.05
Item 3: I get a sort of frightened feeling as if something awful is about to happen	1.37±0.95
Item 4: I can laugh and see the funny side of things	1.43±0.78
Item 5: Worrying thoughts go through my mind	1.16±0.89
Item 6: I feel cheerful	1.05±0.95
Item 7: I can sit at ease and feel relaxed	1.09±0.93
Item 8: I feel as if I am slowed down	1.23±0.98
Item 9: I get a sort of frightened feeling like ‘butterflies’ in the stomach	1.22±0.95
Item 10: I have lost interest in my appearance	1.12±0.84
Item 11: I feel restless as I have to be on the move	1.21±0.87
Item 12: I look forward with enjoyment to things	1.15±1.04
Item 13: I get sudden feelings of panic	1.13±0.91
Item 14: I can enjoy a good book or radio or TV program	1.17±1.01
Total depression score	8.25±4.80
Total anxiety score	9.06±4.70
Total HAD	17.31±8.80

Table 3B

Interpretation of HAD (N = 531)

HAD interpretation	Frequency (Percentage %)
Anxiety
Total score A≤10: doubtful	337(63.5)
Total score A > 10: certain	194(36.5)
Depression
Total score D≤10: doubtful	354(66.7)
Total score D > 10: certain	177(33.3)

3.4 Work ability index

By assessing the WAI items, we have found a mean current work ability of 5.71±2.34 points at the RTW medical visit. Work demands were high (6.37±1.97 points). Self-predicted ability to work in two years was also high (5.37±2.02 points). HCW reported good to very good work ability at the RTW medical visit in 37.8%. The interpretation of the WAI is summarized in Table 4.

Table 4A
Work ability according to Work Ability Index (N= 531)

Questionnaire Items Mean±SD

Work Ability Index (WAI)

Item 1 (Question1): The current work ability compared with their lifetime best 5.71±2.34

Item 2 (Questions 2 and 3): The work ability in relation to the physical and mental demands of the job 6.37±1.97

Item 3 (Question 4): The number of diagnosed illnesses or limiting conditions 5.62±1.40

Item 4 (Question 5): The impact of the health problem (COVID-19) on work capacity. 5.01±1.78

Item 5 (Question 6): The number of days off work due to the disease. 3.04±0.35

Item 6 (Question 7): The own prognosis of the work ability in two years. 5.37±2.02

Item 7 (Questions 8, 9 and 10): The quality of professional and extra-professional life. 2.81±0.88

Total WAI 33.94±7.54

Questionnaire Items	Mean±SD
Work Ability Index (WAI)
Item 1 (Question1): The current work ability compared with their lifetime best	5.71±2.34
Item 2 (Questions 2 and 3): The work ability in relation to the physical and mental demands of the job	6.37±1.97
Item 3 (Question 4): The number of diagnosed illnesses or limiting conditions	5.62±1.40
Item 4 (Question 5): The impact of the health problem (COVID-19) on work capacity.	5.01±1.78
Item 5 (Question 6): The number of days off work due to the disease.	3.04±0.35
Item 6 (Question 7): The own prognosis of the work ability in two years.	5.37±2.02
Item 7 (Questions 8, 9 and 10): The quality of professional and extra-professional life.	2.81±0.88
Total WAI	33.94±7.54

Table 4B

Interpretation of WAI (N= 531)

WAI interpretation	Frequency (Percentage %)
Work ability
Bad (7-27)	109(20.5)
Moderate (28-36)	221(41.7)
Good (37-43)	135(25.4)
Very good (44-49)	66(12.4)

3.5 Other results

A longer delay to RTW was associated with a better-perceived work ability at the RTW medical visit (p = 0.007).

4 Discussion

The RTW of HCW infected with COVID-19 is guided by medical and legal recommendations. The mental health status and the work ability of HCW after a COVID-19 infection are interesting criteria for assessing their fitness to work at the RTW medical visit. Our study aimed to assess the perceived work ability and mental health after COVID-19 infection among the HCW of the Charles Nicolle Hospital at the early stages of the COVID-19 pandemic.

Before discussing our main results, we thought it appropriate to highlight the strengths and weaknesses of this work. Our study is, to our knowledge, the first Tunisian study to focus on the perceived work ability after a COVID-19 infection in HCW at the early stages of the pandemic. The medical visit also allowed us to assess the mental health status and the residual symptoms after medical leave for COVID-19 infection. An early RTW is crucial to avoid the need to employ new workers at these stages characterized by limited human and financial resources. Early RTW for HCW could facilitate their timely and safe return to work after a period of absence, due to COVID-19 infection or post COVID-19 symptoms. Early RTW is critical for several reasons. First, it promotes the overall well-being of the employee by providing a sense of normalcy and routine, which contribute to physical and mental recovery. Second, it helps maintain the continuity of patient care, addressing potential workforce shortages in critical sectors such as healthcare. In addition, early RTW can prevent prolonged disability and associated economic and social consequences. Support in the RTW process is critical for employees, especially HCWs. This support can take several forms, including physical accommodations for HCW with prolonged dyspnea for example, flexible work schedules, and emotional support. The role of different workplace actors, such as supervisors, human resources, and colleagues, is critical in providing this support. Supervisors can facilitate necessary accommodations, human resources can ensure compliance with policies, and colleagues can provide emotional support, and create a collaborative environment. Occupational physicians can also be involved and work with all of these actors to ensure the effective applications of these accommodations. Our effective practices to facilitate RTW included clear communication between the employee and employer, phased return plans, and a supportive organizational culture with psychological support for HCW with emotional distress. Recognizing the burden of mental health issues, we established a psychological support unit in our hospital to promote open communication between HCW and psychologists, reduce stigma, and provide resources for psychological support.

The weaknesses of our study were related to its cross-sectional nature. Thus, it does not allow taking into account the chronology of the pandemic in Tunisia. Finally, only permanent HCW of our hospital who consulted for an RTW medical visit were included. This survey allows only an observation of the included cases which explains the possibility of selection bias if the fact of being absent at the medical visit is related to the disease (extended medical leave/death).

Discussing now our main results, the median age of our population was 40 years (IQR: 31-49 years) [24; 63 years], reflecting predominantly a young population. In an Indian [12] and a Colombian study [13], the median age was respectively 33 years (IQR: 27-40) and 30 years (IQR: 27-34). In international studies among HCW infected with COVID-19, the M/F sex ratio ranged from 0.17 to 1.4 and the average was closer to 0.5 [12 , 14–16]. In our series, the sex ratio was 0.3, thus falling within the range reported in the literature. In a systematic review, nurses infected with COVID-19 were more likely to be female and physicians were more likely to be male. This difference in age and gender was explained by several factors such as the level of academic training and the age of qualification [17]. Our population was composed mainly of paramedics (nurses in 32.4% and health technicians in 24.5% of cases). In the study by Lalić et al, 42% of the study sample (N = 100) were laboratory technicians, 34% were nurses, and 18% were physicians [18]. Published data by Žaja et al on a similar population reported that 78% of the HCW infected with COVID-19 were nurses or laboratory technicians [19]. In our series, HCW were primarily from surgical (36.9%) and medical (36.2%) departments. This could be explained by the large amount of HCW working in these departments and by the redeployment of these departments to receive COVID-19 patients. In a review of the literature, the authors found that HCW working in front-line departments (screening departments, emergency units, and intensive care units) were at higher risk of exposure to COVID-19 infection [20]. The median professional seniority of our population was 10 years (IQR: 4-21), thus a younger population with less experience. In a study by Ashinyo et al, a professional seniority greater than 10 years was not associated with a higher risk of occupational exposure or COVID-19 infection among HCW [21]. Also, the high ability for self-regulation and rehabilitation among older workers could explain the differences between the responses of juniors and seniors to COVID-19, according to Kooij et al. Older workers seem to cope better with work-related difficulties. They respond with different self-regulation and engagement strategies depending on the situation [22].

In our series, pathological medical history was reported by 89.6% represented mainly by osteoarticular disorders (10.4%), asthma (9.9%), hypertension (9.8%), and diabetes (7.9%). In the literature, these comorbidities were associated the most with COVID-19 severity, hospitalization, and mortality, which are considered indirect factors for a longer delay of RTW [23 –26].

In our results, the median delay to RTW was 15 days (IQR: 13–18 days). Data from a Croatian study in our period showed that the median delay to RTW after COVID-19 infection in HCW was 13.6±2.6 days with extremes ranging from 10 to 29 days. Their health insurance allocated full benefits, including fully paid sick leave and psychological support to HCW affected by COVID-19 [18].

Considering the mental health assessment, we used the HAD scale as an instrument to assess the prevalence and severity of mental health problems in HCW infected with COVID-19 [27]. Certain anxiety was found in 36.5% of HCW. Depression was present in 33.3% of them. COVID-19 is known to be associated with neuropsychological symptoms, including anxiety, depression, and sleep disorders. In the study by Liu et al, the prevalence of depressive and anxiety symptoms in HCW was 50.7% and 44.7% respectively [28]. In a review study, anxiety was reported in 27.7% to 100% of the studied populations, and depression was found in 12.4% to 55.7% of them [29]. In a similar Tunisian study carried out in a military hospital, anxiety, and depression were found in 30% and 25.5% of the included HCW [30].

According to Praschan et al, there are often HCW who struggle to return to long-term work after their respiratory symptoms have resolved. Barriers to RTW are often asthenia, cognitive symptoms, and affective symptoms [31]. In another study, an experienced critical care nurse had residual post-viral neurocognitive symptoms; she described a lack of concentration during interviews with patients, forgetting the names of essential medications, and a debilitating fatigue after a typical workday [32].

In addition to the assessment of mental health, the WAI helped us to assess the perceived work ability and workload of the HCW after COVID-19 as recommended in a recent study [33]. The perceived work ability was assessed as good to very good in 37.8% of cases. A prospective study by Andrade et al among 633 Brazilian workers (18.1% were HCW) showed at baseline and follow-up, a work ability score (WAI) between 7.7 and 8.3 points. Work demands were also high (7.6 to 7.8 points). The number of diagnosed illnesses was higher at baseline compared with follow-up for both groups. The infected group had absenteeism, primarily between 9 and 24 days. Approximately 70–75% of workers reported good to very good work ability at baseline and follow-up for both groups [34]. In a recent meta-analysis of 35 studies among nurses, the combined global prevalence of inadequate or poor work ability was 24.7% (95% IC = 20.2% –29.4%). High levels of heterogeneity were detected in the included studies due to differences in sampling and age [35]. Our study investigated work ability among all HCW of all ages and occupational categories.

A longer delay to RTW was associated with a better work ability perceived at the RTW medical visit (p = 0.007). In a study by Rubbi et al, a positive correlation was found between the perceived health status and days since positive RT-PCR (ρ= 0.98; p = 0.004) [36]. In addition, Shenoy et al concluded that the symptom-based RTW strategy resulted in a reduction of 4,097 lost workdays, or an average of 7.2 fewer lost workdays per HCW [37].

In our study period, the occupational medicine department’s strategy for RTW was based on these criteria: isolation duration, residual COVID-19 symptoms, and perceived work ability at the medical visit. RTW guidelines from the Centers for Disease Control and Prevention (CDC) [38] and the Occupational Safety and Health Administration (OSHA) [39] in the United States focused primarily on infection status and resolution of acute symptoms and did not provide guidance for HCW with residual COVID-19 symptoms, leaving healthcare institutions and workers to set their policies or to consider disability benefits [31]. The assessment of mental health as well as perceived work ability is essential to optimize the management of HCW return to work after COVID-19 infection.

Early return to work after COVID-19 infection is valuable for maintaining the workforce and rapid integration of the workers. Post COVID-19 or long COVID-19 conditions could also interfere with the return to work and the work ability of HCW. A review by Gualano et al, highlighted post COVID-19 condition as a rising problem in occupational medicine, with consequences on workers’ quality of life and productivity. The authors highlighted also that the role of occupational physicians could be essential in applying limitations to work duties or hours and facilitating the return to employment in workers with a post COVID-19 condition [40].

5 Conclusions

Our study described the perceived work ability and the prevalence of anxiety and depression among the HCW at the RTW medical visit after COVID-19 infection in the early stages of the pandemic. Our effective practices to facilitate RTW included clear communication between the employee and employer, phased return plans, and a supportive organizational culture with psychological support for HCW with emotional distress. Recognizing the burden of mental health issues, we established a psychological support unit in our hospital to promote open communication between HCW and psychologists, reduce stigma, and provide resources for psychological support. Specific strategies for RTW after a COVID-19 infection among healthcare workers should be guided by a multidisciplinary team specialized in neurology, psychiatry, and pneumology in collaboration with occupational medicine. These strategies, based on an early assessment of mental health and work ability, reinforce psychological support and progressive reintegration of HCW at RTW.

Ethical considerations

Not applicable.

Informed consent

Participants were informed of the objectives of the study. We obtained their oral consent. The anonymity of the respondents was respected.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Funding

The authors report no funding.

References

Lee

, Juang

, Su

, Lee

, Lin

, Chao

. Facing SARS: psychological impacts on SARS team nurses and psychiatric services in a Taiwan general hospital. Gen Hosp Psychiatry. 2005;27:352–8.

Haozheng

, Baoren

, Jing

, Limin

, Lei

, Yongfang

, et al. Psychological impact and coping strategies of frontline medical staff in Hunan between January and March 2020 during the outbreak of coronavirus disease 2019(COVID-19) in Hubei, China. Med SciMonit. 2020;26:e924171.

République Tunisienne [homepage on the Internet]. Arrêté du ministre des affaires sociales et du ministre de la santé du 16 novembre 2020, complétant l’arrêté 10 janvier 1995 fixant la liste des maladies professionnelles. Tunisia: 2020 [updated 2020 November 20]. Available from: http://www.iort.gov.tn/WD120AWP/WD120Awp.exe/CTX_4460-52-NgQFzdNKgw/AfficheJORT/SYNC_594749346

Republique Tunisienne [homepage on the Internet]. Decret n 2000-1986 du 12 septembre 2000, fixant le statuttype des groupements de medecine du travail. Tunisia: 2020 [updated 2020 September 22]. Available from: http://www.iort.gov.tn/WD120AWP/WD120Awp.exe/CTX_4460-52-NgQFzdNKgw/AfficheJORT/SYNC_595085908

Instance Nationale de l’Evaluation et de l’Accréditation en Santé [homepage on the Internet]. Organisation des soins en milieu médical non interventionnel lors de la pandémie COVID-19 réponse rapide. Tunisia: 2020 [cited 2021 December 14]. Available from: https://www.ineas.tn/sites/default/files/guide_organisation_des_soins_en_milieu_medical_non_interventionnel_lors_.pdf

Zigmond

, Snaith

. The Hospital anxiety and depression scale. Acta Psychiatrica Scandinavica. 1983;67(6):361–70.

Tan

BYQ

, Kanneganti

, Lim

LJH

, Tan

, Chua

, Tan

, et al. Burnout and associated factors among health care workers in Singapore during the covid-19 pandemic. J Am Med Dir Assoc. 2020;21(12):1751–8.

Ilmarinen

. The Work Ability Index (WAI). Occup Med. 2007;57:160.

Tuomi

, Ilmarinen

, Seitsamo

, Huuhtanen

, Martikainen

, Nygàrd

, et al. Summary of the finnish research project (1981-1992) to promote the health andwork ability of aging workers. Scand J Work Environ Health. 1997;23(Suppl 1):S66–S71.

10.

Thibault

, Clémentine

Evaluation de la relation entre le score obtenu au questionnaire work ability index et le maintien dans l’emploi à deux ans chez les travailleurs lombalgiques chroniques [Thèse]. Médecine: Angers; 2019:74p. Available from: http://dune.univangers.fr/fichiers/15009131/2019MDETR11448/fichier/11448F.pdf

11.

Institutional Review Board (IRB) Office [homepage on the Internet]. Exempt Review: Institutional Review Board (IRB) Office - Northwestern University USA. USA: 2023. Available from: https://irb.northwestern.edu/submitting-tothe-irb/types-of-reviews/exempt-review.html

12.

Chatterjee

, Anand

, Singh

KhJ

, Rasaily

, Singh

, Das

, et al. Healthcare workers and SARS-CoV-2 infection in India: A case-control investigation in the time of COVID-19. Indian J Med Res. 2020;151(5):459–67.

13.

Rodriguez-Lopez

, Parra

, Vergara

, Rey

, Salcedo

, Arturo

, et al. A case-control study of factors associated with SARS-CoV-2 infection among healthcare workers in Colombia. BMC Infect Dis. 2021;21(1):878.

14.

Leso

, Fontana

, Iavicoli

. Susceptibility to coronavirus (COVID-19) in occupational settings: the complex interplay between individual and workplace factors. Int J Environ Res Public Health. 2021;18(3):1030.

15.

Leeds

, Raviprakash

, Jacques

, Scanlon

, Cundall

, Leeds

. Risk factors for detection of SARS-CoV-2 in healthcare workers during April in a UK hospital testing programme. E Clinical Medicine.. 2020;26:100513.

16.

Piccoli

, Ferrari

, Piumatti

, Jovic

, Rodriguez

, Mele

, et al. Risk assessment and seroprevalence of SARS-CoV-2 infection in healthcare workers of COVID-19 and non-COVID-19 hospitals in Southern Switzerland. Lancet Reg Health –Eur. 2021;1:100013.

17.

Bandyopadhyay

, Baticulon

, Kadhum

, Alser

, Ojuka

, Badereddin

, et al. Infection and mortality of healthcare workers worldwide from COVID- A systematic review. BMJ Glob Health. 2020;5:e003097.

18.

Lalić

. Covid-19 as occupational disease in healthcare workers: A brief review of cases in the Clinical Hospital Centre Rijeka, Croatia. Arch Ind Hyg Toxicol. 2021;72(3):240–3.

19.

Zaja

, Kerner

, Milosević

, Macan

. Diagnosingoccupational COVID-19 in Croatian healthcare workers. Arh Hig RadaToksikol. 2021;72:289–97.

20.

Gupta

, Sahoo

. Pandemic and mental health of the front-line healthcare workers: A review and implications in the Indian context amidst COVID-19. Gen Psychiatry. 2020;33:e100284.

21.

Ashinyo

, Dubik

, Duti

, Amegah

, Ashinyo

, Larsen-Reindorf

, et al. Healthcare workers exposure risk assessment: A survey among frontline workers in designated COVID-19 treatment centers in Ghana. J Prim Care Community Health. 2020;11:2150132720969483.

22.

Kooij

DTAM

. The impact of the Covid-19 pandemic on older workers: the role of self-regulation and organizations. Work Aging Retire. 2020;6(4):233–7.

23.

Modenese

, Casolari

, Rossi

, Della Vecchia

, Glieca

, D’Elia

, et al. Factors associated with SARS-CoV-2 infection risk among healthcare workers of an Italian University Hospital. Healthc Basel Switz. 2021;9(11):1495.

24.

Rizza

, Coppeta

, Grelli

, Ferrazza

, Chiocchi

, Vanni

, et al. High body mass index and night shift work are associated with COVID-19 in health care workers. J Endocrinol Invest. 2021;44(5):1097–101.

25.

Gao

, Piernas

, Astbury

, Hippisley-Cox

, O’Rahilly

, Aveyard

, et al. Associations between body-mass index and COVID-19 severity in 6.9 million people in England: A prospective, community-based, cohort study. The Lancet Diabetes and Endocrinology. 2021;9(6):350–9.

26.

Tian

, Qiu

, Wang

, Zhao

, Jiang

, Niu

, et al. Cancer associates with risk and severe events of COVID- A systematic review and meta-analysis. Int J Cancer. 2021;148(2):363–74.

27.

Zürcher

, Kerksieck

, Adamus

, Burr

, Lehmann

, Huber

, et al. Prevalence of mental health problems during virus epidemics in the general public, health care workers and survivors: A rapid review of the evidence. Front Public. 2020;8:560389.

28.

Liu

, Yang

, Zhang

, Xu

, Cai

, Ma

, et al. Gender differences in mental health problems of healthcare workers during the coronavirus disease outbreak. J Psychiatr Res. 2021;137:393–400.

29.

Bekele

, Mechessa

, Sefera

. Prevalence and associated factors of the psychological impact of COVID-19 among communities, health care workers and patients in Ethiopia: A systematic review. Ann Med Surg. 2021;66:102403.

30.

Mejri

, Youssfi

, Znegui

, Mechergui

, El Kefi

, Hammami

, et al. Mental health status of healthcare workers at a third line Tunisian hospital during COVID-19 pandemic. Tunis Med. 2022;100(10):670–5.

31.

Praschan

, Josephy-Hernandez

, Kim

, Kritzer

, Mukerji

, Newhouse

, et al. Implications of COVID-19 sequelae for health-care personnel. Lancet Respir Med. 2021;9(3):230–1.

32.

Siegelman

. Reflections of a COVID-19 Long Hauler. JAMA. 2020;324(20):2031–2.

33.

Godeau

, Petit

, Richard

, Roquelaure

, Descatha

. Return-to-work, disabilities and occupational health in the age of COVID-19. Scand J Work Environ Health. 2021;47(5):408–9.

34.

Andrade

, Castro

CSM

, Batistão

, Mininel

, Sato

. Occupational profile, psychosocial aspects, and work ability of Brazilian workers during COVID-19 pandemic: IMPPAC Cohort. Saf Health Work. 2022;13(1):104–111.

35.

Romero-Sánchez

, Porcel-Gálvez

, Paloma-Castro

, García-Jiménez

, González-Domínguez

, Palomar-Aumatell

, et al. Worldwide prevalence of inadequate workability among hospital nursing personnel: A systematic review andmeta-analysis. J Nurs Scholarsh. 2022;54(4):513–528.

36.

Rubbi

, Pasquinelli

, Brighenti

, Fanelli

, Gualandi

, Nanni

, et al. Healthcare personnel exposure to COVID- An observational study on quarantined positive workers. Acta Bio Medica Atenei Parm. 2020;91:e2020012.

37.

Shenoy

, West

, Hooper

, Sheehan

, Hashimoto

, Boukus

, et al. Healthcare worker infection with SARS-CoV-2 and test-based return to work. Infect Control Hosp Epidemiol. 2020;41(12):1464–6.

38.

Center for Disease Control and Prevention [homepage on the Internet]. Infection control guidance for healthcare professionals about coronavirus (COVID-19). USA: 2020 [cited 2022 January 10]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html

39.

Occupational Safety and Health Administration[homepage on the Internet]. Guidance on returning to work. USA: 2020 [cited 2022 January 10]. Available from: https://www.osha.gov/Publications/OSHA4045.

40.

Gualano

, Rossi

, Borrelli

, Santoro

, Amantea

, Daniele

, et al. Returning to work and the impact of post COVID-19 condition: A systematic review. Work. 2022;73(2):405–13.