Investigating the effectiveness of tele-counseling for the mental health of staff in hospitals and COVID-19 clinics: a clinical control trial

Abstract Objective To investigate the effectiveness of tele-counseling for the mental health of staff working in hospitals and reference clinics during the COVID-19 outbreak. Methods In the first stage of the study, using a convenience sampling strategy, 313 staff members working at Iran’s hospitals and COVID-19 clinics answered a Hospital Anxiety and Depression Scale and the Short Health Anxiety Inventory online. In a second stage, 95 staff members who were willing to participate in the intervention were randomly assigned to the intervention (n = 51) or control (n = 44) groups. The intervention consisted of seven intensive tele-counseling sessions. Results In the first stage, the percentages of anxiety and depression related to coronavirus were 79.2% and 82.1% and the mean health anxiety score was 17.42. In the intervention phase, anxiety related to coronavirus and to perceived risk of illness (likelihood of illness) were significantly lower in the intervention group in comparison with the control group (p = 0.001). Depression related to coronavirus and anxiety related to the negative consequences of infection were non-significantly reduced in the intervention group compared to the control group (p = 0.08 and 0.12; respectively). Conclusion Continuous monitoring of the negative psychological impacts on medical staff of outbreaks as well as implementation of appropriate interventions to respond to them should be emphasized in order to improve staff mental health. Clinical trial registration: Iranian Registry of Clinical Trials, IRCT20170611034452N11.


Introduction Scientific background and explanation of rationale
Occupational health and mental health have significant impacts on each other. During epidemics, health care providers are continually exposed to the factors associated with the risk of developing mental disorders such as stress, anxiety, and depression.
Being infected or fear of infection have been significantly associated with absenteeism, leaving the workplace, negative attitudes, and decreased efficiency and performance of medical staff. 1 Infections and http://dx.doi.org/10.47626/2237-6089-2020-0176 occupational injuries can lead to more severe forms of distress response in epidemic conditions. 2,3 In pandemics, especially in the case of newly emerging epidemics in which treatment and safety protocols are yet to be properly investigated, a large number of patients are hospitalized and the medical team is subjected to a heavy burden imposed by workload, anxiety, and fear related to the concern of being infected. 4 Unknown infections with unknown transmission routes, rapid global prevalence, and relatively high mortality can affect health care staff more than members of other organizations. These conditions may have a potentially deleterious impact on physical and mental health, ability to manage crises, and performance in patient care delivery. 5 In this scenario, mood disorders, insomnia, perceived negative emotions, and post-traumatic stress disorder are among the problems that can affect the quality of life of staff. 6 The novel beta-coronavirus, associated with a series of respiratory system symptoms and later named SARS- to reduce its negative consequences.

Specific objectives
The aim of this study was to investigate the effectiveness of tele-counseling for improving the mental health of staff in hospitals and COVID-19 clinics in Iran.

Trial design
This study is a randomized controlled trial with one intervention group and one control group, conducted

Outcome measurements
The primary outcome of this study was the frequency of anxiety and depression related to coronavirus and health anxiety (anxiety in two domains caused by the perceived risk of illness as well as associated negative consequences of infection). The secondary outcome was the effect of tele-counseling on the levels of depression and anxiety related to the coronavirus pandemic as well as two domains of heath anxiety.

Ethical considerations
The study was approved by the medical ethics committee at Kerman University of Medical Sciences

Demographics
The information on the sociodemographic data collection form was selected based on the relevant literature as well as the researchers' experience. The findings are presented in Table 1.

The Hospital Anxiety and Depression Scale (HADS)
The HADS was developed by Zigmond In the second stage, to calculate the minimum sample size for the intervention group (those taking part in tele-counseling sessions), the two-point comparison formula was used based on a similar study conducted in China in 2019. 30 The sample size calculated for each

Aim of counseling
To manage anxiety and depression related to the COVID-19 outbreak and the resulting health anxiety of medical workers, the intervention implemented in this study was designed to provide information regarding workers' safety; to be supportive and mindfulnessbased; to clarify workers' cognitive errors regarding the epidemic; to facilitate behavioral modification; and to improve workers' mental health level.

Intervention design
The psychological intervention implemented in this

Counselors
The intervention was delivered by 21 trained counselors who were "Counseling in Midwifery" master's students trained by the lead researcher, who is an associate professor in guidance and counseling, based on the study protocol.

Statistical analysis
Descriptive statistics were reported as frequency, percentage, and mean ± SD. The chi-square test was used to compare demographic variables between intervention group and control group, in view of their homogeneity. The paired t-test was used to compare anxiety and depression scores for each group measured in the initial screening phase with the same parameters at the end of the study. The independent t-test was used to compare the anxiety and depression changes (before-after) between the intervention and control groups. Data were analyzed using the Statistical

Package for the Social Sciences (SPSS) version 22; and
the significance level adopted was 0.05.

Results
This study is a randomized controlled trial with one 111 staff were randomly divided into the intervention (n = 51) and control (n = 44) groups (Figure 1). Table   1 shows demographic data, which were homogenous at baseline in two groups. Table 2    * p-value for comparison between the control and intervention groups at baseline. † p-value for comparison between values before and after intervention, within each group separately; ‡ p-value for comparison of mean difference (before -after) between the control and intervention groups; Using SHAI to measure cognitive factors associated with hypochondriasis, 39 this study revealed that the mean values of the total health anxiety score and its two domain scores (the anxiety of likelihood of illness and anxiety of negative consequences) were higher than they were in some other non-clinical samples. [39][40][41][42] It seems this high level of health anxiety was related to the vulnerability of the members of the sample, who worked in close contact with a new emerging and very highly contagious disease with high mortality and morbidity rates. Individuals in different jobs may experience different levels of health anxiety, but those who are at the core of the crisis are affected more. 13,21,43 Fatal virus pandemics weaken health systems and disrupt plans for protecting the mental health of medical workers and patients. 44 How to best respond to such challenges during outbreaks is unknown. 45 Unfortunately, most of the time, the mental health of the staff is ignored in these situations. 9,46 The lower the level of mindfulness is, the worse staff wellbeing will be. 47,48 Improving health care staff's ability to regulate emotions and enhancing effective coping strategies increase the chances of winning the battle against the pandemic. 11,49 In view of the recommendations on social distancing as well as the crowded and compressed working shifts of medical personnel during the COVID-19 epidemic, attending face-to-face counseling sessions is very inconvenient for medical staff. Therefore, telecounseling is a better option in this situation 20,33 and was planned and delivered for the participants in the second stage of this study.
After the counseling sessions, both the level of anxiety related to coronavirus and the level of anxiety related to likelihood of illness were significantly decreased. The psychological intervention delivered in this study was in the line with the recommendations made by Zhang et al. for responding to the COVID-19 epidemic. 31 The core components of counseling content in this study were cognitive-behavioral and mindfulness-based techniques as well as emotional support that aimed to produce better mental states and coping styles. 50 Cognitive-behavioral therapy is the most researched and widely recommended treatment for alleviating health anxiety. 51,52 Overall, there is evidence for the efficacy of specifically designed psychological interventions in conditions of crisis. 51,53 Even a brief mind-body skill training course was associated with improvements of depression and anxiety. 52 Mindfulness may serve as a protective factor that alleviates or eliminates the negative effects of perceived stress. 16 Symptoms of high levels of depression and anxiety of negative http://dx.doi.org/10.47626/2237-6089-2020-0176 consequences were not significantly decreased in this study. This can be attributed to some factors. Firstly, tele-counseling seems to be less effective than face-toface sessions. 54 Secondly, the goal of holding intensive sessions in this study was to implement an urgent intervention to control the high incidence of depression and anxiety among staff, to maintain their mental health and clinical performance. However, they did not have enough time to do their homework, which was related to the pressure of high workloads.
Limitations: The use of online systems for data collection and intervention may have caused bias in the randomization. Conducting the study with staff who participated voluntarily may reduce the generalizability of the results.

Conclusion
It is suggested that hospital managers focus on psychological support for their staff by providing training and counseling services to enhance their coping strategies. Governments should provide psychiatric services for addressing stress and other negative psychological effects of pandemics. Continuous surveillance and monitoring of the psychological status of medical staff both before and during outbreaks should be emphasized.