How Tunisian physicians of public health hospitals deal with COVID‐19 pandemic: Perceived stress and coping strategies

On 2 March 2020, the first COVID‐19 case was reported in Tunisia. ¹ On 12 March 2020, the World Health Organization declared the COVID‐19 outbreak a pandemic. This pandemic was unprecedented for Tunisians. Tunisian authorities quickly took lockdown measures by establishing general containment on 20 March.

Public hospitals, the only institutions authorized to receive COVID‐19 patients, had to implement a brutal reorganization of health activities. Physicians had to deal with a sudden change in work organization and way of life (e.g., shifts, sorting and screening of patients, post‐shift containment at hospital). This may have caused stress and adaptation efforts. Indeed, communicable disease outbreaks can have an impact on health‐care workers as a result of increased workload, uncertainty about the pathogenicity of the causative agent, and anxiety about becoming infected. ² , ³ Several studies have highlighted the psychological impact of COVID‐19 among physicians. ⁴ , ⁵ In Tunisia, there are no available publications about the stress experience and the coping strategies among health workers. Yet, these aspects have a major impact on prevention and care strategies for physicians.

This study aimed to examine the impact of COVID‐19 on the stress and coping strategies of Tunisian physicians working at public health hospitals during the pandemic. After giving informed consent, participants anonymously took a Web‐based survey between 18 March and 28 May 2020, which was approved by Razi Hospital Ethics Committee. A semi‐structured questionnaire was performed, based on previous studies. ² , ⁴ , ⁶ We requested information about sociodemographic and professional characteristics, and perceptions and concerns about the COVID‐19 pandemic. We used the French 10‐item version of the Perceived Stress Scale (PSS‐10), ⁷ and the French version of the Brief COPE Inventory to asses coping strategies. Items were grouped in four dimensions: Social Support, Problem‐Solving, Avoidance, and Positive Thinking. ⁸ We used the Pearson correlation test (r), the Student's t‐test for independent‐samples, and the analysis of variance test. The significance threshold was fixed to P < 0.05.

The sample consisted of 191 physicians. The average age was 33 years (SD = 7.9) and 80.9% were female. One hundred and nine (57.06%) were physicians in training. We divided the sample into three groups according to the field: medical (82.1%), surgical (10.9%), and emergency (6.2%). A total of 156 physicians (81.6%) worked in hospitals in the north, 22 (11.5%) in the center, and 12 (6.2%) in the south of the country. Physicians’ mean duration of medical practice was 8 years (range: 0.5–37 years). Direct contact with COVID‐19 patients was reported by 26.3% of physicians. More than half of the participants (56.7%) responded that their department had taken appropriate crisis‐response measures. Only 35% considered these measures sufficient and 33.5% felt safe taking care of patients. Their main sources of information during the pandemic were the official Tunisian sources (65.5%); however, only 45.4% considered that the national guidelines for the management of COVID‐19 were clear.

The mean score on the PSS‐10 was 28.86 (SD = 6.19) and 92.14% reported moderate to severe stress perception. Females scored significantly higher (29.65, SD = 5.9) than males (25.53, SD = 6), P < 10⁻³. Physicians in training had higher scores (29.68, SD = 5.8) than seniors (27.8, SD = 6.5), P = 0.039. Age was significantly negatively correlated with PSS‐10 score (P = 0.011, r = 0–1.86). We found no significant effect of having direct contact with COVID‐19 patients on stress (P = 0.74). The field of practice was not associated with stress (P = 0.24).

Physicians who trusted the national police management of the COVID‐19 outbreak were significantly less stressed (27.70, SD = 5.75) than others (29.74, SD = 6.39), P = 0.026.

Mean scores for Social Support, Problem‐Solving, Avoidance, and Positive Thinking were, respectively, 15.47 ± 2.67, 7.82 ± 1.9, 21.47 ± 2.92, and 13 ± 2.2. Stressed physicians used significantly more social support (r = 0.216, P = 0.003), problem‐solving (r = 0.23, P = 0.001), and less avoidance (r = −0.33, P < 10⁻³) to cope with the pandemic. We found no association between coping strategies and sex, age, or being in training status.

The main finding of our study was the high score of stress among female and young physicians in training. We found that a high level of stress was positively correlated with social support and resolving problems, and negatively with avoidance. Taking account of potential social desirability bias related to self‐assessment methods, our participants seemed to adopt appropriate coping strategies, although they reported more perceived stress than other studies using the same ⁹ or other instruments. ⁴ , ⁵ Stressed physicians in our sample had less trust for national police management of the COVID‐19 outbreak.

Our findings highlight the necessity to focus on physicians’ well‐being, especially those who are female and/or young. A medium‐term assessment of the impact of the epidemic would be beneficial.

Disclosure statement

There is no conflict of interest.