Factors mediating the psychological well-being of healthcare workers responding to global pandemics : a systematic review

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Factors mediating the psychological well-being of healthcare workers responding to global pandemics : a systematic review © 2021 the Authors Published version Schneider, Jekaterina; Talamonti, Deborah; Gibson, Benjamin; Forshaw, Mark Schneider, J., Talamonti, D., Gibson, B., & Forshaw, M. (2022). Factors mediating the psychological well-being of healthcare workers responding to global pandemics : a systematic review. Journal of Health Psychology, 27(8), 1875-1896. https://doi.org/10.1177/13591053211012759 2022 https://doi.org/10.1177/13591053211012759 Journal of Health Psychology 1 –22 © The Author(s) 2021 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/13591053211012759 journals.sagepub.com/home/hpq Introduction The novel coronavirus (COVID-19) outbreak, caused by infection with severe acute respiratory syndrome coronavirus-2 (SARs-CoV-2), received pandemic status by the World Health Organization (WHO) in March 2020 (Cucinotta and Vanelli, 2020). Pandemics are defined by the WHO as the worldwide spread of a new disease (WHO, 2020a) and the term has been used to describe outbreaks of similar coronavirus diseases, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), as well as the outbreaks of influenza (H1N1), Swine flu (H1N1/09) and Ebola. Pandemics are also at least partly categorised by their rapid incidence and a consequence of this is that they often put high pressure on healthcare workers (HCWs) and healthcare service capacities. COVID-19 in particular has a high transmission rate, which means that, despite a relatively low mortality rate of 2%, the virus’ associated mortality is higher than that of SARS and MERS combined (Mahase, 2020). Pandemics, therefore, place massive burdens not only on the physical and Factors mediating the psychological well-being of healthcare workers responding to global pandemics: A systematic review Jekaterina Schneider1, Deborah Talamonti2, Benjamin Gibson3 and Mark Forshaw3 Abstract This paper reviewed mediators of psychological well-being among healthcare workers responding to pandemics. After registration on PROSPERO, a systematic review was performed in four databases and 39 studies were included. Worse mental health outcomes, such as stress, depressive symptoms, anxiety and burnout were related to demographic characteristics, contact with infected patients and poor perceived support. Self-efficacy, coping ability, altruism and organisational support were protective factors. Despite limitations in the quality of available evidence, this review highlights the prevalence of poor mental health in healthcare workers and proposes target mediators for future interventions. Keywords COVID-19, healthcare professionals, mediation, mental health, pandemic 1University of Jyväskylä, Finland 2 Research centre and Centre EPIC, Montreal Heart Institute, Canada 3Liverpool John Moores University, UK Corresponding author: Benjamin Gibson, Faculty of Health, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 5AF, UK. Email: [email protected] 1012759HPQ0010.1177/13591053211012759Journal of Health PsychologySchneider et al. review-article2021 Review 2 Journal of Health Psychology 00(0) mental health of the general population (e.g. Vinkers et al., 2020), but also on the HCWs who play key roles during such events (Cullen et al., 2020). Admittedly, however, less is known about their impact on countries across Europe and North America, which have been considerably less affected in recent history. Research has consistently shown that individuals in healthcare professions experience higher levels of work-related stress, burnout and psychological ill-health than the general population, even under ‘normal’ circumstances (Hofmann, 2018), and are reluctant to seek help due to fear of stigma and detrimental effects on future career prospects (Chew-Graham et al., 2003). During acute health crises, such as COVID-19 and other infectious disease outbreaks, these issues may be further exacerbated. Health professionals, especially those working in direct contact with suspected or confirmed patients with infectious diseases, may experience stigmatisation as a result of their job, fear of contagion, fear of spreading the disease to others and feelings of isolation if they have to be quarantined or separated from their loved ones on account of their exposure to high viral loads. Some possible reasons for the adverse psychological outcomes seen in HCWs during health emergencies stem from increased workload and/or work hours, inadequate personal protective equipment (PPE), being overexposed to pandemic reports in the media, experiencing a high rate of infection and feeling inadequately supported by their employer or organisational structure (Cai et al., 2020; Devnani, 2012; Lee et al., 2018; Lietz et al., 2016; Styra et al., 2008; Tam et al., 2004). As HCWs are considered essential workers during outbreaks of infectious diseases, protecting their psychological wellbeing is a priority (Arden and Chilcot, 2020; Bao et al., 2020; Chen et al., 2020; Galbraith et al., 2021; Holmes et al., 2020; Xiang et al., 2020). Specifically, more information is required on the protective and risk factors that influence the psychological well-being of HCWs responding to global pandemics. Previous reviews have been conducted to explore the mental health of HCWs during infectious disease outbreaks. Two recent reviews found a high prevalence of stress, anxiety, depression and insomnia among HCWs during the current COVID-19 outbreak (Pappa et al., 2020; Spoorthy, 2020). Other reviews on the mental health of HCWs during infectious disease outbreaks or following a disaster found that compared with lower risk controls, highrisk HCWs had greater levels of post-traumatic stress, psychological distress and depressive symptoms (e.g. Kisely et al., 2020; Naushad et al., 2019). Several of these reviews have also identified various protective and risk factors associated with psychological distress in HCWs. The most commonly reported protective factors included clear communication, social support, practical support (e.g. the provision of appropriate work attire and access to adequate PPE) and getting sufficient rest. The most commonly reported risk factors included exposure to infected patients, being younger or less experienced, knowing someone who has been infected/having an infected family member, being quarantined, lack of practical and social support and experiencing stigma (e.g. Arora and Grey, 2020; Koh et al., 2005; Maunder et al., 2004; Tam et al., 2004). However, at present, the majority of studies are of low quality due to high risk of bias (e.g. limitations in study design, recall bias, selection bias) and imprecise results (De Brier et al., 2020). Additionally, few studies have so far conducted formal mediation analyses on protective and risk factors that go beyond mere association to identify possible mediators of psychological well-being of HCWs responding to global pandemics. To our knowledge, no systematic review has so far considered all recent global pandemics to identify recurrent mediators of psychological well-being in HCWs. Instead, previous reviews have been limited to COVID-19 or coronaviruses, which might exclude important data and wider patterns, or have been limited in their methodology, with little consideration of risk and protective factors or the quality of the research reviewed. As such, effective strategies for supporting the mental health and Schneider et al. 3 well-being of HCWs in the context of pandemics are currently unclear (Li et al., 2020; Zhang et al., 2020b). Therefore, we performed a systematic review to identify the mediators of psychological well-being in HCWs responding to global pandemics. The findings from this review will provide evidence for the potential mechanisms that can be targeted by interventions to protect HCWs’ mental health and psychological well-being in the current context of the ongoing COVID-19 pandemic and in future emergencies. Methods This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA; Moher et al., 2010) and pre-registered on PROSPERO (ref. CRD42020187340). Data sources and search strategies A systematic search was conducted for papers published up to 7 June 2020 using the databases Google Scholar, PsycINFO, MEDLINE (PubMed) and Web of Science. Boolean combinations of the following search terms and their abbreviations were used: psychological; stress; distress; burnout; mental health; psychiatric issues; psychological well-being; pandemic; severe acute respiratory syndrome; COVID-19, coronavirus, Ebola; influenza; H1N1; swine flu; Middle East respiratory syndrome; doctor; nurse; medical staff; healthcare worker; healthcare professional. Reference sections of included articles were scanned to identify additional studies that met inclusion criteria. Outbreaks were included if they were defined as pandemics by the WHO and included SARS (2002–2003), COVID-19 (2019–ongoing), H1N1/09 (swine flu; 2009–2010), Ebola (2014– 2016), MERS (2015–ongoing) and H1N1 (influenza). Inclusion and exclusion criteria Papers were included if they: (I) related to a global pandemic; (II) were written in English; and (III) investigated mediators of psychological well-being in HCWs using quantitative outcomes. Studies were excluded if they did not conduct a formal mediation analysis related to mental health outcomes in HCWs. We accepted all types of mediation analyses, including: (I) mediation analysis using the PROCESS macro extension, (II) regression with odds ratios, likelihood ratios, or other mediation analyses and (III) structural equation modelling or other path analyses. Data extraction and quality assessment The first three authors independently extracted data from the identified studies. The following data were extracted: (I) author(s) and year of publication, (II) country, (III) type of pandemic, (IV) sample size and sex (percentage women), (V) age in years, (VI) profession of HCWs, (VII) study design, (VIII) measures used, (IX), type of mediation analysis, (X) mental health outcomes and mediators of mental health and (XI) study quality. For studies that described statistically significant outcomes, a p value < .05 was considered significant. Quality was assessed using the Effective Public Health Practice Project (EPHPP) tool, which provides good inter-rater agreement for overall quality (Armijo-Olivo et al., 2010) across a variety of quantitative study designs (Thomas et al., 2004). Studies were assessed on: (I) selection bias, (II) study design, (III) confounders, (IV) blinding, (V) data collection methods and (VI) withdrawals and dropouts. Components were scored as 1 (‘strong’), 2 (‘moderate’), or 3 (‘weak’). EPHPP guidelines were used to generate a global score as follows: no ‘weak’ component ratings = ‘strong’, one ‘weak’ component rating = ‘moderate’ and two or more ‘weak’ component ratings = ‘weak’. The first and third author independently assessed all studies. Cohen’s kappa (Cohen, 1960) was calculated to determine inter-rater reliability, showing good agreement (94.9%) between scores (κ = .902, p < .001). Discrepancies were due to differences in interpretation of criteria and were discussed with the second author until a 100% agreement in coding was reached. 4 Journal of Health Psychology 00(0) Results Paper selection As of 7 June 2020, the search protocol yielded 1467 papers (see Figure 1). After removing duplicates, 1116 papers were reviewed based on the title. Of those, 118 articles were reviewed based on the full text. Fifty-two studies were excluded because they did not conduct formal mediation analyses, 23 studies were excluded because they did not describe mental health outcomes or were not specific to HCWs, and four studies were excluded because the full text of the articles could not be accessed. All full-text articles were independently screened by the first three authors. Study characteristics A final sample of 39 studies was included in this review (see Table 1), consisting of 34 crosssectional studies and five longitudinal studies. The majority of the included studies were rated as ‘weak’ (n = 22) or ‘moderate’ (n = 15), and two studies were rated ‘strong’. Twenty-one studies investigated the SARS pandemic, twelve investigated the COVID-19 outbreak, four investigated MERS and one investigated influenza. Thirteen studies were conducted in China, eight in Canada, five in Taiwan, four in South Korea, two in Singapore and one each in India, Israel, Italy, Japan and Saudi Arabia. Most of the studies (n = 28) included multiple hospital staff members such as doctors, nurses, Records identified through database searching (N= 1,431) ScreeningIncluded Eligibility Identification Additional records identified through other sources (N= 36) Records after duplicates removed (N=1,116) Records screened (N= 548) Records excluded (N= 430) Full-text articles assessed for eligibility (N= 118) Full-text articles excluded, with reasons (N= 79) No formal mediation analysis n=52 Not describing mental health outcomes or not specific to HCWs n=23 No access to full text n=4 Studies included in systematic review (N= 39) Figure 1. PRISMA flowchart of study selection. HCWs: healthcare workers. Schneider et al. 5 Table 1. Characteristics of the reviewed studies. Study information Participants Methods Study quality Author (year) Country Pandemic N (% Female) Age years M (SD) Profession Study design Key measures Mediation analysis Mediators of psychological well-being Alsubaie etal. (2019) Saudi Arabia MERS 516 (doctors: 31%, other HCWs: 78%) – Doctors, nurses, technicians, respiratory therapists CS Anxiety Logistic regression with ORs Other HCWs > anxiety about contracting MERS and transmitting it to family than doctors; concern over transmitting MERS to family predicted anxiety in other HCWs 3 Amerio etal. (2020) Italy COVID-19 131 (48%) 52.3 (12.2) GPs CS PHQ-9, GAD-7, ISI, SF-12 PROCESS macro Anxiety and depressive symptoms mediated relationship between sleep and HRQOL (mental component) 3 Bai etal. (2004) Taiwan SARS 338 (52%) 39.1 (9.4) Hospital admin personnel, HCWs, unidentified hospital staff CS SARS-related stress reactions Logistic regression with ORs Quarantine was the most related factor in development of an acute stress disorder 3 Chan and Huak (2004) Singapore SARS 661 (–) 60.5% 25–40 years Doctors, nurses CS GHQ-28, IES, changes in life’s priorities, coping Logistic regression with ORs Support from supervisors and colleagues, clear communication and valuing work as important associated with decreased PTSD and psychiatric symptoms 2 Chew etal. (2020) India, Singapore COVID-19 906 (64%); India n = 426, Singapore n = 480 Median (IQR) = 29 (25–35 years) Doctors, nurses, allied healthcare professionals, other HCWs CS Physical symptoms, DASS-21, IES-R Logistic regression with ORs HCWs with physical symptoms more likely to report depression, anxiety, stress and PTSD 2 Chong etal. (2004) Taiwan SARS 1257 (81%); initial phase n = 727, repair phase n = 530 31.8 (6.4) Nurses, doctors, technicians, admin staff, other HCWs L Exposure to SARS, IES, CHQ Logistic regression with LRs Exposure to SARS and being in the repair phase predicted risk of psychiatric morbidity 2 Dai etal. (2020) China COVID-19 4357 (77%) 35.0 (8.6) Doctors, nurses, technicians, support staff CS Exposure to COVID-19, risk perception, GHQ12 Logistic regression with ORs Identifying as female, working in Wuhan, and working in primary hospitals predicted psychological distress 2 Fiksenbaum etal. (2006) Canada SARS 333 (95%) 43.8 (10.0) Nurses CS Contact with SARS patients and experience of quarantine, perceived SARS threat, positive feedback, SPOS, MBI, STAXI SEM Perceived SARS threat mediated relationship between lower perceived organisational support and emotional exhaustion and between lower perceived organisational support and state anger 3 (Continued) 6 Journal of Health Psychology 00(0) Study information Participants Methods Study quality Author (year) Country Pandemic N (% Female) Age years M (SD) Profession Study design Key measures Mediation analysis Mediators of psychological well-being Ho etal. (2005) Hong Kong SARS 97 (83%) – Recovered HCWs (doctors, nurses, allied health professionals, support staff) CS SFS, SES, IES-R Multiple regression SFS insecurity, SFS instability and SFS infection were significant predictors of IES-R total (48.1% variance explained) 3 Jung etal. (2020) South Korea MERS 147 (100%) – Nurses CS IES-R, supervisor support, turnover intention, GHQ-12, stress levels during and after outbreak Multiple regression with covariates Work experience 1–4 years, direct involvement with the treatment of a suspected patient, higher PTSD score and higher supervisor support (inverse) were associated with turnover intention 3 Kang etal. (2020) China COVID-19 994 (86%) 64.4% 25–40 years Doctors, nurses CS PHQ-9, GAD-7, ISI, IES-R, exposure, accessed mental healthcare services, health status SEM Mental health services partially mediated the relationship between exposure risk and mental health 3 Kim and Choi (2016) South Korea MERS 215 (94%) 28.2 (5.5) Nurses CS Burnout, job stress, fear of infection, hospital resources for treatment of MERS, support from family and friends Multiple regression Job stress, poor hospital resources, poor support from family and friends predicted MERS-related burnout (47.3% variance explained) 2 Koh etal. (2005) Singapore SARS 10511 (82%) 36.6 (11.3) HCWs from 3 SARS and 6 SARSfree hospitals CS Perceived exposure, perceived risk of infection, impact on personal and work life, IES Logistic regression with ORs Working at a SARS hospital, being clinical staff, daily exposure to SARS patients and high IES score predicted risk perception; high IES score predicted stigmatisation; working at a SARS hospital, daily exposure to SARS patients, being a nurse, being married and high IES score predicted work stress 3 Lai etal. (2020) China COVID-19 1257 (77%) 64.7% 26–40 years Doctors, nurses CS PHQ-9, GAD-7, ISI, IES-R Logistic regression with ORs Being from Wuhan and engaging in direct diagnosis, treatment and care of patients with COVID-19 were associated with a higher risk of symptoms 2 (Continued) Table 1. (Continued) Schneider et al. 7 Study information Participants Methods Study quality Author (year) Country Pandemic N (% Female) Age years M (SD) Profession Study design Key measures Mediation analysis Mediators of psychological well-being Lancee etal. (2008) Canada SARS Survey n = 448 (86%), survey and interview n = 139 (87%) Survey: 41.3 (10.2), survey and interview: 45.0 (9.6) Nurses, other HCWs L IES, K10, MBI, increases in harmful behaviours, perception of adequacy of training, protection and support Logistic regression Previous psychiatric history, years of healthcare experience (inverse) and perception of being adequately trained or supported by hospital or clinic (inverse) predicted onset of psychiatric diagnosis after SARS 3 Liu etal. (2012) China SARS 549 (75%) 35% 36– 45 years, 32% >45 years Hospital employees CS SARS exposure, other exposure to traumatic events, perception of risk, current job stress, CES-D, IES-R Logistic regression with mediation analyses Quarantining, work exposure, being single, exposure to other traumatic events, perceived risk, altruistic acceptance (inverse) and high PTSD symptom level predicted higher levels of depressive symptoms 3 Lu etal. (2006) Taiwan SARS 127 (58%) Doctors: 36.5 (6.3), nurses: 31.6 (5.5), other HCWs: 31.1 (7.6) Doctors, nurses, other HCWs CS Impact of SARS, PBI, EPQ, CHQ SEM Neuroticism mediated the relationship between maternal protection and mental health symptoms 2 Lu etal. (2020) China COVID-19 2299 (medical staff: 78%, admin staff: 76%) 40% 31–40 years Medical staff, admin staff CS Fear, HAMA, HAMD Logistic regression with ORs High-risk medical staff were more likely to report fear, anxiety and depression than admin staff 2 Lung etal. (2009) (follow-up of Lu etal., 2006) Taiwan SARS 127 (58%) (n = 123 completed followup) Doctors: 36.5 (6.3), nurses: 31.6 (5.5), other HCWs: 31.1 (7.6) Doctors, nurses, other HCWs L PBI, EPQ, CHQ SEM Neuroticism mediated the relationship between maternal protection and mental health symptoms 1 Marjanovic etal. (2007) Canada SARS 333 (95%) 43.8 (10.0) Nurses CS MBI, STAXI, avoidance, vigour, SPOS, trust in equipment/infection control initiatives, contact with SARS patients, quarantine Multiple regression Contact with SARS patients, vigour (inverse) and trust in equipment/ infection control initiatives (inverse) predicted emotional exhaustion (25% variance explained); time in quarantine, organisational support (inverse), vigour (inverse) and trust in equipment/infection control initiatives (inverse) predicted state anger (25% variance explained) 3 (Continued) Table 1. (Continued) 8 Journal of Health Psychology 00(0) Study information Participants Methods Study quality Author (year) Country Pandemic N (% Female) Age years M (SD) Profession Study design Key measures Mediation analysis Mediators of psychological well-being Matsuishi etal. (2012) Japan H1N1 1625 (76%) 30.3% 20–29 years Doctors, nurses, other HCWs CS H1N1-related stress, IES Multiple regression Anxiety about infection higher in younger HCWs, nurses and high-risk environments; exhaustion higher in older HCWs, nurses and high-risk environments; workload stress higher in nurses and high-risk environments; feelings of being protected higher in older HCWs and nurses 3 Maunder etal. (2006) Canada SARS 769 (–) – HCWs from 9 SARS and 4 SARSfree hospitals CS IES, K10, MBI, increases in harmful behaviours, perception of stigma and interpersonal avoidance, adequacy of training, protection and support, job stress Multiple regression Maladaptive coping, perceived adequacy of training, protection and support (inverse) explained 18% of variance in burnout and 21% of variance in posttraumatic stress; maladaptive coping, attachment anxiety, experience in healthcare (inverse) explained 31% of variance in psychological distress 3 Maunder etal. (2004) Canada SARS 1557 (75%) 40.2 (11.0) Hospital staff CS IES, attitudes towards SARS Multiple regression with mediation analyses Health fear, social isolation and job stress fully mediated the association of SARS patient contact and being a nurse with psychological stress (29% of variance in total IES score explained) 3 McAlonan etal. (2007) Hong Kong SARS 176 (73%) in 2003 and 184 (64%) in 2004 Range: 30–50 years Doctors, nurses and healthcare assistants L PSS-10, DASS-21, IES-R Multiple regression with mediation analyses Post-traumatic stress scores partially mediated the relationship between high risk of SARS exposure and perceived stress 1 Nickell etal. (2004) Canada SARS 510 (–) – Allied healthcare professionals, nonpatient-care staff, nurses, doctors CS GHQ-12, Occupation/ work history, concerns about SARS, use and effects of precautionary measures, Logistic regression Being a nurse, part-time employment status, lifestyle affected by SARS outbreak and having ability to do one’s job affected by the precautionary measures predicted emotional distress 3 Park etal. (2018) South Korea MERS 187 (100%) 31.2 (6.8) Nurses CS SF-36, PSS-10, DRS-15, stigma PROCESS macro The influences of stigma and hardiness on mental health were partially mediated through stress 2 (Continued) Table 1. (Continued) Schneider et al. 15 effects of tailored interventions that take into consideration nationality and ethnicity, though this will require more Western research into HCW’s mental health and experiences. Most studies included in this review were not longitudinal in nature, indicating that similar, rapid investigations could also be conducted across the UK, United States and Europe. At present, the majority of studies have been conducted in Asia (China, Taiwan, South Korea, Singapore, Japan and India) and North America (Canada), with two conducted in the Middle East (Israel and Saudi Arabia) and only one included study conducted in Europe (Italy). This is an important consideration when extrapolating findings from this review to other countries, where national medical systems (i.e. free healthcare in Europe) may have different expectations of, and impact on, HCWs. Overall, the findings of this review highlight the need to focus on the mental health of HCWs before, during, and after pandemics, to promote psychological well-being and reduce adverse mental health outcomes, burnout and turnover. Below we highlight some implications of this review for policy and practice, particularly with regards to suggested targets for future interventions. Such interventions can be delivered at an individual level, by for example targeting HCWs with pre-existing physical or psychological conditions (e.g. depression) or at an organisational level, for example by providing HCWs with adequate PPE, balanced work schedules, mental health support, and appropriate accommodation and compensation. Policy implications and recommendations Recent evidence suggests that ability to cope (particularly resilience) can be targeted through interventions (Chmitorz et al., 2018). Such interventions could be put in place by hospitals and other places of work. Unsurprisingly, this review found that workplaces that offered inhouse mental health support served as a protective factor against depression, anxiety and stress in HCWs (Kang et al., 2020). This result, though to be expected, should reinforce the need for such services to be made available more widely. HCWs are generally reluctant to seek out mental health support even under more normal circumstances (Chew-Graham et al., 2003), but having these services in places might help with that, even if it just shows that hospitals and health workplaces are seen to be more accepting of HCWs’ mental health needs. Indeed, hospital administrators and policymakers should make efforts to ensure that nurses do not suffer from infectious disease-related stigma such as social rejection, prejudice or discrimination during the early stages of a pandemic, so that they may perceive less stress and maintain better mental health, enabling them to concentrate on caring for their patients (Park et al., 2018), even if this requires challenging accepted work cultures. Additionally, psychoeducational training (pre-pandemic) could be provided for all HCWs to help them cope with stress and negative emotions, as well as to reduce burnout. An example of such an approach is the recent application of mindfulness interventions for a variety of HCWs and healthcare settings, with promising evidence for enhanced psychological well-being outcomes (Luken and Sammons, 2016; Morgan et al., 2015; Raab, 2014). Mindfulness training can also enhance altruistic acceptance of risk among HCWs (Cameron and Fredrickson, 2015), which was found to be an important mediator of positive mental health outcomes in the current review. Similarly, the American Psychological Association (APA) has successfully piloted a psychoeducational programme to provide information about mental health to those experiencing distress, and to identify high-risk individuals who may need further intervention. Once released, the programme is planned to be available for free to psychologists and other mental health practitioners (APA, 2020). In these ways, workplaces can help ensure that HCWs perceive their job to be secure and unaffected by pandemics and other crises, as fear of turnover was a commonly reported issue (Jung et al., 2020). 16 Journal of Health Psychology 00(0) Workplaces can help in other ways too. This review’s findings suggest that there is a role for providing accurate and timely information to HCWs and the public to reduce uncertainty and minimise stigmatisation of HCWs (Liu et al., 2012). Moreover, at least one study in the current review found that social media and the news cycle negatively impacted HCWs’ mental health and that having reliable and timely information from trustworthy sources was important (Wong et al., 2007), which supports recent statements on efficient leadership and ‘fake news’ (Van Bavel et al., 2020). Indeed, recent research has shown that the use of social media and exposure to COVID-19-related information through mainstream media are associated with increased levels of negative affect (Lades et al., 2020) and depression (Olagoke et al., 2020). Notably, the way mainstream media reports outbreak information is likely to differ between countries and false information and rumours are arguably easily spread online (Amin, 2020). In line with this concern, the WHO has published guidance on supporting mental and psychosocial well-being during the COVID-19 pandemic (WHO, 2020b). The guidance advises the general population to minimise the frequency of obtaining information, particularly when it causes feelings of anxiety or distress, and to seek information only from trusted sources, such as the WHO website and local health authority platforms. Finally, it is important that healthcare organisations do not simply rely on blanket acceptance of HCWs’ duty to put their lives on the line during global pandemics. Although the contributions of volunteers and essential workers are critical during such events, social support and work safety for workers are crucial. HCWs should be aware of potential consequences of working during ongoing pandemics and be provided with the choice to withdraw from their duties, if they believe their well-being is at risk. In addition, to maintain the safety of HCWs, while also ensuring that the healthcare system can cope with increased patient cases, HCWs should be provided with compensation in the form of suitable accommodation, mental health support and social support. For the following recommendations, we must acknowledge the political, cultural, financial and other systemic factors that are likely to influence the possibility of providing suitable accommodation and the availability of other resources for HCWs. However, wherever possible, providing suitable housing to HCWs would benefit those who are concerned about the risk of infecting loved ones. Additionally, policy makers and mental health professionals working to prepare for potential disease outbreaks should be aware that the experience of being quarantined can, in some cases, lead to long-term adverse mental health consequences (Bai et al., 2004; Brooks et al., 2020; Liu et al., 2012). Similarly, perceived support has been found to be crucial and should therefore be considered a priority area for intervention. Finally, adequate PPE is an important contributor to feelings of safety among HCWs responding to infectious disease outbreaks and should be provided for all frontline workers (Simms et al., 2020). Strengths, limitations and future directions Despite the rigorous search criteria and study reviews conducted, this review is not without limitations. Firstly, we found high variation among the included studies regarding outcome measures, study populations and measurement tools; thus, it was difficult to synthesise the results. Quantity of findings regarding mediators should not replace quantitative analysis of effect size through meta-analysis. At present, the quality of available studies is too limited to conduct such an analysis. Readers should be mindful that any conclusions we draw about protective and risk factors are therefore subject to scrutiny, and we encourage future research to continue better understanding the outcomes that affect HCWs’ mental health during pandemics. Secondly, the majority of studies lacked quality in study design and data collection methods. Due to the novelty of COVID-19 and other similar events that were typically investigated during the initial phase of the Schneider et al. 17 outbreak, many studies included unvalidated measures and failed to report the reliability of their scores, thus undermining the robustness of their findings and limiting generalisation of our conclusions. Similarly, most studies failed to properly control for confounding variables in their analyses. Assuming this was not an oversight in the analysis itself, this may well have been an issue with reporting, in which case, authors should in the future be careful not to sacrifice speed for transparency and clarity regarding the scientific process. Secondly, it is still unclear what the long-term effects of pandemic outbreaks on the mental health of HCWs are. Nearly all of the studies included in the current review were cross-sectional, with publications tending to decrease drastically after the outbreaks subsided. While data from crosssectional studies can provide an insight into the potential mediators of mental health outcomes in HCWs, no causal inferences can be made from these observations, and longitudinal research is required to substantiate these findings. However, research interests in global pandemics seemed to dwindle as soon as the pandemic lost its novelty. Given that global pandemics are expected to become more frequent in the future (IPBES, 2020), it is crucial to increase the number of large-scale studies in order to understand which of the many variables explored so far are the most effective in increasing HCWs’ mental health in response to future outbreak situations. Finally, there is also a need to explore the effect of pandemics on HCWs in different countries, given that available studies for the present review were conducted in few countries. Although several intervention studies are already in progress to develop and pilot mental health support packages to assist HCWs during the pandemic (e.g. Blake et al., 2020), work in this area should continue to be prioritised in order to develop multidisciplinary guidelines that may be shared at international level during the outbreak of pandemics (Zaka et al., 2020). It is important to note that, although we did not find systematic differences across pandemic type, none of the final studies included in this review examined the effects of Ebola or influenza strains outside of H1N1. It is therefore important to exercise caution before applying lessons learned from this review generally across other types of pandemics. Conclusions The findings of this review are crucial to appropriately support HCWs during current and future global pandemics, as they provide up-todate evidence on risk and protective factors that mediate the well-being of HCWs. Previously published reviews have generally focused on mental health factors exclusively or on specific outbreaks, and often failed to follow gold standard guidelines (Brooks et al., 2020; Galbraith et al., 2021), thus limiting the reliability of results and the conception of holistic interpretations. Our review is particularly relevant because it shows that individual characteristics have a significant impact on psychological outcomes during global health crises. For instance, HCWs should be aware that a history of illness may put them at higher risk of experiencing psychological symptoms and may be educated on methods of coping that are specific to their risk factors. Similarly, the well-being of those working directly with infected patients, such as nurses, should be especially monitored. The combined available evidence also shows that perceived support plays a vital role during pandemics. A safe, supporting, and efficient work environment is not only likely to impact HCWs’ well-being in various aspects of their life and work but may also benefit the hospitals. Providing appropriate training and protection to medical and administrative staff, as well as acknowledging HCWs’ need for mental care support, would reduce risk of turnover, increase medical performance in the long term, and provide positive feedback for the organisation. Data availability statement Data availability is not applicable to this article as no new data were created or analysed in this study. 18 Journal of Health Psychology 00(0) Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. ORCID iDs Jekaterina Schneider https://orcid.org/0000-0002 -6069-4783 Benjamin Gibson https://orcid.org/0000-0002 -9932-7403 References Alsubaie S, Hani Temsah M, Al-Eyadhy AA, et al. 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