key: cord-0963429-obx00dy5
authors: LANGE, Marie; LICAJ, Idlir; BOULOUARD, Michel; GARON, David; RICHARD, Estelle; LE BAS, Jeanne; SALMON, Rémi; STROIAZZO, Rhéda; LE BAS, François; HUMBERT, Xavier
title: Psychological impact of the COVID-19 outbreak in community pharmacists: A longitudinal study
date: 2021-12-14
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2021.12.004
sha: 2a25e28b2427bdf210bce9c77d158fd6f4232686
doc_id: 963429
cord_uid: obx00dy5

Background COVID-19 has negatively impacted the mental health of frontline health care workers, including pharmacists. Objective(s) The aim of this longitudinal study was to assess the psychological impact of the COVID-19 outbreak in French owner community pharmacists. Methods We carried out a postal-based survey to assess the psychological difficulties of the COVID-19 outbreak in French owner community pharmacists based on three psychologically validated self-report questionnaires: Perceived Stress Scale (PSS), Impact of Event Scale-revised (IES-R) and Maslach Burnout Inventory. The baseline assessment was during the first sanitary lockdown period and the second one 5 months later. Results The sample consists of 135 owner community pharmacists. At follow-up, 67 answered the questionnaires (response rate: 49.6%). The mean scores of the PSS and IES-R significantly decreased (p=0.002). Fifteen pharmacists reported significant posttraumatic stress symptoms (23.1%) at baseline and eleven at follow-up (16.4%, p=0.02). Age and sex were not significantly associated with persistent posttraumatic stress or burnout symptoms. Conclusion This is the first longitudinal study that showed the psychological impact of owner community pharmacists as health care workers dealing with their community's COVID-19 outbreak. Based on validated self-report questionnaires, stress, posttraumatic stress and burnout symptoms decreased during follow-up. It is necessary to continue monitoring psychological difficulties for health care workers, especially during consecutive waves of the COVID-19 outbreak.

causing a cluster of pneumonia cases in China. 1 Three months later, the World Health 3

Organization declared the COVID-19 outbreak a pandemic. 4

Many cross-sectional studies have reported the psychological impact of the COVID- 19 5 outbreak on anxiety, stress and sleep disturbances in the general population and in health care 6 workers. [2] [3] [4] The first data on longitudinal follow-up started to be published one month after the 7 first assessment. In the general population, anxiety, depression and stress decreased 1 month 8 after the initial outbreak in China. 5 Nevertheless, at this time, very few published studies 9 included a follow-up several months after the initial outbreak. In the general population, 2-and 10 4-month follow-ups in Spain and the United States showed diminutions of depression, 11 posttraumatic stress disorder and distress. 6,7 12 To date, very few studies have reported a psychological impact of COVID-19 on health 13 care workers using longitudinal data. 8, 9 14 Pharmacists, as health care workers, by advising patients on precautionary measures and 15 providing appropriate information, play a crucial role in hindering the spread of coronavirus. 10 16 Indeed, in the 434 independent pharmacies of Lower Normandy (France), owner community 17 pharmacists provided more information on vaccine availability, the importance of wearing 18 masks, on how to get medication refills if their physician's office is closed due to the pandemic, 19

what COVID-19 symptoms to look for, or where to get COVID-19 testing. Consequently, they 20 were particularly exposed during this period because demands during the pandemic were likely 21 increased. In a previous study, we found that up to 35% of owner community pharmacists 22

reported psychological difficulties during the first sanitary lockdown. 11 It is important to 23 investigate the long-term effect of this unprecedented situation. 1 2

The objective of this longitudinal study was to assess the psychological impact of the COVID- 19 4 outbreak in French owner community pharmacists. Baseline assessment was performed during 5 the first sanitary lockdown period and the follow-up 5 months later. who are owners of their community pharmacist. In France, there are more than 200 different 20 chains of pharmacies that include 50% of the pharmacists. 12 Community replacement and 21 assistant pharmacists were not included. The first survey was conducted on April 15 th , 2020, one 22 month after the first COVID-19 sanitary lockdown. The second survey was conducted 5 months 23 after the first survey. No reminder has been sent. The end of the first French lockdown was May 1 11 th , 2020. The first French sanitary lockdown consisted of restricting travel except for work, 2 childcare, emergency care and pharmacy access and closure of nonessential stores and places of 3 recreation. During the first French COVID-19 lockdown, owner community pharmacies were 4 opened according to the usual hours. 5

The study methodology has been published previously. 11 Briefly, it consisted of 6 sociodemographic (age, sex), geographic areas (rural or urban 11 ), university activities, changes in 7 the work environment and three psychologically validated self-report questionnaires. The 8 original version of the questionnaire was English, and it is available in several languages. The 9

self-report questionnaires used were the Perceived Stress Scale (PSS) 13 (higher score represents 10 high level of stress), the Impact of Event Scale-revised (IES-R) 14 (higher score represents high 11 level of stress and significant posttraumatic stress symptoms were defined by a score ≥ 33) and 12 the Maslach Burnout Inventory (MBI; emotional exhaustion (EE), depersonalization (DP) and 13 personal accomplishment (PA)). 15 Higher scores for EE and DP represent higher burnout 14 symptoms. Higher score of PA represents lower burnout symptoms. High burnout symptoms 15 were defined by scores ≥ 30 and ≥ 12 for EE and DP, respectively, and ≤ 33 for PA. In the 16 second survey sending, activity modification and decrease (level of overall work pharmacists 17 reported by these health care workers during the COVID-19 outbreak) during the lockdown were 18 collected. Guidelines used by the French Health Ministry and National Order of Pharmacy 19 (whose roles are to ensure compliance with professional duties, to ensure the defense of the 20 honor and independence of the profession, to ensure the competence of pharmacists, to help to 21 promote public health and the quality of care in particular the safety of professional acts) were 22 also questioned. 16 Three self-report questionnaires were proposed for this second survey sending 23 (follow-up) to assess psychological difficulties. Persistent psychological difficulties were defined 1 by posttraumatic stress symptoms or high burnout symptoms at baseline and follow-up 2 assessments. Follow-up surveys were sent to owner community pharmacists who responded to 3 the baseline surveys. 4

The responses were anonymous, and identification numbers were used to match owner 5 community pharmacist inclusion and follow-up responses. No formal informed consent was 6 required, but a declaration to the French authorities in charge of personal data protection was 7 made. Indeed, the Ethics Department of the University of Caen Normandy approved this study 8 (Authorization n° TG_COMPO_PEDAGO_SANTE_14-20180529-01R1, April 6 th , 2020). 9

Quantitative variables were described with means and standard deviations, and qualitative 

During the first survey, 434 were sent, 135 participants (mean age=47.9 ± 11.4 years; Table 1)  22 completed and returned the questionnaire (baseline questionnaire response rate: 31.1%), 11 Pharmacy or professional associations, although the Ministry of Health (or regional healthy 8 agency) guidelines were used as a baseline. There were no significant differences in age, sex or 9 geographic area (rural or urban) between the 67 owner community pharmacists who agreed to 10 answer the follow-up questionnaires and those who did not (Table 1) . 11 Table 2 community pharmacists are rarely mentioned in this context. Thus, in the COVID-19 pandemic, 20 owner community pharmacists are particularly exposed to mental disorders, especially burnout. 21

In contrast, COVID-19 mass vaccination had not yet started at the time of our study in France. 22

Very few studies have reported the longitudinal psychological impact of the COVID-19 23 outbreak in health care workers. During the first three months of the COVID-19 outbreak, a 1 study conducted in the United States, including mainly physicians, showed a decline in distress. 9 2 In the outbreak period, Wuhan nurses had significantly higher risks for anxiety, depression and 3 posttraumatic stress symptoms than those in the stable period. 8 Our results in owner community 4

pharmacists are in line with these results. 5

If women reported more stress, posttraumatic stress and burnout symptoms during the 6 first sanitary lockdown period, 11 during follow-up, only higher posttraumatic stress symptoms 7 were observed among them. Novotny et al. 18 have already shown in a longitudinal cohort of 715 8 general population participants in Eastern Europe that COVID-19 lockdown-induced mental 9

distress was more severe in women than men (p=0.01). They also described that the observed 10 increase in the severity of depressive symptoms was significantly higher in women than in men 11 (p=0.002). 18 Moreover, women who work full-time jobs experience a higher degree of burnout 12 than men because they also take care of their families and their work responsibilities. Thus, the 13 COVID-19 pandemic impacted remote learning for children, which probably mainly impacted 14 the mothers, especially during the COVID-19 lockdown when school and nurseries were closed. 15

For example, Dillon et al. 19 showed that burnout was more common among women than among 16 men (39.0% vs. 22.7%, p<0.01) in 3,176 USA physicians. More women than men reported that 17 childcare/caregiving impacted work during the COVID-19 pandemic (32.9% vs. 19.0%, 18 p<0.01). 19 19 Persistent posttraumatic stress or burnout symptoms were not associated with 20 demographic data. Nevertheless, our sample is small to perform a more comprehensive analysis, 21 including additional factors associated with persistent psychological difficulties. The low 22 response rate, especially at follow-up, is another limitation of the present study, although no 23 differences were observed among those who accepted and those who did not. Furthermore, 1 questionnaire use induces selection bias. A memory bias is also possible. Finally, there was no 2 control group. 3 4

This is the first longitudinal study that showed the psychological impact of the COVID- 19 6 outbreak in owner community pharmacists. Based on validated self-report psychological 7 questionnaires, stress, posttraumatic stress and burnout symptoms decreased during follow-up. It 8 is necessary to continue monitoring psychological difficulties for health care workers, especially 9

during the second wave of the COVID-19 outbreak. 10 

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Impact on mental health of the COVID-19 outbreak among community pharmacists during the sanitary lockdown period

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* Maslach Burnout Inventory, missing answer = 3

Sample size is reduced to pharmacists with available information both at baseline and 5-month follow-up

To Union Régionale des Professionnels de Santé Pharmaciens Normandie and to all the participants.J o u r n a l P r e -p r o o f