Problems With Public Hospitals in India Peer Review

Introduction

The COVID-19 outbreak was alleged equally a global pandemic on March 11, 2020 (1). Although social distancing is the nearly effective way to comprise the outspread of this virus, this is not easy to implement for healthcare professionals who require direct contact with COVID-19 patients and puts them under a high chance of being infected themselves (two). Frontline healthcare professionals are especially vulnerable during this pandemic owing to their delivery to contain the disease (three). As of October 15, 2020, in that location were around four,797 COVID-xix cases for doctors and nurses with more than 100 deaths of physicians in Bangladesh (4). Besides physiological threats, such public health emergency affects the psyche of healthcare workers, including professional stress, fearfulness of infection, and feeling helpless (5).

The number of doctors in Bangladesh regime healthcare facilities is scarce (5.26 doctors/x,000 people). Hence, many healthcare professionals worked around 17 h, including long tele-counseling shifts each solar day (half dozen). To mitigate this claiming, the government appointed an additional 2,000 doctors on May 2020 (vii). Further, healthcare professionals faced acute shortage of masks, hand gloves, and personal protective equipment (PPE) to protect themselves from COVID-19 infection (8). Moreover, locally produced PPEs, masks, and other kits provided by the authority are being reported to be of depression quality and unable to protect the medical workforce from being infected (9).

Healthcare professionals likewise suffered from insomnia, loneliness, slumber disorder, and mental depression as a result of the workload and related stress (10). They were experiencing anxiety attacks every bit well as frustration due to a lack of knowledge, environmental changes, and fear of infection both past themselves and by their family members (11). Currently, healthcare professionals are likewise bound to maintain physical distance from their family members to reduce the run a risk of contagion, which results in farther psychological distress (12). Hence, a special attending to monitor the psychological issues of high-gamble population exposed to COVID-19 becomes more essential (13).

When it comes to the challenges faced by the healthcare professionals of People's republic of bangladesh during COVID-xix pandemic, concerns raised from bad governance cannot exist ignored. The number of PPEs provided past the government was insufficient for healthcare professionals, and they were mostly untrained regarding how to use them. This resulted into an alarming rate of infection among the medical workforce (14). Contempo studies emphasize on strengthening the healthcare governance in Bangladesh by properly distributing healthcare facilities betwixt urban and rural areas, public and private facilities, enhancing the role of media, increasing the recruitment of healthcare workers, and concentrating on the provision of necessary healthcare equipment such as intensive intendance units and oxygen supply (fifteen–17).

Doctors are facing tremendous difficulties at work during the COVID-xix pandemic (18). Despite these obstacles, healthcare professionals accept adapted to deal with the prevailing health crunch. A previous study (19) has shown that meditation, relaxation as well as music therapy tin aid to mitigate the daily stress. During the severe astute respiratory syndrome (SARS) outbreak in 2005, healthcare professionals took some initiatives to cope with the stress associated with the pandemic. The coping mechanisms included abstention of news about the SARS pandemic, modest gatherings after work where problems can exist shared likewise as participating in other recreational activities (twenty). Proper training, PPE, and medical assistance are important to support healthcare providers (six); nonetheless, these are not bachelor in Bangladesh. A number of studies have been conducted on COVID-19-related issues in Bangladesh; still, there are no qualitative studies on the challenges faced by healthcare professionals during the current COVID-xix pandemic. As qualitative research is known for generating rich information in health inquiry (21), we attempted to address this enquiry gap to get a more in-depth knowledge of the individual experiences, beliefs, opinions, behaviors, and feelings of the healthcare professionals during the pandemic (22).

Theoretical Framework

We used the stress theories to understand the challenges healthcare professionals in Bangladesh are facing during the COVID-nineteen pandemic. The COVID-19 outbreak has generally caused public stress (23) as people go through a series of concrete and mental challenges both within and outside which affects their own subjective evaluations (24). Ursin and Eriksen (2004) provide a farther explanation on how people go through stress during a crisis. The authors used the term "stress" to announce four different views, namely, "stress stimuli," "stress experience," "non-specific general stress response," and "experience of the stress response" (25). According to Cognitive Activation Theory of Stress (CATS) theory, people learn knowledge when handling adversities, and a normal, well-counterbalanced stress at such situations should be common. Response to stress is of import as this provides the energy that enables them to fight against the odds. However, when in that location is a disparity between the expected and actual circumstance, the stress response mechanism starts struggling (26). While stress response is essential to confront challenges, higher levels of sustained stress tin lead to physical and mental disorders. Nosotros contend that the sustained workload and mental stress of the healthcare professionals during the pandemic originate an acquired expectancy referred to equally "hopelessness"(27).

Methods

An exploratory qualitative research was employed to sympathise the in-depth cognition of challenges dealt past wellness workers from Khulna and Dhaka urban center in Bangladesh from May to Baronial 2020. Doctors and nurses who are willing and provided treatment at dissimilar hospitals and clinics in People's republic of bangladesh during the COVID-19 pandemic participated in this report. We selected xv respondents for the in-depth interviews through the snowball sampling technique. The participants were recruited through referrals of healthcare professionals from our previous acquaintances. We used this technique as healthcare professionals who were willing to participate in this report were extremely hard to notice during the pandemic. The in-depth interview was conducted through telephone. We developed an in-depth interview guide to probe questions for the interview procedure. The items for the interview guide were generated through searching the relevant literature. Only contents related to the present written report were considered, while pieces of pure medical literature were excluded from the review. The guide consisted of questions on barriers related to workload, severity of the affliction and associated stress, availability and quality of PPE, COVID-nineteen-related challenges, and coping strategies to manage the barriers.

SRR, TY, TBA, and MSI (academicians who completed their 2nd caste) conducted the interviews and collected data through multiple sessions and with the convenience of the participants. The elapsing of each session was xxx–40 min in general, and the interviews were recorded through an audio recording application/device, which was transcribed in the next phase. We used the follow-upwardly questions to excerpt rich data during the interviews. Verbal probes such as repeating the ideas and phrases of participants and showing enthusiasm to a particular topic during the interviews were part of the probing strategy. Apart from the authors, ii trained research administration were appointed to manage the data collection and transcription. TBA and MSI independently coded the information from verbatim transcript equally the process included the development of a lawmaking construction initially. The whole coding procedure was reviewed and finalized with the consent of all authors. We applied a deductive approach suggested by Miles and Huberman (1994) (28) using thematic analysis technique (29). The most recurring and significant quotes were selected to exemplify the predetermined themes. While analyzing, we focused on the meaning, context, phrases, frequency, and intensity of the statements of our participants. We analyzed the data both manually and using QDA Miner (version v) software. The QDA miner is useful in managing a large volume of qualitative information extending the scope of manual analysis. It is largely used by researchers and experts for conducting qualitative research worldwide.

We maintained standard ethical protocols to conduct this research. The study protocol was approved by the person who blinded for peer review. At the showtime of the interviews, informed consent was sought from each participant after a briefing about purpose of the research was done. The identities of the respondents were kept confidential, and they bodacious that the information provided by them would only be used for academic enquiry.

Results

Characteristics of Report Participants

Xv respondents were included in the in-depth interview. The summary of the participants and their details are provided in Table 1.

Tabular array 1. Sociodemographic profile of participants.

Seven themes emerged from the unstructured interviews, i.e., workload, PPE, social acceptance, mental health, incentives, coping strategies, coordination, and management of the respondents during the COVID-19 pandemic.

Loftier Workload

Participants indicated that the health sector faces a shortage of medical workers. Moreover, many registered doctors practice no practice medicine, resulting in higher workload past the agile medical workforce in public besides as in private facilities. In the private facilities, doctors were usually provided with a 1-day intermission each week. Doctors were working for long shifts in their working days and during holidays via telecommunications. For case, Participant 3 said,

You are request the doctors well-nigh their workload! When people were decorated partying at the eve of Eid-ul-Fitr festival, we were working in the hospital. I had a shift even on Eid mean solar day. Moreover, I was diagnosed as COVID-19 positive on 15 ^th of June 2020, which demands for at least a 21 days recovery procedure after being further tested as existence COVID-19. Just we cannot afford that luxury every bit the hospital does not have enough human resources. Consequently, I had to join my work correct after accomplishing my recovery from the virus.

Apart from enduring tremendous physical pressure level, excessive workload also leads to increased mental stress. Medical facilities likewise have few nurses, who had to piece of work sixteen–17 h shift per day. Additionally, fear of infection prevented workers from joining their workplace. Participant five said,

Since we take completed our nursing degree, so we are supposed to be psychologically well equipped to serve people in any medical emergency. Just at the very beginning of the coronavirus outbreak, many of us suffered from a fear of infection and were besides agape to come to work. This turn down in the regular number of nurses created too much workload for us.

Healthcare professionals who were younger and working in Dhaka-based hospitals reported of higher workload in this study. This might be due to a higher piece of work assignment for younger people and a greater outbreak of COVID-19 in the capital metropolis. When asked near workloads, Participant 12 shared with frustration,

Dhaka is hitting near severely during the get-go wave of COVID-19. It is the majuscule city of the country with xx meg population and the largest international airdrome. People are landing hither from countries with loftier infection rate every day and the disease is spreading like bushfire. We are admitting a large number of patients each day and having a actually difficult time dealing with it.

Lack of PPE

Participants repeatedly pointed out that PPE supplied by their hospitals were either inadequate or of depression-quality. Though the government demanded on the mass media that every hospital has been provided with the required numbers of PPEs, the fact on the ground was different. Especially, study participants in private medical facilities demand to buy their ain PPEs as they were not certain of the availability in the health facilities. Participant 1 corroborated the issue.

Despite the need to have a regular supply of PPEs, the hospital does not have enough of them in its possession. I accept received ane PPE per week from Nippon People's republic of bangladesh Friendship Hospital, which is not sufficient. Consequently, I am needed to buy PPE at my expenses to ensure my safety during work. Some other threatening fact regarding PPEs came into my discover from a number of national newspapers. Some decadent businessmen are generating new PPE'due south from the ones that have been dumped as medical wasted in Keraniganj, Dhaka. This upshot gave me quite a daze and made me question my oath to serve the mass people in any given situation.

The PPEs provided by the authority were fabricated of plastic-blazon cloth. The shortage of PPE as well declined to some extent with time. An additional complaint came from the nurses that they had to face up astute shortage of PPEs as doctors were the primary focus here and the need for an acceptable supply of PPEs for nurses was relatively ignored. Participant six noted,

At the first slot, we were provided with a huge number of poor-quality PPEs which made the pandemic situation more vulnerable for health professionals like us. Only as of now (month of June), we have a steady supply of adept quality PPEs which tin efficiently protect united states from this virus. From my perception, there is no lack of PPE in the present condition.

Low Social Acceptance

Social stigma was another claiming for the healthcare professionals during the COVID-nineteen pandemic. The neighbors perceived them as a nuisance and usually avoided advice for fear of infection. In some cases, landlords raised monthly house rents of the medical workers and evicted them from their property if they were tested COVID-positive. Sometimes, their maintenance of social distance became rather brutal, and this disturbed the healthcare professionals. Two of the statements represent this status:

Participant iii: "Haha! Mass people always perceive u.s. doctors as "butchers" in this country. Nosotros are shown some respect over social media posts, only there is no respect for doctors in the real-world. Blood-red flags are used to marker the zone containing COVID positive patients, simply from my perspective, these flags are playing the role of barriers. While nosotros need more psychological support from full general people, working within the red zone has completely excluded us from society."

Participant v: "Actually, I feel deeply disturbed when I talk almost the issue of social credence. When I started serving contagious patients during this pandemic, people of my community treated me in a manner which made me experience like I was a raped adult female… (Crying). But I have taught myself to endure that hurting and work as a frontline fighter against this deadly virus."

Parents of healthcare professionals remained concerned about their children working in such a risky surround. They often tried to bargain with them to stay home, but it was but parental concern, and the participants continued piece of work after pacifying them. Generally, their relatives maintained a social altitude and refrained from visiting their houses. Simply participants considered this as positive to ensure the condom of both their relatives and their family members.

Mental Health Issues

People working in the medical sector are trained to remember and act steadily in any medical emergency. Regardless of that training, participants mentioned that they had to cope with dissimilar psychological challenges, including anxiety, depression, insomnia, and fear of sudden death during the COVID-xix pandemic. Participant two said,

Being a md has taught me to have full control over my mind. Despite that control, the electric current pandemic makes me anxious sometimes as many doctors are beingness infected during their service toward COVID-19 patients. At that place is one incident worth mentioning in this context. Witnessing the expiry of patients is office of the job for united states of america, but I had to witness the death of a medical dr. in Sylhet due to COVID-19, which was a offset for me. It was the near shocking thing during my lifetime working feel. Afterwards this feel, I started having trouble sleeping.

Healthcare givers serve in an atmosphere where the fear of infection prevails at its largest. Despite that, participants were more concerned about family members existence infected by them rather than themselves being infected, leading to further mental stress. Participant 4 mentioned,

To me, psychological pressure mainly consists of anxiety regarding the safety of my family. I am a widow, and my daughters are dependent on me both economically and for the sustenance of their daily lives. This familial condition puts me in a lot of pressure and forces me to think near what would happen to my daughters if I was diagnosed as a corona virus-positive and died. The constant thought of leaving my daughters all lonely in this globe is quite stressful.

Witnessing sudden death of colleagues created a feeling of helplessness amidst the healthcare professionals, leading to many of them to feel indisposition. The lack of appreciation by colleagues also caused psychological pressure. 1 of the nurses mentioned that doctors practice not appreciate them enough.

Participant vi: Nosotros work with extreme fearfulness and risk of infection risking our lives, but we get no appreciation. People recall only doctors are contributing to save lives. Nosotros (nurses) are always ignored and underpaid in this state. It's nothing new.

Lack of Incentives

All participants were aware that there was no extra-incentive for them despite working extra hours. Some incentives were promised by the government, such as providing treatment cost in case of infection and providing an isolation room to ensure safe inhibition. Only none was implemented in the real life. Further, participants strongly believed that these initiatives were non going to be implemented soon. For case, Participant 3 said,

Government announced that if anyone got infected past coronavirus during their service, the authorization would provide some money for treatment. Surprisingly, I did not receive any budgetary support to bear my treatment price when I was diagnosed every bit COVID-positive. Their announcement is void every bit always, and it is never going to be implemented. Though we are getting ii basic salaries of around 50,000, which is not plenty for us.

While the incentives provided by the authority for the employees in the authorities facilities were not satisfactory, the condition of the healthcare professionals working in private facilities was fifty-fifty worse. There was no monetary incentive for the healthcare professionals working in private facilities if they got infected or died during their service. The participants were depressed near this discrimination between public and private employees. Moreover, they were as well deprived of basic amenities such equally break between work shifts or provision of meals raising frustrations. Participant noted,

We have seen that roster system is in place to arrange the shifts of the health professionals in the government hospitals. As a consequence, regime doctors get seven days off after completing a seven-day shift with Corona patients. Unfortunately, we, the private clinic workers, do non get any incentive like that. I don't even get my meals from the hospital.

Lack of Coordination and Direction

The WHO and authorities guidelines were changing continuously given the disease is new and previous cognition is little. Consequently, doctors remained uncertain about the line of treatment. These uncertainties created additional mental stress for medical professionals.

The participants reported that patients were unaware of any safety protocols. COVID-19-positive patients often come to medical facilities to receive standard medical consultation, which put COVID-negative patients as well as the medical workers at-chance. In several cases, doctors and nurses got infected because patients did non reveal that they were COVID-nineteen-infected. A loftier-level coordination failure was prevalent in the healthcare administrations.

Moreover, healthcare workers were dissatisfied most some discriminatory initiatives taken upwards past the authority. Participants mentioned the case of the bank sector, where employees worked for only 20 days in Apr and May. In contrast, healthcare professionals did double or triple shifts, which was frustrating. Besides, they did not have any training regarding how to role correctly in a virus outbreak. Information technology was too perceived that the authorisation involved more than administrators and fewer specialists to tackle downwards this pandemic. For example, Participant 3 mentioned,

I want to mention ane more than issue here. It is needed to create a committee containing doctors every bit well as virologists who are specialized in providing guidelines in the context of how to handle the current COVID-xix state of affairs in Bangladesh best. Instead, the government has created a task forcefulness containing DCs, UNOs and other administrative personnel who possess no noesis almost the virus.

Coping Strategies

All of the participants expressed that belief upon God kept them relaxed. Support from family members and colleagues was also an essential coping mechanism. The healthcare professionals maintained regular conversations with colleagues maintaining social altitude and tried to be chivalrous with each other in their workplace. This supportive environment helped them a great bargain in reducing their mental stress. Keeping their sacred adjuration in mind, they were always more concerned well-nigh their patients than their well-being. This business organisation for the well-being of mass people served as a coping machinery on its own. For instance, Participant four said,

I cope with the challenges faced in my workplace with the support of my family unit, colleagues and a house conventionalities on the almighty's plans for all of us. The back up of my close ones and trust in the almighty provides me with a sense of mental forcefulness encourages me to stay positive whatever crunch. I also have mental notes that this is my job, and I must do information technology. If I become nervous in performing my duties, then how would the general people survive?

Apart from taking mental support from friends and families, healthcare professionals tried to follow every medical rule and regulation in their ability to go along safe from infection. The study protocol was approved by the Ethical Clearance Committee of Khulna University. Other participants reported meditation every bit means to increasing mental strength. Overall, participants put faith in a greater force in this crunch and keep reminding themselves that as they were working for the well-being of humanity.

Discussion

Our results showed that frontline healthcare professionals in Bangladesh had an increased workload during this crisis and a potential organisation failure in the healthcare sector. Lack of sufficient healthcare workers, noesis about the virus, and bones training were some of the reasons leading to excessive workload, which consequently gave rise to psychological stress. This finding is consistent with some of the existing literature (xxx, 31). A previous study also showed that excessive work pressure level was responsible for mental distress, insomnia, concrete weakness as well equally fright of infection of the healthcare professionals (32). Our study also focused on the lack of quality PPEs prevalent in the healthcare facilities. Information technology was reported that the insufficiency consequently led to an increasing rate of infection amongst healthcare professionals in People's republic of bangladesh. Several studies have found that bereft PPE triggered the spread of the viruses among healthcare professionals (33, 34). Likewise, wearing PPE for a long time was a crucial challenge for participants, subsequently resulting in drinking less water than necessary, which might have affected their immunity (35).

Coordination failure was prevalent among unlike administration sections in each facility where the respondents worked, resulting in a chaotic environment. Consequently, both doctors and patients were unsure nearly the protocols needed to maintain safe, which further increased the risk of infection. Insufficiency of medical staff and equipment was common, resulting in excessive workload and prophylactic hazard (36). This workload and constant fear of infection both for themselves and for their family members put participants nether substantial psychological stress (eleven). Social acceptance from neighbors, colleagues, and peer groups could act as a lifeline in removing this psychological stress. Merely the social reaction of almost cases was notwithstanding adverse toward the medical workforce, and they were shunned from their social life. Hence, the experience of medical professionals was pretty challenging during the pandemic. They still took coping strategies such as putting their religion in God, treating each other with kindness, and soothing conversation with a peer group to cope upwardly with the stress to some extent.

We observed that most of the participants in this study required acceptable protective supplies and proper residue, which is consistent with the present study (37). Psychological stress faced by healthcare professionals during public health emergencies included abiding worries well-nigh infecting children and parents of an individual, fear of death, anxiety about critical patients, and personal danger (38, 39). Healthcare professionals felt anxious when their colleague was infected past COVID-xix (ix). Nosotros also observed that healthcare professionals who had children were emotionally distressed to maintain distance from their loved ones due to a higher risk of being infected by COVID-nineteen. The finding was similar to another previous enquiry (20). Nurses expressed dissatisfaction with the workload equally they are not appreciated plenty, although information technology is evident that they often provide quality healthcare services like the doctors (40).

Healthcare professionals besides faced stigma from their neighbors and relatives. Neighbors perceived that the health workers carry a college hazard of infection from their exposure to patients. As a outcome, healthcare professionals were shunned from society and treated harshly, which sometimes demotivated them to serve patients. However, previous study documented that healthcare professionals need social support from their family unit members, relatives, and neighbors. Being devoid of that, support can consequence in feet and depression for healthcare professionals (41, 42). We predict that incentives such as economical support, abiding supervision, sufficient protective equipment, and adequate workforce could motivate health workers to contribute more during pandemic situations. Unfortunately, Bangladeshi healthcare professionals are mostly deprived of these facilities. Some of the infected healthcare professionals of this study mentioned that though the government announced some financial incentives, they did not receive information technology in reality.

When comparing our finding with the SAARC countries, we see some striking similarities. These countries already have a vulnerable economy characterized by weak medical infrastructure that rarely managed to provide its people with sufficient medical care, at least providing the healthcare professionals with necessary psychological help (43). Inadequate PPEs, social stigma, and being victims of violence added extra psychological stress for healthcare professionals in the center of their already hectic schedule (44). Besides, healthcare professionals from different age, gender, and socioeconomic groundwork suffer from dissimilar psychological issues. A specialized set up of interventions are required for healthcare professionals depending on their mental health condition (45). Although the National Health Policy of People's republic of bangladesh (2011) promises an adequate supply of logistics and manpower in government healthcare facilities, and coordination betwixt unlike healthcare services-related departments (46), the reality is different. Nosotros observed that the lack of coordination and skilled manpower all the same remains a key problem affecting the healthcare services quality in the country, which corresponds to the existing literature (47, 48).

The spread of an epidemic tin can cause psychological trauma for healthcare professionals (ten, 35). Therefore, effective coping strategies are required. Studies suggest that self-intendance, confidence, teamwork, and gathering among coworkers are some applied ways to alleviate mental force per unit area, work stress, and posttraumatic experiences amongst emergencies of caregivers (49, l) which was consequent with the results of this study. The stress theories also argue that the sustained response to stress for the healthcare professionals may lead to physical illness through proven pathophysiological ways (51, 52). We suggest as the pandemic prevails, healthcare professionals will face up further physical and mental adversities; therefore, they will demand a special attending to avoid this helpless situation.

Strengths and Limitations

A forcefulness of this report is using the exploratory qualitative inquiry to analyze what challenges the healthcare professionals in Bangladesh are facing and how they managed these adversities during the COVID-19 pandemic. However, the large book of data was difficult to collect, analyze, and maintain. The researchers put a greater corporeality of effort and time to offset the limitations. Nosotros followed the consolidated criteria for reporting qualitative research (COREQ) checklist for our in-depth interviews and for reporting this written report. The interviews were not restricted to specific questions and topics which helped producing rich and detailed data. We used the snowball sampling technique as we were unable to find a large number of healthcare professionals who were willing to let us sufficient time and cooperation during the pandemic. Because of the hectic schedule of the healthcare workers, interviews had to be kept short in some cases. However, we managed to reach the desired number of participants required to complete the study. As qualitative inquiry relies on the depth of information instead of the number participants, 15 healthcare professionals who participated in this study were enough for information saturation. Besides, executing a qualitative study through phone interviews had its ain limitations, although the researchers put their best effort to reply to the state of affairs. We acknowledge that direct observation and methodological triangulation might have provided further insight into the topic.

Conclusions

The present report explores the challenges faced by healthcare professionals during COVID-nineteen pandemic in People's republic of bangladesh. We found that insufficiency of medical staff too as medical equipment was common and resulted in increased workload. Apart from this, shortage of PPE, fear of being infected, social exclusion, and mismanagement contributed further to put the healthcare professionals in adversity. Although the National Health Policy of People's republic of bangladesh (2011) recommends enhancing skilled manpower and logistic support, we found the actual scenario to be different. Especially during the COVID-19 outbreak that put the healthcare sector into unprecedented claiming, the promised coordination and support in the healthcare sector rather reflects a disparity between the policy and the practice. Despite the recently introduced National Infectious Diseases Human action (2018), lack of a standardized COVID-19 protocol kept the medical professional under constant risk of infection and mental pressure. We conclude that the healthcare professionals need to be supported with adequate resources for both physical and mental health. While workloads need to be lessened, a proper coordination and access to information as promised in the National Wellness Policy during this public health emergency should exist put in practice to ensure quality healthcare services.

Information Availability Statement

The original contributions presented in the report are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics Argument

The studies involving man participants were reviewed and approved by Ethical Clearance Committee, Khulna University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

SR conceived the idea. SR, TY, TA, and MI analyzed the data. SR and TY drafted the manuscript. SR, SI, HG, and PW critically reviewed and approved the final version of the manuscript.

Conflict of Interest

The authors declare that the inquiry was conducted in the absenteeism of whatever commercial or financial relationships that could be construed equally a potential conflict of interest.

Publisher's Annotation

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any production that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We express our gratitude to all the healthcare professionals who participated in this study despite their busy schedule during the pandemic. We are likewise thankful to the administrations of wellness facilities for their kind cooperation throughout the data collection.

Supplementary Textile

The Supplementary Material for this article tin can be found online at: https://www.frontiersin.org/articles/x.3389/fpubh.2021.647315/total#supplementary-material

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