Prepared and highly committed despite the risk of COVID-19 infection: a cross-sectional survey of primary care physicians’ concerns and coping strategies in Singapore

Background Primary care physicians (PCPs) are first points-of-contact between suspected cases and the healthcare system in the current COVID-19 pandemic. This study examines PCPs’ concerns, impact on personal lives and work, and level of pandemic preparedness in the context of COVID-19 in Singapore. We also examine factors and coping strategies that PCPs have used to manage stress during the outbreak. Methods Two hundred and sixteen PCPs actively practicing in either a public or private clinic were cluster sampled via email invitation from three primary care organizations in Singapore from 6th to 29th March 2020. Participants completed a cross-sectional online questionnaire consisting of items on work- and non-work-related concerns, impact on personal and work life, perceived pandemic preparedness, stress-reduction factors, and personal coping strategies related to COVID-19. Results A total of 158 questionnaires were usable for analyses. PCPs perceived themselves to be at high risk of COVID-19 infection (89.9%), and a source of risk (74.7%) and concern (71.5%) to loved ones. PCPs reported acceptance of these risks (91.1%) and the need to care for COVID-19 patients (85.4%). Overall perceived pandemic preparedness was extremely high (75.9 to 89.9%). PCPs prioritized availability of personal protective equipment, strict infection prevention guidelines, accessible information about COVID-19, and well-being of their colleagues and family as the most effective stress management factors. Conclusions PCPs continue to serve willingly on the frontlines of this pandemic despite the high perception of risk to themselves and loved ones. Healthcare organizations should continue to support PCPs by managing both their psychosocial (e.g. stress management) and professional (e.g. pandemic preparedness) needs. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01370-7.


Background
The World Health Organisation (WHO) has characterized the novel Coronavirus Disease 2019 (COVID- 19) outbreak as a pandemic, with 57,882,183 confirmed cases and 1,377,395 deaths globally as of 22nd November 2020 [1]. Much academic and media coverage on healthcare workers has rightly focused on the rigours faced by frontline hospital staff. However, it is often easy to forget the critical role played by primary care physicians (PCP) during this health crisis, as individuals who develop a febrile illness or respiratory symptoms are likely to first seek treatment from a PCP. This means that PCPs are often the first medical professionals to encounter suspected COVID-19 cases and will need to make crucial decisions on how to manage these cases appropriately in order to limit community spread.
PCPs in Singapore generally fall under two models of practice. Public clinics (i.e. polyclinics) operate in a group practice setting and provide subsidized primary care, accounting for approximately 21% of all primary care outpatient visits in the country [2,3]. Private clinics (i.e. general practitioners, family medicine clinics) may be operated by PCPs as either a single-individual practice or a group practice, and account for the remaining 79% of outpatient visits [2,3]. With 20 polyclinics and approximately 1700 private clinics, including eight family medicine clinics, the crucial role of primary care in managing the COVID-19 outbreak in Singapore is underscored by the Public Health Preparedness Clinic (PHPC) scheme, which provides government assistance to approximately 940 private practice PCPs with financial subventions, personal protective equipment (PPEs) and medical supplies from the national stockpile during public health emergencies, as well as continued professional training to build outbreak management capacity [4,5]. This support has not been misplaced; as of 17th March 2020, 108 of the 158 locally transmitted COVID-19 cases (68.4%) had visited a PCP before being diagnosed [6]. The role of primary care in this pandemic is also highlighted elsewhere across the world in guidelines and literature that acknowledge how PCPs are often first points-of-contact between suspected cases and the healthcare system [7][8][9][10].
A commonly overlooked angle is the potential psychosocial impact of the outbreak on PCPs as they place themselves at increased infection risk. For example, while the efforts of healthcare professionals were publicly lauded during the Severe Acute Respiratory Syndrome (SARS) outbreak, these same professionals were treated with a degree of fear and prejudice by laypeople in social spaces and on public transport [11][12][13]. PCPs serving the community in Hong Kong during this period also reported high levels of anxiety about their own wellbeing and the safety of their immediate families [14]. In addition, potentially detrimental deviations to PCPs' standard clinical practice in order to prevent infection (e.g. avoiding physical examination of patients) were observed [14]. Studies conducted to understand the pandemic preparedness of PCPs and other healthcare professionals during the H5N1 avian influenza outbreak also found that the majority (80-95%) of PCPs were concerned that their profession would put their own health at risk; over half felt that family, friends or the general public would avoid them due to possible contact with H5N1 cases during the outbreak [2,15]. Similarly, studies conducted to examine the emotional impact, concerns and coping strategies of healthcare professionals regarding Middle Eastern Respiratory Syndrome (MERS-CoV) suggested that the majority felt at risk of being infected in their workplace but ethically obligated to continue caring for patients during the outbreak [16,17] When asked to share about what would motivate them in future pandemics, healthcare professionals reported that 1) organizational support to increase outbreak preparedness, 2) an assurance of financial and emotional support for their family members while they worked overtime to care for patients, and 3) appreciation from health authorities, supervisors and the public were the most important factors [17].
To our understanding, no prior study has yet examined the social and psychological impact of the COVID-19 outbreak on PCPs. Given the critical role that primary care must perform in containing and mitigating this global public health crisis, the current research seeks to understand the concerns and perceived pandemic preparedness of PCPs in Singapore in the context of the COVID-19 situation. We also examine PCPs' personal coping strategies and perceived impact of the outbreak on their personal and professional lives.

Study design and setting
As the exigencies of COVID-19 outbreak control measures in Singapore discouraged face-to-face interaction between research teams and potential participants, the present research utilized a cross-sectional online design. Participants were cluster sampled via email invitation disseminated by three organizations: the National University Health System (NUHS) Primary Care Network (PCN), National University Polyclinics (NUP), and the College of Family Physicians Singapore (CFPS). NUHS is one of the three integrated public healthcare systems in Singapore, with a catchment area approximating 1.1 million residents in the western region of the island [18]. The PCN and NUP are member organizations that coordinate and manage private and public primary care clinics respectively within the NUHS catchment area [19,20]. The CFPS is a professional society that provides vocational and continued professional development for PCPs and other family medicine practitioners in Singapore [21].
The sampling frame comprised of all medical doctors who were either 1) a PCP practicing within an NUP polyclinic, or 2) a PCP practicing within an NUHS PCN private clinic, or 3) a Member or Fellow of the CFPS, and 4) had a registered email address within the respective organizations. This resulted in a total of 2866 viable email addresses, although there was the possibility of overlap as potential participants could have been part of either NUP or NUHS PCN and also a member of the CFPS. To protect the confidentiality of PCPs, individual email addresses were not released to the study team. The data collection period lasted from 6th March 2020 to 29th March 2020.
To put this study in perspective, Singapore began implementing its COVID-19 outbreak response upon diagnosing the first confirmed case on 23rd January 2020. The country raised its Disease Outbreak Response System Condition (DORSCON) to "Orange" (i.e. the same level of severity as during the SARS period) on 7th February 2020.

Measures
The anonymous self-administered online questionnaire (see Supplementary File 1) was adapted from prior studies on PCPs and healthcare workers during the H5N1 avian influenza and MERS-CoV outbreaks [2,15,17]. The questionnaire was administered via the REDCap web application for data collection and management [22].
The first three sections consisted of statements adapted from Wong and colleagues' H5N1 study, grouped into work-and non-work-related concerns (16 items), perceived impact on personal life and work (10 items), and outbreak preparedness (six items), all with reference to COVID-19 [2]. The questionnaire also included statements from Khalid and colleagues' study on MERS-CoV; these were grouped into two sections on factors that might help PCPs reduce stress (13 items), and personal coping strategies to alleviate stress (13 items), during the COVID-19 outbreak [17]. Participants responded to these items using 4-point Likert-type scales (e.g. strongly disagree, disagree, agree, strongly agree).
In addition, participants also provided demographic data consisting of gender, broad age band, ethnicity, marital status, number of children (if married, divorced, or widowed), whether residing with family or alone, number of people living in the same household, type of primary care practice, years of experience in medical practice, and highest professional or academic medical qualification.

Statistical analyses
All statistical analyses were performed using IBM SPSS Statistics Version 22.0 [23]. Frequencies and proportions were used to present participant demographic data.
Frequencies and proportions were used to present data for the statements on work-related and non-workrelated concerns, perceived impact on personal life and work, and outbreak preparedness. We dichotomized participant responses for the 4-point Likert-type scales into "agreement" (i.e. strongly agree, agree) and "disagreement" (i.e. strongly disagree, disagree) responses. Cronbach's alpha was used to assess internal consistency for the items within each of these three sections.
Participant responses on the statements about factors that might help reduce stress were converted into a point-based system (i.e. "extremely effective" being worth four points, to "not at all effective" being worth one point). Similarly, responses for the statements on personal coping strategies were converted into a pointbased system (i.e. "always used" being worth four points, to "never used" being worth one point). Points per item were summarised across the sample and the items ranked accordingly.

Ethics approval
Ethical approval to conduct this study was provided by the National University of Singapore's Institutional Review Board (Reference Code S-20-071) in accordance with the Declaration of Helsinki. Informed consent to participate was obtained from all participants.

Sample demographics
A total of 216 PCPs provided informed consent to participate in the online questionnaire (7.54% response rate). Of these, 58 questionnaires were unusable (defined as having at least two sections incomplete), leaving a final sample of 158 participants. The sample was predominantly of Chinese ethnicity (80.4%), married (84.2%) and residing with family (91.8%). There were more private than public practice PCPs (61.5%). A full description of sample demographics can be found in Table 1.

Work-and non-work-related concerns
Nearly all PCPs felt that their job would put them at high risk of exposure to COVID-19 (89.9%), and the majority agreed or strongly agreed that they were worried about falling ill with the disease (69.0%). Most PCPs were also concerned about the risks that they posed to loved ones because of their job (74.7%) and the majority felt that their loved ones would likewise be worried about being infected by them (71.5%). However, PCPs disagreed that they should not be looking after COVID-19 patients (85.4%) and did not feel that the risk they were exposed to was unacceptable (89.9%); almost all agreed that they accepted the risk of COVID-19 infection as part of the job (91.1%). Similarly, PCPs disagreed that they would leave their profession because of these risks (93.0%). The Cronbach's α for work-and nonwork-related concerns was 0.85, suggesting acceptable reliability [24]. Response frequencies and proportions for each statement are presented in Table 2.

Perceived impact on personal life and work
The majority of PCPs perceived that they would feel more stressed at work (73.4%), experience an increase in workload (67.1%) and would have to engage in work not usually done by them (70.3%). Most PCPs disagreed that they would avoid telling their loved ones about the risks they were exposed to (78.5%) or the nature of their job (81.6%). Most PCPs also did not think that there would be more intra-workplace conflict during this COVID-19 period (71.5%). The Cronbach's α for perceived impact on personal life and work was 0.75. Response frequencies and proportions for each statement are presented in Table 3.

Outbreak preparedness
The agreement was high (75.9 to 89.9%) for every item in this section. Notably, the top three statements were that PCPs felt personally prepared for the COVID-19 outbreak (89.9%), that they had received adequate PPE training (88.6%), and they had someone to turn to if they were unsure of the use of PPEs (86.1%). The Cronbach's α for outbreak preparedness was 0.85. Response frequencies and proportions for each statement are presented in Table 4.

Factors that might help reduce stress and personal coping strategies
The five highest-ranked (i.e. proportion of sample rating moderately or extremely effective) stress-reduction factors were 1) PPEs being provided to PCPs by their workplace (96.2%), 2) clear guidelines for infection prevention (95.0%), 3) no COVID-19 infections among colleagues after implementing protective measures (93.6%), 4) loved ones not being infected (92.4%), and 5) confidence in fellow medical colleagues should the PCPs themselves be infected with COVID-19 (91.1%). The five most often utilized (i.e. proportion of sample rating often or always used) coping strategies by PCPs during this COVID-19 outbreak were 1) following strict personal protective measures (90.5%), 2) reading about COVID-19, its transmission mechanisms and prevention (89.2%), 3) engaging in relaxation activities such as exercise and prayers (64.0%), 4) avoiding public spaces to minimize exposure risk (60.1%), and 5) communicating with loved ones for stress relief and emotional support (57.0%). Scores and subsequent rankings for each statement are presented in Table 5.

Discussion
This study was a cross-sectional exploratory survey of PCPs' concerns, perceived pandemic preparedness, possible stress-reduction and coping strategies in the context of the COVID-19 outbreak in Singapore. We found that PCPs perceived themselves to be at high risk of COVID-19 infection and a source of risk and concern to loved ones. Nonetheless, they reported acceptance of these risks and the need to care for COVID-19 patients. Overall perceived pandemic preparedness was extremely high. PCPs prioritized availability of personal protective equipment, strict infection prevention guidelines, accessible information about COVID-19, and well-being of their colleagues and family as the most effective stress management factors.

PCPs' concerns, impact on work and personal life, and outbreak preparedness
The majority of PCPs perceived themselves as being at risk of COVID-19 infection and were concerned about the risks that they could be bringing to their loved ones. Interestingly, unlike findings from similar studies conducted in  Singapore during the SARS and H5N1 outbreaks, most PCPs did not feel that they or their loved ones would face social stigmatisation [2,25]. Moreover, the majority did not feel the need to hide the nature of their work or the risks that they could potentially face from loved ones and the public. Only a very small proportion of PCPs had considered resigning from their jobs, and the acceptance and readiness to provide medical care for COVID-19 patients was very high. PCPs differed in their opinions on colleagues resigning due to their fears, although a higher proportion (54.4%) responded with acceptance. Most seemed to feel that the COVID-19 outbreak would increase their workload and work-related stress, and have to take on work not normally performed by them, but would not otherwise be a cause of workplace conflict. These encouraging findings suggest a high level of ethical obligation and medical professionalism in our sample of PCPs to continue serving their communities, despite the personal and family risks incurred. Health authorities and institutions should continue to keep watch for signs of burnout among PCPs as they suffer increased stress and take on both a higher level of workload and range of tasks during this pandemic; international evidence from prior outbreaks has shown the vulnerability of frontline healthcare professionals to long-term psychological outcomes such as anxiety, depression, and post-traumatic stress disorder [26,27]. Perceived preparedness for the COVID-19 outbreak was extremely high amongst the sample. There are two possible reasons for this encouraging finding. Firstly, the Singapore Ministry of Health has gradually strengthened overall pandemic preparedness within the healthcare system since the national experiences of SARS and H1N1, which has resulted in readily available outbreak response frameworks, guidelines and protocols for both healthcare professionals and the lay public [28]. The second possibility is that nearly two-thirds of the private practice PCPs in our sample were members of PHPCs. Under this scheme, their medical practices would specifically have been prepared for outbreak management with 3 months' worth of PPEs provided at no cost, priority medical supplies, and standardized training on infection prevention measures [4,29]. These government-funded schemes are likely to have facilitated a high level of pandemic preparednessin terms of PPE availability and infection prevention trainingamong Singaporean PCPs as compared to healthcare professionals in other, less-resourced settings [30][31][32].

Stress management and coping strategies among PCPs
Clear infection prevention guidelines and personal protective measures, access to information about COVID-19 and a reliable supply of PPEs were the most important factors for PCPs in coping with stress during the outbreak. This corroborates with what has been reported in SARS and MERS-CoV, where safety precautions and prompt knowledge about the disease were key motivators in incentivizing healthcare professionals to continue providing medical care through an outbreak [17,33,34]. PCPs also rated the prevention of their medical colleagues and loved ones from being infected with COVID-19 as the next most important factor in their own stress management. This is perhaps expected given the aforementioned finding that PCPs perceived themselves as being a source of infection risk and concern to their family members due to the nature of caring for COVID-19 patients.
As it was with healthcare professionals during the SARS, H1N1 and MERS-CoV outbreaks, PCPs are likely to suffer immense emotional pressure should their colleagues and loved ones fall victim to COVID-19; considerable research has also highlighted the tendency for healthcare professionals to disregard their own physical and mental wellbeing, especially during crises [17, 33, [26,36,37]. Stress management strategies could take the form For scoring purposes," not at all effective" = 1 point; "mildly effective" = 2 points; "moderately effective" = 3 points; "extremely effective" = 4 points b For scoring purposes," never used" = 1 point; "sometimes used" = 2 points; "often used" = 3 points; "always used" = 4 points of both formal and informal peer support groups, crisis counselling hotlines, or provisions for personal as well as group mindfulness exercises [35,38].

Limitations and implications for future research
As this study was designed to meet the expediencies of the ongoing COVID-19 pandemic, several key limitations must be taken into consideration. Most significantly, the generalisability of our findings is limited by the non-random sampling strategy employed and the low response rate. This was perhaps expected due to the frontline and high intensity nature of PCPs' roles as outbreak control efforts continue to implemented in Singapore, and we recognize that our findings may only represent PCPs who were able to find the time to respond amidst their hectic schedules. We also recognize that the quantitative descriptive nature of the present study could mean that PCPs may have had other concerns that were not included in our questionnaire. We were also unable to qualitatively probe the stress-reduction and coping strategies to understand the opinions of PCPs on how the government or healthcare institutions might be able to better support their needs. Lastly, as this study was conducted while community cases of COVID-19 were on the rise, we elected to focus on PCPs' existing concerns, coping strategies and preparedness, and did not probe their possible motivators to continue serving in future outbreaks.
Future studies could seek to overcome some of these limitations by implementing a more rigorous, probabilistic sampling strategy and utilizing mixed-methods designs to include qualitative interviews with PCPs. Nonetheless, the feasibility of these suggestions will inevitably depend on the progress of the COVID-19 pandemic in Singapore and around the world; social distancing measures and overwhelmed healthcare systems, for example, may prove to be immense challenges in conducting research with PCPs or other healthcare professionals.