This study aimed to assess the mental health of Iranian PHEM personnel. This assessment showed that the subjects were mostly suffering from moderate levels of stress, anxiety, and depression. Overall, the prevalence of depression, anxiety, and stress was estimated to be 36.2, 36.7, and 31.1%, respectively. These are similar to the rates of reported for the general Iranian population , but lower than the rate reported by Sarbozi et al. (2020). for the healthcare teams working under pandemic conditions . Given that the present study coincided with the fifth peak of the Covid-19 pandemic in Iran, most of the participants and their families were already vaccinated, and they had fairly better access to protective equipment (e.g. masks, personal protective clothing, and disinfectants). This lower rate of depression, anxiety, and stress may indicate that the psychological impact of the COVID-19 pandemic on PHEM personnel is diminishing .
The results of a similar study on the outbreaks of SARS and Ebola (2015) showed the higher prevalence of psychological disorders such as anxiety, stress, and depression among healthcare staff and PHEM personnel working in affected areas, which was attributed to the psychological pressure of living in those areas . However, in the present study, subjects were working under the Covid-19 pandemic, which has affected a huge number of people across the world.
Dadashzadeh et al. (2017) found that PHEM personnel in Iran suffered from high levels of stress and anxiety . Lai et al. (2020). discovered high levels of depression (50.4%) and anxiety (44.6%) in medical staff working in Wuhan, China, during the outbreak of Covid-19 . The present study; however, showed lower levels of depression, anxiety, and stress in PHEM personnel compared to the above two studies. One possible explanation for this discrepancy is that Lai’s study was performed near the onset of the COVID-19 pandemic, when medical personnel encountered the first peak, which may have caused them to have more severe psychological reactions. Our study, on the other hand, was performed when most medical personnel had been vaccinated or had already infected with the disease, which may have affected their level of stress and anxiety in the face of the pandemic.
A study on the SARS epidemic in Hong Kong (2004) reported that only 30% of staff, including pre-hospital emergency personnel had contact with SARS patients due to concerns about illness, disability and death of family members. They experienced more anxiety than other personnel , which was consistent with our findings because the two studies were conducted in the same stage of the pandemic.
This study found a significant relationship between age and depression, as people aged 41-55 years were more depressed. With increasing age and approaching retirement, it seems that the incidence of burnout due to activity on holidays and away from family increases. On the other hand, due to lack of manpower and intensive shift work in the morning, evening, night, sleep patterns are disrupted, indicating physical problems and underlying diseases that are interrelated with psychological problems, and can explain the relationship between age and depression .
The present study also found a significant relationship between age and anxiety, which was consistent with the findings of Khamseh et al. (2011). One study examined five stressors among 413 people from different nursing groups and showed a significant relationship between age and anxiety. Interpersonal stressors, patient care, and physical environment were the causes of anxiety among the personnel of different nursing groups. Since, pre-hospital emergency personnel encounter various accidents during their shift work, it is consistent with the present study .
The present study found a significant relationship between age and stress, which was consistent with the results of Ghasemi et al. (2011). Findings of Ghasemi study showed that there is a significant relationship between nurses’ job stress and age variable and 43.5% of nurses over 40 years of age had high job stress. It seems that high work pressure, the presence of the patient’s relatives on her bed and their high expectations, hard work, exposure to violence and threats in the workplace are the reasons for the relationship between age and stress .
This study also found a significant relationship between the level of education and the levels of depression, anxiety, and stress, which was consistent with similar results reported from China . It appears that PHEM personnel with higher levels of education experience higher levels of depression, anxiety, and stress because of poor life-work balance, the gap between reality and expectations, and higher engagement with media, scientific journals, the internet, etc ..
The present study indicated a significant relationship between the history of underlying diseases, stress, anxiety, and depression, which was consistent with the findings of Hosseinabadi that were performed on nurses during the Covid-19 pandemic . Various studies revealed that PHEM personnel experienced elevated levels of catecholamine and cortisol because of emotional stress and missions in unfamiliar environments and different shift work , which might affect their mental health state. Furthermore, PHEM personnel cannot control their stress and anxiety problems for prolonged periods, which will increase the likelihood of stress, anxiety, and depression among them (poor mental health) .
Our study found a significant relationship between work experience and stress, anxiety, and depression; the more experienced the PHEM personnel, the higher the levels of stress, anxiety, and depression. According to Sakko Onsri et al. (2016), 33% of PHEM personnel with over 10 years of work experience had a high level of stress , which was consistent with our findings. One of the reasons for this finding is that people with more work experience are more likely to have underlying diseases and family issues, which are in turn associated with psychological problems .
The present study reported,there was a significant relationship between employment type stress, anxiety, and depression, as hired employees had higher levels of stress, anxiety, and depression than people with other types of employment did. This finding is consistent with the study of Bahrami et al. , but not consistent with the study of Ghasemi et al. . It appears that while the PHEM is a stressful profession, the hiring process, the higher level of organizational competition among these employees, and their higher awareness of work conditions and environment can aggravate the stressful work conditions .
In this study, PHEM personnel, who quarantined themselves at the end of each shift work showed higher levels of anxiety, which was consistent with the results of Wester et al. (2019) , because these people were more likely to experience psychological disorders due to being isolated from their families or infected with the virus [40, 41]. Therefore, the development of applications for social support of pre-hospital emergency personnel can play an important role in providing quality services in the community.
The cross-sectional nature of this study is considered one limitation, meaning that longer studies may yield different or more accurate results. In addition, the study only focused on the eastern parts of Iran, which could raise the possibility of bias due to inadequate distribution of facilities and human resources. Another limitation was the use of electronic questionnaires because of the guidelines issued by Iran’s national anti-corona headquarters to prevent the spread of COVID-19, meaning that sampling was voluntary and could therefore be biased. It is suggested that future studies examine depression, anxiety and stress in other parts of Iran. It is also essential that there are practical studies to promote PHEM mental health.