Introduction

Frontline healthcare workers (FLHCW) coping with large-scale infectious diseases such as COVID-19 are under enormous physical and psychological pressure (^{Wu et al., 2009}) and frequently manifest high stress levels, as well as emotional and trauma-related disorders (^{McAlonan et al., 2007}; ^{Liu et al., 2020}; ^{Li et al., 2020}), especially those who work in emergency rooms, intensive care, and isolation wards (^{Naushad et al., 2019}). This calls for the implementation of prevention strategies to safeguard their mental health and, therefore, the success of medical care (^{Low & Wilder-Smith, 2005}), emergency control, and social recovery (^{Liu et al., 2013}).

According to previous reports of FLHCW facing COVID-19 (^{Chen et al., 2020}), additional efforts should at the very least include training in personal protective equipment (PPE) ‒which has proven effective in building confidence in infection control measures and an adaptive response to stress (^{Chua et al., 2004})‒, as well as in techniques to deal with uncooperative, hostile, and anxious patients and relatives, frequently encountered given the psychological difficulties they experience in response to restrictions to visitors in highly stressful circumstances (^{Klompas, 2020}).

Given that COVID-19 is a highly contagious disease that makes it necessary to minimize the number of health team members with face-to-face interactions (^{Ho, Chee, & Ho, 2020}), and taking advantage of contemporary technological development, most mental health interventions for FLHCW coping with COVID-19 have been remote, through video-conferencing platforms or based on smartphone applications (for example, ^{Ho et al., 2020}; ^{Liu et al., 2020}).

In this sense, the pandemic constitutes an unforeseen event leading to a shift in mental health care provision towards e-health prevention, treatment, and care (^{Wind, Rijkeboer, Andersson, & Riper, 2020}). Fortunately, e-learning strategies have proven to be effective for health promotion along lifespan (e.g., ^{Elliot Lindemulder, Goldberg, Stadler, & Smith, 2013}), including adults coping with stressful events (^{Atherton & Majeed, 2011}), and allows for the availability and cost-effectiveness of interventions to people who cannot receive them face-to-face for several reasons (including the need for social distancing, but also the lack of time or the limited access to face-to-face services that many FLHCWs experiment now).

Health professionals facing the COVID-19 pandemic are diverse: general practitioners, medical specialists, nursing personnel, medical residents, and psychological staff, among others. In general, women have been found to be more sensitive than men to the emotional demands associated to their activities within the health system (^{Theorell, 2000}), which makes them more willing to seek health-care (^{Liddon, Kingerlee, & Barry, 2018}). Therefore, the design of e-health interventions must have the capacity to provide clear, effective information for both men and women, regardless of their specific health profession.

The Secretaría de Salud (Mexican Ministry of Health) in Mexico has promoted the development and dissemination through smartphones’ applications of two sets of brief psycho-educational videos covering FLHCWs’ educational needs on the most widely-used evidence-based techniques for self-care promotion (psychoeducation on burnout and preventive measures based on healthy habits) (^{Pines & Aronson, 1988}; ^{Figley, 2002}; ^{Rothschild & Rand, 2006}), personal stress management (mindfulness exercises and relaxation techniques) (^{Ho et al., 2020}), strategies to handle uncooperative or aggressive patients (^{Casey, 2019}), and acquisition of new skills (modeling) (^{Bandura, 1977}).

The first set included six brief videos with the following contents: psychoeducation on burnout in FLHCWs (available at: https://www.youtube.com/watch?v=rNnrBch7Lb8); self-care ( https://www.youtube.com/watch?v=j_vvjHw0WG4; sleep hygiene measures (https://www.youtube.com/watch?v=2K5nA4aIHws); stress management techniques, including diaphragmatic deep breathing (https://www.youtube.com/watch?v=Gq3PuDz6tBs); mindfulness exercises (https://www.youtube.com/watch?v=QHNJyiMUgnQ); and progressive muscular relaxation (https://www.youtube.com/watch?v=IjIw0ZUvUcA). These videos were developed and produced by mental health specialists at the Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz (INPRFM, Mexican National Institute of Psychiatry) and then approved by the Secretaría de Salud.

The second set of videos comprised two longer productions, one with strategies for handling anxious, uncooperative, and hostile patients and relatives (available at: https://www.youtube.com/watch?v=Blgr4iWtxV8), and another to offer training in the use of PPE (https://www.youtube.com/watch?v=vkL-OsUH3P0). These videos were developed and produced by specialized personnel at the Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INER, Mexican National Institute of Respiratory Diseases) and then approved also by the Secretaría de Salud.

All videos were delivered through the federal coronavirus microsite (coronavirus.gob.mx) and the INPRFM’s website and social networks (e.g. Facebook) since April 2020, when Clusters of Cases transmission scenario for COVID-19 began in Mexico. Table 1 offers a description of the content and format of these videos.

This is the first report on the usefullness of such strategy from the perspective of FLHCWs coping with COVID-19 in five COVID-19 centers in Mexico, with the ultimate purpose gathering of having information on the relevance of the escalation of this preventive intervention to other COVID-19 health care settings. Thus, our research question was: A video-delivered mental health promotion strategy to cope with FLHWWs with COVID-19 is feasible in terms of their usability and clarity?

Method

Results

The videos were sent to a total of 75 potential participants, over 30% of whom (n = 24, 32%) provided feedback with answers that could be analyzed. The FLHCPs who decided not to participate in the study were 32 men (62.7%) with an average age of 37 (SD = 10.1, range = 20-60 years). Of these, 29.4% (n = 15) were nursing personnel, 23.5% (n = 12) stretcher-bearers, 9.8% (n = 5) medical specialists, 7.8% (n = 4) surveillance personnel, 7.8% (n = 4 ) medical residents, 5.9% (n = 3) general practitioners, 5.9% (n = 3) custodial staff, 3.9% (n = 2) psychology staff, and the remaining three participants were engaged in social work, administrative and public health, respectively (2% of the sample each).

Conversely, the participating FLHCWs (n = 24) included 18 women (75%) with an average age of 42 (SD = 8.4, range = 24-60 years). Generally, they were specialist doctors (25%, n = 6) and psychologists, followed by medical residents (12.5%, n = 3), nurses (12.5%, n = 3), social workers (12.5%, n = 3), stretcher-bearers (8.3%, n = 2), and a general practitioner (4.2%).

Most of them were working at the Hospital Civil Nuevo de Guadalajara (58.3%, n = 14), followed by the Hospital General Dr. Manuel Gea González (29.2%, n = 7), the Hospital de Alta Especialidad Ixtapaluca (4.2%, n = 1), the Hospital General de Zona 32 IMSS (4.2%, n = 1), and the Hospital Municipal Tepetlixpa (4.2%, n = 1).

According to site coordinators (field notes), the emotional climate among the staff in the participating centers was perceived with anxiety, uncertainty about the immediate future, fear of contagion, as well as physical and emotional exhaustion after several weeks of preparation for COVID-19. Although feedback on the videos was low, personnel were receptive to the initiative. An attempt was made to gather informally, through individual talks, the reasons why they had not responded, to which the staff argued little time available as well as “shame” of not knowing how to express themselves adequately, although all verbally mentioned their interest in the material, its usefulness, and that they even shared it among their colleagues and close people outside the work environment.

Table 2 presents representative samples of qualitative responses to each theme and subthemes. As can be seen, the general of category “content evaluation” grouped together expressions of functionality or improvement after applying what had been learned in the videos (utility), comments on the relevance of the material in terms of its timeliness and appropriateness to FLHCWs’ circumstances (pertinence), as well as references to the clarity, specificity, and practicality of the contents. All participants consider the strategies provided in the videos as beneficial in the workplace, reflecting real situations, and viable to be extended to their everyday personal life and family environment. In this respect, they stand out, from the first block of videos, those dedicated to progressive relaxation and deep breathing, and from the second block, the video on how to handle with anxious, uncooperative and hostile patients and relatives, linking its utility to the increase in patients’ and relatives’ dissatisfaction with health services due to lack of resources. All participants also agreed over the need for information when time they received it, and highlighted its practicality, particularly in the video training on the use of PPE.

The general category labeled “dissemination and other needs” includes expressions of willingness both to share the videos and to receive more of them, as well as the need for further training. All participants reported that they will share the videos with someone else, the main suggested new recipients being their residents (in the case of doctors), and their relatives and friends (in the case of both doctors and other FLHCWs). Most participants also asked for more videos, particularly those with new contents: 1. strategies for children in isolation and relationship problems (due to lockdown), 2. mental health services for FLHCWs, and 3. research advances in COVID-19. Some doctors requested more information on how to manage difficult patients.

The third general category on “format aspects” included comments on the quality of the design, audio and image (attractiveness) as well as on the length of the videos. Although most participants’ opinions about the videos’ attractiveness and short length were favorable, there were some negative comments. Two participants, a psychologist and a social worker, did not like the illustrations or would have preferred human models in the first set of videos - while the rest of the sample liked then or found them enjoyable. Regarding the second set of videos, opinions were divided about the length of the material. One resident felt the videos were too long, while two participants (specialists) suggested including more detailed information or even organizing courses on these issues.

Discussion and conclusion

The present study aimed to response if a specific video-delivered mental health promotion strategy for FLHWWs coping with COVID-19 is feasible in terms of their usability and clarity. According to our results, all participants found the videos content very beneficial, relevant, and applicable in the workplace and even in their everyday personal and family lives; and were willing to share them and to receive more videos on other issues, including strategies for handling problems related to isolation.

The generalized opinion about the beneficial effects of the techniques (including psychoeducation and personal stress and others hostility management) and methods for training in new skills such as the use of PPE (i.e., modelling) shows the importance of using evidence-based strategies (^{Bandura, 1977}; ^{Casey, 2019}; ^{Ho et al., 2020}; ^{Figley, 2002}; ^{Pines & Aronson, 1988}; ^{Rothschild & Rand, 2006}), and add evidence about their feasibility to be applied through remote tools in adults coping with stressful events (^{Atherton & Majeed, 2011}).

The relevance and applicability of the material seems related to the expected (^{McAlonan et al., 2007}; ^{Liu et al., 2020}; ^{Li et al., 2020}; ^{Wu et al., 2009}) and confirmed (trough participant observation and FHCW answers) psychological pressure and high stress levels among FHCW coping with COVID-19. Furthermore, FHCW’s willing to share the videos with their colleagues and relatives, as well to receive more videos confirm such favorable opinions about the material’s usability and clarity.

However, as is also the case with face-to-face mental health service seeking, only half as many men than women participated in this remote preventive intervention (^{Harris et al., 2016}) and specific efforts should be made to reduce cultural and gender related beliefs and attitudes (^{Brenner et al., 2018}) that also hinder men’s mental health care in remote modalities and during sanitary emergencies such as COVID-19. Both men and women may benefit from these interventions; we consider that the lack of feedback among men can be explained by their reluctance to emotional disclosure (^{Liddon et al., 2018}), although this should be analyzed in greater detail in future studies.

According to the frequency of participation by profession (which was higher among medical doctors and psychologists), it seems that health professionals, due to their professional activities which include continuous face-to-face contact with patients, could be more aware of the need of preventive interventions focused on mental health issues. Themes such as burnout and self-care promotion could be considered relevant according to their field of study and action (^{Ferrer & Vaño, 1990}). We hypothesize that other health-care workers, such as nurses and stretcher-bearers lack of sufficient information to consider mental health issues as relevant to their work activities in the hospitals where they reside. However, any firm conclusion can be drawn from this result; these differences should be considered in order to assure than mental health and self-care issues are an integral part of the working activities that health professionals carry out, as well as of their importance for their self-care.

The interventions could be complemented with a third set of psycho-educational videos covering evidence-based information and strategies to manage isolation due to lockdown, in both children and couples. In line with a previous study on Chinese FLHCWs (^{Chua et al., 2004}), topics related to psychological and behavioral issues with one’s own children and partner constitute central interests among our sample. Moreover, among those who agree to receive information this way, it could be useful to deliver some important news about research progress on the field as they might not have the time to search for recent scientific studies that could give them useful clinical guidelines.

Additionally, as we expected given previous literature on the field (^{Klompas, 2020}), more detailed information about how to deal with difficult patients and relatives would be welcomed by some FLHCWs, specially doctors, who usually lack the extensive training in strategies to cope with negative emotions and attitudes other professionals (such as psychologists) receive.

It seems FLHCWs are not only worried about how to manage COVID-19 infection but also the numerous negative consequences it has for personal, loved ones’ and patients’ mental health. The present material could be improved according some participants’ suggestions and preferences, but could be used as a basic structure to deliver useful, pertinent and practical information in a brief, inexpensive, and feasible (remote) way. Although all efforts pale in comparison with what FLCWs deserve, cost-effective preventive strategies are necessary in contexts such as Mexico, characterized by scarce human and financial mental health resources. As ^{Wind et al. (2020)} suggest, e-mental health promotion strategies seems promising to do so given their capacity to be easily disseminated to a wide range of FHCW working in geographical distant centers without face-to-face mental health services and in the need for social distancing. Moreover, present study reports for the first time on COVID-19 FLHCWs’ perception of the utility, relevance, and practicality of psycho-educational videos under study. Thus, the escalation of this preventive intervention to other COVID-19 centers and future similar epidemics is highly recommended.