Analyzing the Impact of COVID-19 Trauma on Developing Post-Traumatic Stress Disorder among Emergency Medical Workers in Spain

International Journal of Environmental Research and Public Health Article Analyzing the Impact of COVID-19 Trauma on Developing Post-Traumatic Stress Disorder among Emergency Medical Workers in Spain Carmen M. Martínez-Caballero 1,† , Rosa M. Cárdaba-García1,2,3,† , Rocío Varas-Manovel 1, Laura M. García-Sanz 1, Jorge Martínez-Piedra 4, Juan J. Fernández-Carbajo 1, Lucía Pérez-Pérez 2,3,5 , Miguel A. Madrigal-Fernández 2,3,6 , M. Ángeles Barba-Pérez 2,3,6 , Elena Olea 2,3,7 , Carlos Durantez-Fernández 8and M. Teresa Herrero-Frutos 1,*   Citation: Martínez-Caballero, C.M.; Cárdaba-García, R.M.; Varas-Manovel, R.; García-Sanz, L.M.; Martínez-Piedra, J.; Fernández-Carbajo, J.J.; Pérez-Pérez, L.; Madrigal-Fernández, M.A.; Barba-Pérez, M.Á.; Olea, E.; et al. Analyzing the Impact of COVID-19 Trauma on Developing Post-Traumatic Stress Disorder among Emergency Medical Workers in Spain. Int. J. Environ. Res. Public Health 2021,18, 9132. https:// doi.org/10.3390/ijerph18179132 Academic Editors: Richard Gray, Sonia Udod and Marcello Covino Received: 6 July 2021 Accepted: 26 August 2021 Published: 30 August 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1Emergencies Management (SACYL), 40002 Segovia, Spain; [email protected] (C.M.M.-C.); rcar[email protected] (R.M.C.-G.); [email protected] (R.V.-M.); [email protected] (L.M.G.-S.); [email protected] (J.J.F.-C.) 2Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; [email protected] or [email protected] (L.P.-P.); [email protected] or [email protected] (M.A.M.-F.); [email protected] (M.Á.B.-P.); [email protected] (E.O.) 3Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain 4Health Transportation Group, 40195 Segovia, Spain; [email protected] 5Primary Care Management Valladolid West (SACYL), 47012 Valladolid, Spain 6University Clinical Hospital of Valladolid, 47003 Valladolid, Spain 7 Instituto de Biología y Genética Molecular (IBGM), Universidad de Valladolid-CSIC, 47005 Valladolid, Spain 8Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Spain; [email protected] *Correspondence: [email protected] or therr[email protected] † Mrs. Carmen M. Martínez-Caballero and Dra. Rosa M. Cárdaba-García have contributed as IP in the research. Abstract: The early stages of the COVID-19 pandemic presented the characteristics of a traumatic event that could trigger post-traumatic stress disorder. Emergency Medical Services workers are already a high-risk group due to their professional development. The research project aimed to analyse the impact of the COVID-19 pandemic on EMS professionals in terms of their mental health. For this purpose, we present a descriptive crosssectional study with survey methodology. A total of 317 EMS workers (doctors, nurses, and emergency medical technicians) were recruited voluntarily. Psychological distress, post-traumatic stress disorder, and insomnia were assessed. The instruments were the General Health Questionnaire-12 (GHQ-12), the Davidson Trauma Scale (DTS-8), and the Athens Insomnia Scale (AIS-8). We found that 36% of respondents had psychological distress, 30.9% potentially had PTSD, and 60.9% experienced insomnia. Years of work experience were found to be positively correlated, albeit with low effect, with the PTSD score (r= 0.133). Finally, it can be stated that the COVID-19 pandemic has been a traumatic event for EMS workers. The number of professionals presenting psychological distress, possible PTSD, or insomnia increased dramatically during the early phases of the pandemic. This study highlights the need for mental health disorder prevention programmes for EMS workers in the face of a pandemic. Keywords: emergency medical services; post-traumatic stress disorder; mental status; sleep disorders; COVID-19 pandemic 1. Introduction In Spain, the SARS-CoV-2 pandemic started on 31 January 2020, when the first case was diagnosed on the island of La Gomera, and the first death from Coronavirus Disease 2019 (COVID-19) occurred on 13 February 2020 in Valencia. Since the first confirmed case was reported on 31 January 2020, more than 405,000 cases and 28,000 deaths have been reported in Spain [ 1 ]. According to the ENE–COVID seroprevalence study, one in ten Int. J. Environ. Res. Public Health 2021,18, 9132. https://doi.org/10.3390/ijerph18179132 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021,18, 9132 2 of 18 Spaniards had been infected with the virus by November 2020 [ 2 ]. It was not until 14 March 2020 that the Spanish state decreed a state of alarm and limited the movement of people throughout the territory [ 3 ]. On 28 March, all nonessential onsite work activities were suspended for 15 days [ 4 ]. Spain has suffered four waves of the COVID-19 pandemic, with the first wave being the most aggressive in terms of morbidity and mortality, with the highest number of deaths in March and April. The highest number of coronavirus deaths in one day (950) was recorded on 2 April [ 5 , 6 ]. We are currently in the fifth wave of the pandemic, although, as of 26 June 2021, it is not mandatory to wear masks outdoors if safe distances of at least 1.5 m are maintained between individuals [7]. Post-traumatic stress disorder (PTSD) is defined in the DSM-V in section B as the “presence of one or more of the following intrusive symptoms associated with the traumatic event, beginning after the traumatic event” [ 8 ]. The symptoms referred to are: recurrent, involuntary, intrusive, or distressing memories of the traumatic event; recurrent distressing dreams in which the content of the dream is related to the traumatic event; dissociative reactions such as flashbacks in which the subject feels or acts as if the traumatic event is being replayed; intense or prolonged psychological distress on exposure to internal or external factors resembling the traumatic event; and intense physiological reactions to internal or external factors resembling the traumatic event. This definition is specified with other characteristics that do not exactly fit the object of study of this research. It should be noted that the current definition of PTSD does not state that a specific time must have passed since the traumatic event in order for an individual to suffer from this syndrome only that the associated symptoms must remain for at least one month and negatively affect the individual’s life [8]. The scientific literature indicates that traumatic symptoms may appear immediately, after weeks, or even months after exposure, and, in most cases, they appear in the first six months after the triggering event. Unlike an acute stress reaction, PTSD symptoms do not disappear after a few weeks and tend to persist over time [9]. PTSD was originally described in wartime contexts, and shortly thereafter, it was also seen in survivors of death camps and sexual assaults. Natural disasters and terrorist attacks are also documented as triggers for PTSD [ 10 ]. PTSD has also been associated with previous epidemics, such as the one generated by the Ebola virus [11]. Individuals working in the emergency medical services experience direct contact with death and with events that can be considered traumatic. Although their academic training should be adequate to deal with these situations, the reality is that this is not the case [ 12 ], and, in hostile situations such as wars, natural disasters, and terrorist attacks, it is not uncommon for PTSD to develop in health personnel on the front line. [ 13 ]. Despite this, professionals often do not readily accept that they suffer from symptoms associated with PTSD, as it is often understood to be a weakness at work [ 14 ]. It is assumed that health personnel who work in EMS have the capacity to cope with events that can be traumatic, which is not always the case—it should not be forgotten that the most frequently attended incidents in these services are not emergent but urgent and that the actual and practical experience in catastrophic situations such as a pandemic may only be theoretical [ 15 ]. In fact, these professionals should be trained to face situations similar to those experienced during the COVID-19 pandemic, but the reality is quite different; as a result, such individuals are at risk of developing PTSD [ 16 ]. Despite several studies on the mental health of EMS workers in recent years, there is not enough previous data prior to the last two decades, as there was previously not much interest in assessing the mental health of frontline EMS workers [17]. It is widely known that since the beginning of the COVID-19 pandemic, an increase in mental illness has been observed [ 18 ]. A decrease in psychological wellbeing associated with higher values of anxiety and depression has been observed in the general population, in COVID-19 patients, and, above all, in healthcare workers, especially among those on the front line [ 19 – 21 ]. One of the most common symptoms in healthcare personnel has been insomnia [ 22 , 23 ]. Some studies relate these consequences to occupational factors such Int. J. Environ. Res. Public Health 2021,18, 9132 3 of 18 as professional category, workplace, and the means available to protect against possible COVID-19 infection, among others [24,25]. We are aware that previous studies have been published on the impact of the pandemic on healthcare workers [ 26 , 27 ], highlighting the deterioration in mental health and problems related to sleep and rest, but, to our knowledge, no studies have yet been published with data on the negative impact on mental health and PTSD symptoms focusing on emergency medical services (EMS) workers. Moreover, the scientific literature offers few examples that include all professional categories involved in Spanish EMS (physicians, nurses, and emergency medical technicians (EMTs)) who have worked during the pandemic [ 28 ]. EMS workers are considered to be a group at particular risk of developing PTSD in general terms [ 9 ], since, while the prevalence of PTSD in the general population ranges between 1% and 3% [ 13 ], in EMS in particular, it is estimated to be 11% during catastrophic events [ 29 ]. The initial hypothesis of the study was that the COVID-19 pandemic was associated with poor mental health status, insomnia, and an increased risk of developing PTSD in prehospital emergency professionals. The overall objective was to determine the impact of the early stages of the COVID-19 pandemic on the mental health of workers of the “Gerencia de Emergencias Sanitarias de Castilla y León” (GESACYL) and the “Servicio de Urgencias Médicas de Madrid 112” (SUMMA 112). Specifically, validated instruments were used to quantify the mental health of the first responders, to measure the presence of insomnia, to assess the frequency of PTSD, and to describe the variables most frequently related to the three previous aspects. In this paper, readers will find a descriptive study methodology based on survey data collection. Next, a descriptive analysis of the main variables is presented to further the search for correlations between variables that have significance in the development of mental health problems, insomnia, and PTSD. In this way, a discussion is established with the findings of other authors, accepting the limitations of this research, and assessing the implications that the results have for clinical practice. 2. Materials and Methods 2.1. Design A descriptive crosssectional study with survey methodology is presented. 2.2. Study Sample The study population was EMS workers (physicians, nurses, and EMTs) from two different regions of Central Spain: Castile and León “Gerencia de Emergencias Sanitarias de Castilla y León” (GESACYL) and Madrid “Servicio de Urgencias Médicas de Madrid 112” (SUMMA 112). A total of 317 workers were recruited, and the response rate was 37.6%. A volunteer sampling method was adopted, via corporate email. The inclusion criteria established were as follows: over 18 years of age, working in GESACYL or SUMMA112, being a physician, nurse, or EMT, being active during the COVID-19 pandemic, having worked almost exclusively in prehospital care (at least 90% of the total number of working days), agreeing to participate in the investigation, having basic computer skills, and being Spanish-speaking. Those who did not meet the aforementioned inclusion criteria and those who ticked the box on the questionnaire stating that they did not consent to participate in this study were excluded. 2.3. Ethical Aspects The study was approved by the Ethics Committee for Drug Research of the Valladolid East Health Area, with registration code PI 139-20 NO HRHV, on 6 June 2020. This study conformed to the STROBE Initiative (Strengthening the Reporting of Observational Studies in Epidemiology) for observational studies of the EQUATOR Initiative [30]. Int. J. Environ. Res. Public Health 2021,18, 9132 4 of 18 2.4. Recruitment of the Sample The sample was recruited by contacting the participants through the corporate email service of the emergency institutions of Castile and Leon and Madrid, sending them a link to the self-administered survey developed using the online Google Forms ® tool, in which the participants declared that they met the requirements to be part of the study sample. The recruitment strategy was carried out by sending an email reminder one and three weeks after the initial referral. In no case were participants offered any incentive to be part of the sample. The data collection period was from 20 May 2020 to 26 July 2020, a period early on during the first wave of the pandemic; according to the DSM-V definition of PTSD, this was appropriate, as symptomatology may appear immediately after a traumatic event [ 8 ]. 2.5. Study Variables The variables considered were sociodemographic (age, sex, number of people living together during the pandemic, and change in body weight during the pandemic); workrelated (professional category, place of work, type of unit, experience in the service, and change of function during the pandemic); occupational safety aspects (previous practical training in the use of protective equipment, availability of sufficient protective equipment in the unit, removal of protective equipment that did not comply with regulations, information on the pandemic and its evolution, testing for COVID-19, need for home isolation, presence of COVID-19 symptoms, and hospitalization for COVID-19); and variables associated with psychological health (concern about the possibility of contracting the disease, concern about harming loved ones, anxiety symptoms before the pandemic, anxiety symptoms during the pandemic, treatment of anxiety before the pandemic, treatment of anxiety during the pandemic, need for psychological support before the pandemic and during the pandemic, knowledge of the existence or not of a psychological support unit for employees, work environment of the unit, and existence of specific training courses for anxiety control for workers). 2.6. Instruments The instruments used were the General Health Questionnaire-12 (GHQ-12), the Davidson Trauma Scale (DTS-8), and the Athens Insomnia Scale (AIS-8). 2.6.1. General Health Questionnaire-12 The General Health Questionnaire-12 (GHQ-12) is a 12 item self-administered questionnaire that detects psychological distress. There are six positive items (e.g., “Have you been able to concentrate?”) and six negative items (e.g., “Have you lost confidence?”). Each item has four possible responses—according to a four-level Likert scale—aimed at capturing the intensity of the respondents’ feelings for the given item. The possible responses for the six positive items in the questionnaire, together with the score assigned to them, were 0 = more than usual; 0 = same as usual; 1 = less than usual; and 1 = much less than usual. For the negative items, possible responses were 0 = absolutely not; 0 = no more than usual; 1 = somewhat more than usual; and 1 = much more than usual. Thus, the possible total score on the questionnaire ranged from 0 to 12. The interpretation of the total score is as follows: from 0 to 4: no psychological distress; from 5 to 6: probable psychological distress; and from 7 to 12: psychological morbidity. The GHQ-12 has a reliability according to different studies with Cronbach’s alpha ranging from 0.82 to 0.86 [ 31 , 32 ]. In the sample of this study, a result of 0.85 was obtained for the mentioned test. 2.6.2. Davidson Trauma Scale The Davidson Trauma Scale (DTS-8) is a questionnaire that can be self-administered or interviewed and consists of eight items. This scale is used to detect suspicion of a potential diagnosis of post-traumatic stress syndrome. The questions refer to the last week and are measured by a five-level Likert scale, with possible values (0,1,2,3,4). Value 0 corresponds to the least stressful response. The total score of the questionnaire is obtained by adding Int. J. Environ. Res. Public Health 2021,18, 9132 5 of 18 the scores of the eight items, and it therefore ranges from 0 to 32. Higher scores on the scale are related to a higher possibility of suspected PTSD. The interpretation established by the authors of the original test is by means of ranges as follows: from 0 to 7: no suspicion of PTSD; from 8 to 11: it cannot be determined whether or not PTSD exists; 12 or more: suspicion of PTSD [ 33 ]. The scale presents adequate internal consistency, with a Cronbach’s alpha of 0.71–0.91 [ 34 ]. The value of Cronbach’s alpha obtained in the study sample was 0.87. 2.6.3. Athens Insomnia Scale The Athens Insomnia Scale (AIS-8) is a self-assessment survey consisting of eight items. Its purpose is to detect insomnia-type sleep disorders. The first four items assess possible insomnia problems from a quantitative point of view, the fifth item asks about sleep quality, while the last three items assess the daytime impact of insomnia. The evaluation questions refer to the last week and are measured on a four-level Likert scale, which translates into values (0,1,2,3), with 0 being the absence of a problem and 3 the maximum severity. The total score of the questionnaire is obtained by adding the scores of the eight items, and it therefore ranges from 0 to 24. Higher scores on the questionnaire are associated with more insomnia. Authors who have evaluated the scale based on the diagnosis of insomnia of the International Classification of Diseases in its 10th revision (ICD-10) establish that a score equal to or higher than six points determines a diagnosis of insomnia. The internal consistency of the test measured by Cronbach’s alpha is around 0.90 [ 35 ]. The AIS-8 showed a high degree of internal homogeneity, obtaining a Cronbach’s alpha of 0.91 for the whole sample. 2.7. Data Analysis The statistical procedure and data analysis were performed by means of a descriptive analysis of frequencies and response percentages, centrality (mean), and dispersion (standard deviation) in quantitative variables. Quantitative variables were analyzed by normality test (Kolmogorov–Smirnov) prior to the inferential analysis, looking for significant relationships between variables by means of Pearson’s rtest, ANOVA, and Student’s t test. The statistical significance level used was p= 0.05 or lower. The statistical program used was SPSS®v.24. 3. Results 3.1. Sample Description The sample consisted of 317 health professionals from the Health Emergency Services of Castile and Leon (80.4%) and Madrid (19.6%), who voluntarily agreed to participate in the study. In relation to the sociodemographic variables of the sample, 52.7% were men, 46.4% women, and 0.9% replied “Other”. The most frequent age range was between 40 and 49 years (42.9%). Only 16.1% lived alone during the pandemic, while households of four or more constituted 41.3% of the total. Overall, 120 respondents (37.9%) gained weight during the pandemic. Of those who gained weight, 61.2% declared having gained less than 1 kg. 3.2. Occupational Considerations The following is a description of the variables related to the health profession and work setting. By professional category, 61 respondents were physicians (19.2%), 78 nurses (24.6%), and 178 emergency health technicians (56.2%). Half of the respondents worked in advanced life support units (50.5%). The most common time period for which respondents had worked in the service was between 10 and 20 years (54.9%), followed by less than 10 years (25.6%). Overall, 223 respondents (70.3%) changed their care functions during the pandemic, but only 41 persons (12.9%) were reassigned to a specific contingency hospital for patients diagnosed with COVID-19. Int. J. Environ. Res. Public Health 2021,18, 9132 6 of 18 3.3. Job Security in the Pandemic Working in healthcare during the pandemic has entailed a number of risks, which are described below. A large number of people (94.3%) felt worried about the possibility of contracting the disease at work and about the possibility of passing it on to their family members (96.8%). Overall, 202 respondents (63.7%) stated that they had received prior theoretical training in their service on the use of personal protective equipment (PPE) necessary in case of biological risk, and 60.6% stated that they had received practical training regarding the use of personal protective equipment. In total, 205 respondents (64.7%) had adequate means of protection in their work during the pandemic, but in 78.9% of cases, it was necessary to remove the protective equipment provided by their service as it did not comply with the protection regulations. In total, 238 respondents (75.1%) affirmed that they had not been informed by their service of the possibility of a COVID-19 pandemic occurring prior to the state of confinement, while 48.3% (153) had been informed by the public health administration of the evolution of the pandemic. Most of the workers (93.4%) had been tested for SARS-CoV-2 infection; in 35.3% of cases, they had been tested with both a PCR test and an antibody screening test. A total of 19.2% (61) required home isolation because they had had a high-risk encounter in their work environment. A total of 33.8% had experienced symptoms associated with COVID-19 infection, but only six persons (1.9%) required hospital admission. 3.4. Mental Health Considerations The respondents reported their mental health in terms of its preand postpandemic status as follows. Twelve percent had experienced symptoms of anxiety prior to the pandemic, compared to 65.6% who stated that they had experienced anxiety-related symptoms during the pandemic. Overall, 20.5% had taken anxiolytics prior to the pandemic, a figure that decreased to 18.9% during the pandemic. Similarly, the need for psychological support was reported by 24.0% before the pandemic and by 9.8% during the pandemic. In total, 37.2% of the respondents stated that their service had a psychological support unit, but a similar number, 36.0%, did not know if they had access to such a support unit. Training courses aimed at anxiety control were given within the unit in which they worked in 26.2% of the cases, and in 46.7% of the cases, the psychological health of the workers could be dealt with normally. 3.5. Questionnaire Results Regarding the mental health of the participants, in the GHQ-12, the mean score of the sample in the questionnaire was 5.26 (SD = 3.18). The GHQ-12 scores of the participants indicate that 37.5% showed no pathology, 26.5% showed possible psychological pathology, and 36% showed signs of psychological pathology, according to the cutoff points of the scale. In relation to PTSD, assessed by the DTS-8 questionnaire, the mean score was 9.26 ( SD = 6.04 ). According to the cutoff point of this scale ( ≥ 12 points), 30.9% of the people in the sample present suspected post-traumatic stress syndrome. Regarding the perception of sleeping difficulties, which was measured by the AIS-8 scale, the mean score of the participants on the instrument was 7.39 (SD = 4.94). Regarding the cutoff point of the scale (≥6 points), 60.9% experienced sleeping difficulties. The most significant items in each of the three instruments (GHQ-12, DTS-8, and AIS-8) are shown in Table 1. If we take into account those variables that offer responses other than the YES/NO dichotomy, we can observe that the groups with the greatest number of individuals suffering from sleep difficulties were: the age group between 40 and 49 years, women, EMTs, EMS workers in Castilla y León, EMS workers in advanced units, those who had been working for between 10 and 20 years, those who lived with four Int. J. Environ. Res. Public Health 2021,18, 9132 7 of 18 or more people, those who had undergone serological tests, and those who had gained less than 1 kg in weight. In general, these groups also demonstrated the greatest prevalence of signs of suspected psychological pathology, suspected PTSD, and insomnia (Table 2). Table 1. Items from the GHQ-12, DTS-8, and AIS-8 instruments with the greatest significance (n= 317). GHQ-12 Items with the highest scores in the scale Percentage (%) Thinking of self as worthless 88.3 Losing confidence 75.7 DTS-8 Items with the highest scores in the scale Percentage (%) Experiencing less interest in things previously enjoyed 4.7 Imagining or remembering painful, recurring images that cannot be put out of mind 3.8 AIS-8 Items with the highest scores in the scale Percentage (%) Sleep induction 4.4 Final awakening 3.2 Total sleep duration 3.2 Sleep quality 3.2 Table 2. Sociodemographic distribution of polytomous variables according to the results of GHQ12: suspected psychological pathology (GHQ-12 = 5–6), DTS-8: suspicion of post-traumatic stress disorder (DTS-8 ≥12), and AIS-8: insomnia (AIS-8 ≥6) (n= 317). Variables GHQ-12 Psychological Pathology DTS-8 PTSD AIS-8 Insomnia n%n%n% Age (years) ≤29 19 4.1 29 9.1 29 9.1 30–39 31 9.8 26 8.2 42 13.2 40–49 41 12.9 39 12.3 78 24.6 50–59 26 8.2 22 6.9 40 12.6 ≥60 3 0.9 2 0.6 4 1.3 Gender Female 68 21.5 52 16.4 108 34.1 Male 46 14.5 43 13.6 82 25.9 Professional category Physician 19 6 15 4.7 36 11.4 Nurse 31 9.8 22 6.9 54 17 Emergency medical technician 64 20.2 61 19.2 103 32.5 Emergency Service SACYL 90 28.4 74 23.3 148 46.7 SUMMA 112 24 7.6 24 7.6 45 14.2 Int. J. Environ. Res. Public Health 2021,18, 9132 8 of 18 Table 2. Cont. Variables GHQ-12 Psychological Pathology DTS-8 PTSD AIS-8 Insomnia n%n%n% Type of EMS ALS 56 17.7 39 12.3 99 31.2 BLS 40 12.6 41 12.9 70 22.1 Work experience (years) <10 29 9.1 18 5.7 52 16.4 10 to 20 63 19.9 56 17.7 106 33.4 21 to 30 18 5.7 18 5.7 27 8.5 >30 4 1.3 6 1.9 8 2.5 Number of people per household 1 21 6.6 18 5.7 33 10.4 2 21 6.6 20 6.3 39 12.3 3 21 6.6 15 4.7 34 10.7 >4 51 16.1 45 14.2 87 27.4 Tests PCR 14 4.4 14 4.4 18 5.7 Ig M/Ig G 43 13.6 79 24.9 90 28.4 Both 50 15.8 39 12.3 70 22.1 Weight gained (Kg) <1 64 20.2 58 18.3 113 35.6 1 to 2 4 1.3 4 1.3 5 1.6 2 to 3 10 3.2 3 0.9 12 3.8 3 to 4 19 6 18 5.7 28 8.8 >4 28 8.8 9 2.8 10 3.2 Abbreviations: PTSD, post-traumatic stress disorder; SACYL, Sanidad de Castilla y León; SUMMA 112, Servicio de Urgencias Médicas de Madrid; EMS, emergency medical services; ALS, advanced life support; BLS, basic life support. 3.6. Comparison of Means and Correlations Subsequently, an inferential analysis was carried out between variables, with the intention of searching for relationships between the general variables and the results of the total scores of the GHQ-12, DTS-8, and AIS-8, which, in all cases, approximately followed a normal distribution. Depending on the type of variable, Student’s ttests were used for dichotomous variables, ANOVA for variables with more than two possible answers, and Pearson’s r correlation coefficient for quantitative variables. Relationships were found between the GHQ-12 total score indicating the psychological health of the person and the following variables: gender, changes in job functions, having undergone previous theoretical and practical training on the use of PPE, the type of SARS-CoV-2 test, having required isolation, having experienced symptoms of the disease, having had adequate PPE during the pandemic, having had PPE removed from the service because it was not adequate, having been worried about contracting the disease and about transmitting it to family, anxiety symptoms prior to and during the pandemic, use of anxiolytics during the pandemic, requiring psychological support prior to and during the pandemic, and dealing with mental health issues normally in the work unit. Int. J. Environ. Res. Public Health 2021,18, 9132 9 of 18 In addition, relationships were found between the DTS-8 total score, showing the risk of post-traumatic stress, and the following variables: gender, changes in job duties, having had prior theoretical and practical training on the use of PPE, the type of SARSCoV-2 testing, having had appropriate PPE during the pandemic, having been worried about contracting the disease, anxiety symptoms prior to and during the pandemic, use of anxiolytics prior to and during the pandemic, requiring psychological support prior to and during the pandemic, and dealing with mental health issues normally in the work unit. Relationships were also found between the AIS-8 total score indicating the presence of insomnia and the following variables: gender, service in which they work, having undergone previous theoretical and practical training on the use of PPE, having been worried about contracting the disease, weight gain during confinement, anxiety symptoms before and during the pandemic, use of anxiolytics before and during the pandemic, requiring psychological support before and during the pandemic, and dealing with mental health issues normally in the work unit (Tables 3and 4). Table 3. Inferential analysis: Student ttest means comparison. Variables Instrument (Total Score) Levene Test tValue Level of Significance p IC 95% Min Max Emergency service AIS-8 0.554 −1.964 0.050 * −2.743 0.002 Functions GHQ-12 0.696 −2.449 0.015 * −1.716 −0.187 DTS-8 0.846 −2.540 0.012 * −3.248 −0.408 Theoretical training GHQ-12 0.340 2.422 0.016 * 0.168 1.620 DTS-8 0.005 2.213 0.028 * 0.178 3.084 AIS-8 0.055 3.389 0.001 * 0.809 3.047 Practical training GHQ-12 0.295 2.693 0.007 * 0.263 1.689 DTS-8 0.000 2.755 0.006 * 0.571 3.441 AIS-8 0.250 2.608 0.010 * 0.361 2.579 Need for quarantine GHQ-12 0.929 −2.428 0.016 * −1.979 −0.207 COVID-19 symptoms GHQ-12 0.645 −2.392 0.017 * −1.637 −0.159 Adequate personal equipment GHQ-12 0.000 4.145 0.000 * 0.742 2.084 DTS-8 0.021 4.946 0.000 * 2.040 4.735 AIS-8 0.160 4.800 0.000 * 1.593 3.805 Contagion concern GHQ-12 0.337 −4.790 0.000 * −5.050 −2.109 DTS-8 0.023 −3.978 0.000 * −8.519 −2.881 AIS-8 0.090 −2.884 0.004 * −5.762 −1.089 Transmission concern GHQ-12 0.012 −3.775 0.000 * −5.757 −1.812 Weight gained AIS-8 0.222 −2.604 0.010 * −2.597 −0.362 Anxiety prepandemic GHQ-12 0.629 −3.135 0.002 * −2.771 −0.634 DTS-8 0.651 −2.362 0.019 * −4.490 −0.409 AIS-8 0.449 −3.003 0.003 * −4.201 −0.875 Anxiety during pandemic GHQ-12 0.356 −11.104 0.000 * −4.179 −2.921 DTS-8 0.001 −8.946 0.000 * −6.566 −4.197 AIS-8 0.960 −7.188 0.000 * −4.975 −2.836 Anxiety treatment prepandemic DTS-8 0.254 −2.645 0.009 * −3.840 −0.564 AIS-8 0.027 −4.491 0.000 * −4.318 −1.687 Anxiety treatment during pandemic GHQ-12 0.837 −7.468 0.000 * −3.977 −2.318 DTS-8 0.080 −6.147 0.000 * −6.652 −3.426 AIS-8 0.838 −5.717 0.000 * −5.199 −2.537 Need for psychological support prepandemic GHQ-12 0.855 −2.197 0.029 * −1.734 −0.096 DTS-8 0.071 −3.338 0.001 * −4.150 −1.072 AIS-8 0.001 −4.170 0.000 * −4.515 −1.604 Int. 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