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Evaluation of stress score and correlation of stress score with heart rate, blood pressure and serum cortisol levels among health care workers in DCH and DCHC hospitals during covid-19 duty

1 Department of Physiology, Government Medical College, Ratlam, Madhya Pradesh, India
2 Department of Community Medicine, Government Medical College, Ratlam, Madhya Pradesh, India

Date of Submission27-Jan-2022
Date of Decision03-Mar-2022
Date of Acceptance10-Mar-2022

Correspondence Address:
Jagdish Hundekari,
Department of Physiology, Government Medical College, Ratlam - 457 001, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_75_22


Introduction: In the basic setting of the Coronavirus pandemic, medical care workers are at the forefront, participating directly in the consideration, determination, and therapy of patients with Coronavirus from the last two years. This exposes them to a higher danger of creating ongoing pressure, mental misery, and some other psychological wellness side effects. Objective: To evaluate stress, serum cortisol level, and blood pressure in a health workers population and, in addition, to measure serum cortisol concentration as a current biomarker of stress. Materials and Methods: Sixty health workers (22 men & 38 women) from Dedicated Covid Hospital and Dedicated Covid health Centre were included in this study. In these participants, after obtaining the data of socio-demography and perceived stress, serum cortisol was measured by automated chemiluminescent method. This is a hospital-based cross-sectional study. The studied population was divided into two groups: Group A (workers in direct contact with Covid patients) and Group B (workers not in direct contact with patients). Stress scores, serum morning cortisol levels, systolic and diastolic BP and heart rate of all the participants were measured and compared with controls using a Student's t-test. Stress scores of HCW in direct contact with patients were correlated with heart rate, systolic and diastolic BP, and serum morning cortisol levels and Pearson correlation coefficient (r) were calculated. Results: Stress scores are significantly increased whereas serum morning cortisol levels, heart rate and systolic and diastolic BP were non-significantly increased in Group A as compared with controls that is, Group B (P < 0.05). Stress scores of HCW in direct contact with patients were found to correlate strongly with serum morning cortisol levels, heart rate and systolic and diastolic BP with r values 0.397 (P < 0.0001), 0.322 (P < 0.001), 0.717 (P < 0.001), and 0.810 (P < 0.0001), respectively. Conclusion: Stress scores were elevated in HCW in direct contact with patients and were strongly correlated with serum cortisol levels, heart rate, and BP. It is the responsibility of the health authorities to implement strategies to manage this psychological stress.

Keywords: Blood pressure, Covid 19 pandemic, health care workers, serum cortisol, stress score

How to cite this URL:
Wasnik S, Hundekari J, Mittal R, Kot LS. Evaluation of stress score and correlation of stress score with heart rate, blood pressure and serum cortisol levels among health care workers in DCH and DCHC hospitals during covid-19 duty. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=344580

  Introduction Top

The World Health Organization announced Covid 19 a pandemic disease on March 13, 2020.[1] In this pandemic, for the last 2 years, healthcare workers are on the front directly managing Covid patients with regards to the mind, determination, and treatment which put them under tremendous pressure associated with mental disturbances. High infectivity of Coronavirus, absence of explicit therapy, and inadequate medical facilities along with an increasing number of Covid cases overwhelming workload, and absence of individual protection equipment builds the psychological stress of medical care workers.[2],[3] Previous studies conducted during the 2003 Severe acute respiratory syndrome (SARS) outbreak showed adverse psychological reactions among healthcare workers. In this HCW, high levels of stress along with symptoms of anxiety and depression[4] associated with uncertainty, stigmatization, reduced work efficiency, and resignation from the job[5],[6] were observed. Several studies found that the nursing staff from the emergency department was more likely to develop stress and behavioral changes.[7],[8],[9] In the present scenario, facing the pandemic caused by COVID-19, health workers who take care of these patients experience similar effects on their mental and physical health. The health crisis establishes an environment of vulnerability and stress that demands both evaluation and control of healthcare worker (HCW). So far, the majority of the examinations about Coronavirus have focused on epidemiological examinations, prevention, analysis, and treatment. Hardly any examinations have explored the emotional wellness issues that influence HCW during the pandemic[10],[11] Most of the studies in frontline workers during COVID-19 pandemic was done on perception of anxiety, psychological stress, anddepression after exposure to physical and mental burden during the pandemic but only few literatures are available on the association between perception of stress and biochemical stress markers. Besides, chronic stress-related to the work environment, known as burnout, leads to hypothalamic-pituitary-adrenal (HPA) axis disturbances which lead to altered cortisol levels in the blood.[12]

Our Government medical college is established in 2018 and the hospital was about to start in 2020. The government-aided medical college hospital was fully converted into Dedicated Covid Hospital (DCH) and Dedicated Covid Health Centre (DCHC). We conducted the study from the last week of December 2020. In such type of hospital setup, physical and psychological burden of Covid 19 and non-Covid patient care along with teaching activities with additional burden due to shortage of staff as few of the HCW's frequently got infected with Covid 19 during their duties. During the second wave of Covid 19, patients overload well as mortality was also too high in comparison to the first wave. So, it is important to study the effect of stress on health in such type of medical college associated hospital setting because its negative effects can impact the professional, physical, and mental health on a long term basis and also on the health institution itself, by increasing staff absenteeism, and on the quality of care provided by increasing medical errors and diminishing patient safety, it is essential to see the impact of stress. So, this study proposed to evaluate the emergence of physical and mental stress in HCW during COVID19 pandemic and to associate the impact of physical and mental stress over the blood pressure and serum cortisol level in HCW.

  Materials and Methods Top

The present study was carried out after institutional ethical committee approval (Ethical committee Registration No. ECR/1192/Inst/MP/2019) was obtained with letter No. GMC Ratlam/2020/IEC/Approval/2019 dated 14/12/2020. This is a hospital-based cross-sectional study to compare stress between health care workers in direct contact with patients and workers not in direct contact with patients from DCH and DCHC. Health workers (n = 60) 22 men (31.65 ± 6.33) and 38 women (30.52 ± 6.45) from the age group between 25-40 yrs were included in the study. Known cases of diabetes hypertension, Individuals under treatment with glucocorticoids, psychotropic drugs, HPA axis alterations, or a previous diagnosis of mental health disorders, dyslipidemia, central obesity, and CVD were excluded from the study. Written informed consent was obtained from all participants and they were divided into two groups. Group I (n = 30) contains health care workers in direct contact with patients and group II (n = 30) contains HCW not in direct contact with patients.

Researchers provided pretested questionnaire on psychological stress perception to the subjects and a filled questionnaire was collected. Stress scores of all subjects were then evaluated using the DASS-21 scale[13] which comprises seven questions and sub-items can be rated as Normal, mild, moderate, severe, and extremely severe. Each item is scored on a self-rated Likert scale for 0 (Did not apply to me) to 3 (Applied to me to some degree, considerable degree, and very much) for the past 1 week.

As HCW are doing shift duties with 8hrs/day, so only those HCW were selected with morning shift i.e., 8:00 a.m. to 2:00 p.m. to remove the bias as shift duties also affect serum cortisol. Selected participants (n = 60) are on a mixed diet and in both cases we have not considered the dietary pattern. All the subjects were then called the next morning with an empty stomach at 8:00 a.m. Subjects were allowed to take rest for 10 min before testing BP and heart rate. BP was tested in a lying down position with a digital sphygmomanometer and Heart rate was measured with Electrocardiogram (ECG). Venous blood was drawn for serum cortisol (morning) and was measured by automated chemiluminescent method (Immulite 2000 autoanalyzer, Siemens, LA USA) and results were expressed in μg/dl.

Statistical analysis

Statistical analysis was done in two parts: in the first part, stress scores, cardiovascular risk factors, and morning serum cortisol of Group A and Group B were compared using Student t-test. Stress scores of all the participants in direct contacts with patients were correlated with heart rate, systolic, diastolic blood pressure and serum cortisol level and Pearson correlation coefficient (r) was calculated in second part. The value of Pearson correlation coefficient (r) ranges between +1 and -1, where 1 is total positive correlation, 0 is no correlation and -1 is total negative correlation. Statistical software used for statistical analysis was Epi Info.

  Result Top

A total of 60 HCW were recruited for this study. Group A included 30 workers in direct contact with patients and Group B included 30 age- and sex-matched workers who are not in direct contact with patients working in the same DCH and DCHC hospital. Both groups together consist of 22 men and 38 women. [Table 1] shows that the stress scores were elevated significantly in Group A as compared to Group B (P = 0.003). Morning serum cortisol levels in Group A were found to be non-significantly higher than in Group B (P = 0.385). When comparing Group A workers to Group B workers, both systolic and diastolic blood pressure increased non-significantly (P = 0.554 and 0.455, respectively). Group A had a non-significant rise in heart rate as compared to Group B (P = 0.394).
Table 1: Comparison of blood pressure, Serum cortisol concentration and stress score in the studied population

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[Table 2] shows a correlation between stress scores of workers in direct contact with Covid 19 positive patients admitted in DCH and DCHC Hospitals with serum morning cortisol and cardiovascular risk factors such as heart rate, systolic and diastolic BP, and Pearson correlation coefficient (r) was calculated. Stress scores were found to be strongly correlated with serum cortisol levels with r values 0.397 (P < 0.0001). Correlation between stress scores and heart rate, systolic and diastolic BP was also found to be strong with r values 0.322 (P < 0.001), 0.717 (P < 0.001) and 0.810 (P < 0.0001), respectively.
Table 2: Correlation of stress scores with other risk factorsof Physical and psychological stress in workers coming in direct contact with patients

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  Discussion Top

This study aimed to determine whether participants working in DCH and DCHC can experience increased stress and can demonstrate increased levels of serum cortisol than their colleagues who worked in the same hospital setup but not in direct contact with patients. In the present study, stress score and serum cortisol level were evaluated in health care front liners at DCH and DCHC hospital in the context of the COVID-19 pandemic.

The results in the present study revealed an elevated level of stress scores in health care workers doing COVID-19 duties as compared to controls. Recent studies have similarly shown that COVID-19 duties affect mental health outcomes such as anxiety, depression, and post-traumatic stress symptoms.[14],[15] Furthermore, healthcare workers constitute a population particularly vulnerable to developing adverse mental health events due to long working hours, risk of infection, lack of personal protection elements, physical fatigue, and separation from their families.[16] To our knowledge, in India, this is one of the few studies in which a stress biomarker such as serum cortisol was evaluated in this population.

In the present study, stress score, serum cortisol, and blood pressure were shown to increase non-significantly in workers doing Covid 19 duties as compared to controls. Several studies report that chronic stress alters HPA axis activity, which adds to the development of psychiatric disorders such as depression, anxiety, and burnout.[17],[18],[19] Few studies have shown that chronic stress can deregulate the axis feedback system, increase cortisol levels.[20] However, most of the studies evaluating HPA axis alterations in physical and mental exhaustion are controversial. Some studies report increased cortisol values[21] (Grossi et al. 2005), others do not show any modification in cortisol levels[22] (Bellingrath et al., 2008), and others even show the reduced activity of the axis[23] (Pruessner et al., 1999).

Our results show that HCW in direct contact with Covid patients were presented with altered serum cortisol values as compared to workers, not in direct contact with Covid patients. In addition, a strong association between perceived stress and serum cortisol levels, heart rate, and blood pressure was observed, particularly in workers doing Covid 19 duties, which was similar to the study done by Ibar et al.[24] who found a positive correlation between the stress perceived and hair cortisol levels in health workers during the COVID-19 pandemic. Baig et al.[25] had shown that evening serum cortisol concentration was significantly associated with the Perceived Stress Scale stress score. Sawai et al.[26] had shown that mental stress elevates BP in young men.

In summary, our study demonstrates the importance of evaluating mental and physical stress in health workers, a vulnerable population in the context of the COVID-19 pandemic. Additionally, serum cortisol concentrations have been a valuable screening instrument for stress.


A probable limitation of this study is related to the small number of HCW evaluated as only HCW's working in the morning shift, i.e., from 8:00 a.m. to 2:00 p.m. were selected for the study. However, depression scores through the inventory are clinically confirmed. Besides, the levels of stress and cortisol are indicators that strengthen the results of this research.

  Conclusions Top

Stress scores were elevated in HCW in direct contact with patients and were strongly correlated with serum cortisol levels, heart rate, and BP which will affect physical and mental health on long term basis. It is the responsibility of the health authorities to implement strategies to manage this psychological stress.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2]


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