Cited by 455COVID-19 and Mental HealthDisaster Response and ManagementHealthcare professionals’ stress and burnout

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Risk Perception and Impact of Severe Acute Respiratory Syndrome (SARS) on Work and Personal Lives of Healthcare Workers in Singapore: What Can We Learn?

Koh, David, Lim, Meng Kin, Chia, Sin Eng, Ko, Soo Meng, Qian, Feng, Ng, Vivian, Tan, Ban Hock, Wong, Kok Seng, Chew, Wuen Ming, Tang, Hui Kheng, Ng, Winston, Muttakin, Zainal, Emmanuel, Shanta, Fong, Ngan Phoon, Koh, Gerald, Kwa, Chong Teck, Tan, Keson Beng-Choon, Fones, Calvin·2005·Medical Care

DOI 10.1097/01.mlr.0000167181.36730.cc

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Abstract

INTRODUCTION: Healthcare workers (HCWs) were at the frontline during the battle against Severe Acute Respiratory Syndrome (SARS). Understanding their fears and anxieties may hold lessons for handling future outbreaks, including acts of bioterrorism. METHOD: We measured risk perception and impact on personal and work life of 15,025 HCWs from 9 major healthcare institutions during the SARS epidemic in Singapore using a self-administered questionnaire and Impact of Events Scale and analyzed the results with bivariate and multivariate statistics. RESULTS: From 10,511 valid questionnaires (70% response), we found that although the majority (76%) perceived a great personal risk of falling ill with SARS, they (69.5%) also accepted the risk as part of their job. Clinical staff (doctors and nurses), staff in daily contact with SARS patients, and staff from SARS-affected institutions expressed significantly higher levels of anxiety. More than half reported increased work stress (56%) and work load (53%). Many experienced social stigmatization (49%) and ostracism by family members (31%), but most (77%) felt appreciated by society. Most felt that the personal protective measures implemented were effective (96%) and that the institutional policies and protocols were clear (93%) and timely (90%). CONCLUSION: During epidemics, healthcare institutions have a duty to protect HCWs and help them cope with their personal fears and the very stressful work situation. Singapore's experience shows that simple protective measures based on sound epidemiological principles, when implemented in a timely manner, go a long way to reassure HCWs.

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Background
Mapping infectious disease hospital surge threats to lessons learnt in Singapore: a systems analysis and development of a framework to inform how to DECIDE on planning and response strategies
Singh, S. R., Coker, R., Vrijhoef, H. J., Leo, Y., Chow, A. L., Lim, P. L., Tan, Q., Chen, M. I.-C., & Hildon, Z. J. (2017) · BMC Health Services Research · doi:10.1186/s12913-017-2552-1 · Cited by 126
“Previous studies show that provision of adequate PPEs, infection control training helped the staff feel confident enough to stay put [26, 27] in any ID outbreak despite the fact that they knew the high risk of contracting infection.”
Background
An assessment of the level of concern among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia
Abolfotouh, M. A., AlQarni, A. A., Alghamdi, S. M., Salam, M., Alassiri, M., & Balkhy, H. H. (2017) · BMC Infectious Diseases · doi:10.1186/s12879-016-2096-8 · Cited by 122
“A structured, self-administered questionnaire was designed on the basis of a survey previously used in studies of the concerns of HCWs with regard to severe acute respiratory syndrome (SARS) and avian influenza pandemics [6, 8].”
Method
Subjective Overload and Psychological Distress among Dentists during COVID-19
Mijiritsky, E., Hamama‐Raz, Y., Liu, F., Datarkar, A. N., Mangani, L., Caplan, J., Shacham, A., Kolerman, R., Mijiritsky, O., Ben‐Ezra, M., et al. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17145074 · Cited by 117
The Psychological Impact of the COVID-19 Epidemic on Guangdong College Students: The Difference Between Seeking and Not Seeking Psychological Help
Liang, S., Chen, R., Liu, L., Li, X., Chen, J., Tang, S., & Zhao, J. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.02231 · Cited by 130
“Generally, psychosocial responses to such stressors are varied and include feelings of anxiety, shame, personal and social failure, or weakness (Verghese, 2004); underestimation of the possibility of survival; overestimation of the likelihood of infection (Koh et al., 2005); excessive and inappropriate preventive meas…”
Background
The global prevalence of depression and anxiety among doctors during the covid-19 pandemic: Systematic review and meta-analysis
Johns, G., Samuel, V. M., Freemantle, L., Lewis, J., & Waddington, L. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.11.026 · Cited by 121
“The prevalence of depression and anxiety symptoms among doctors also falls within the range reported in research conducted during the SARS epidemic ranging from 18% to 57% (Tam et.al, 2004; Chan & Huak, 2004; Phua, Tang & Tham, 2005; Nickell et.al, 2004; Maunder et al., 2004; Koh et al., 2005).”
COVID-19-related stigma and its sociodemographic correlates: a comparative study
Yuan, Y., Zhao, Y.-J., Zhang, Q.-E., Zhang, L., Cheung, T. C. C., Jackson, T., Jiang, G.-Q., & Xiang, Y. (2021) · Globalization and Health · doi:10.1186/s12992-021-00705-4 · Cited by 113
“Married people reported higher levels of stigma than those who were unmarried, which is consistent with earlier findings from Singapore during the SARS outbreak wherein married healthcare workers perceived more severe social stigma than did unmarried peers and tended to believe that “people avoid my family because of…”
Result
Factors affecting healthcare workers’ compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: rapid evidence review
Brooks, S. K., Greenberg, N. L., Wessely, S. C., & Rubin, G. J. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-049857 · Cited by 128
“Length of time in role was not significantly associated with compliance in five studies [12,16,17,18,30], while two studies suggested that longer experience of working in healthcare was associated with greater compliance [31,33] and one suggested that less than ten years’ experience was associated with significantly h…”
Result
Factors Associated with the Willingness of Health Care Personnel to Work During an Influenza Public Health Emergency: An Integrative Review
Devnani, M. (2012) · Prehospital and Disaster Medicine · doi:10.1017/s1049023x12001331 · Cited by 109
To Evacuate or Not to Evacuate: Lessons Learned From Louisiana Nursing Home Administrators Following Hurricanes Katrina and Rita
Dosa, D. M., Grossman, N., Wetle, T. T., & Mor, V. (2007) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2006.11.004 · Cited by 109
Workplace factors associated with mental health of healthcare workers during the COVID-19 pandemic: an international cross-sectional study
Khajuria, A., Tomaszewski, W., Liu, Z., Chen, J., Mehdian, R., Fleming, S. S., Vig, S., & Crawford, M. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06279-6 · Cited by 121
“Studies from the 2003 SARS pandemic reported higher levels of depression [12], anxiety [13], posttraumatic stress disorder (PTSD) [14], burnout [15] and stress [10] amongst HCWs, with symptoms persisting up to 1 year after the pandemic [10] and nursing staff reporting the worst outcomes [16].”
Background
Mental health of healthcare professionals in China during the new coronavirus pandemic: an integrative review
Paiano, M., Jaques, A. E., Nacamura, P. A. B., Salci, M. A., Radovanovic, C. A. T., & Carreira, L. (2020) · Revista Brasileira de Enfermagem · doi:10.1590/0034-7167-2020-0338 · Cited by 113
Effective communication is key to intensive care nurses’ willingness to provide nursing care amidst the COVID-19 pandemic
Lord, H., Loveday, C., Moxham, L. J., & Fernandez, R. S. (2020) · Intensive and Critical Care Nursing · doi:10.1016/j.iccn.2020.102946 · Cited by 100
Sustainable practice of ophthalmology during COVID-19: challenges and solutions
Lim, L. W., Yip, L. W. L., Tay, H. W., Ang, X. L., Lee, L. K., Chin, C. F., & Yong, V. K. Y. (2020) · Graefe s Archive for Clinical and Experimental Ophthalmology · doi:10.1007/s00417-020-04682-z · Cited by 97
Cuidar al que cuida: el impacto emocional de la epidemia de coronavirus en las enfermeras y otros profesionales de la salud
Bueno‐Ferrán, M., & Barrientos‐Trigo, S. (2020) · Enfermería Clínica · doi:10.1016/j.enfcli.2020.05.006 · Cited by 103
The Willingness of U.S. Emergency Medical Technicians to Respond to Terrorist Incidents
DiMaggio, C. J., Markenson, D. S., Loo, G. T., & Redlener, I. (2005) · Biosecurity and Bioterrorism Biodefense Strategy Practice and Science · doi:10.1089/bsp.2005.3.331 · Cited by 95
Evaluation of stress, burnout and hair cortisol levels in health workers at a University Hospital during COVID-19 pandemic
Ibar, C., Fortuna, F., González, D., Jamardo, J., Jacobsen, D., Pugliese, L. J., Giraudo, L., Ceres, V., Mendoza, C., Repetto, E. M., et al. (2021) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2021.105213 · Cited by 96
A hybrid inductive-abductive analysis of health workers’ experiences and wellbeing during the COVID-19 pandemic in the United States
Hennein, R., & Lowe, S. R. (2020) · PLoS ONE · doi:10.1371/journal.pone.0240646 · Cited by 98
“Similar to our findings, HWs faced social isolation that negatively impacted their wellbeing during the Severe Acute Respiratory Syndrome (SARS) pandemic in 2002 [35].”
A Systematic Review of the Impact of Viral Respiratory Epidemics on Mental Health: An Implication on the Coronavirus Disease 2019 Pandemic
Luo, Y., Chua, C. R., Xiong, Z., Ho, R., & Ho, C. S. H. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.565098 · Cited by 93
Concerns, Perceived Impact and Preparedness in an Avian Influenza Pandemic – a Comparative Study between Healthcare Workers in Primary and Tertiary Care
Wong, T. Y., Koh, G. C., Cheong, S. K., Lee, H. Y., Fong, Y. T., Sundram, M., Koh, K., Chia, S. E., & Koh, D. S. Q. (2008) · Annals of the Academy of Medicine Singapore · doi:10.47102/annals-acadmedsg.v37n2p96 · Cited by 89
Self-citation
The impact of pandemics on healthcare providers' workloads: A scoping review
Doleman, G., Leo, A. D., & Bloxsome, D. (2023) · Journal of Advanced Nursing · doi:10.1111/jan.15690 · Cited by 97
The association between witnessing patient death and mental health outcomes in frontline COVID‐19 healthcare workers
Mosheva, M., Gross, R., Hertz‐Palmor, N., Hasson‐Ohayon, I., Kaplan, R., Cleper, R., Kreiss, Y., Gothelf, D., & Pessach, I. M. (2021) · Depression and Anxiety · doi:10.1002/da.23140 · Cited by 96
Psychological Impact of Deploying in Support of the U.S. Response to Ebola: A Systematic Review and Meta-Analysis of Past Outbreaks.
Vyas, K. J., Delaney, E. M., Webb-Murphy, J. A., & Johnston, S. L. (2016) · Military Medicine · doi:10.7205/milmed-d-15-00473 · Cited by 80
Impact of COVID-19 on eating habits, physical activity and sleep in Brazilian healthcare professionals
Mota, I. A., Sobrinho, G. D. D. O., Morais, I. P. S., & Dantas, T. F. (2021) · Arquivos de Neuro-Psiquiatria · doi:10.1590/0004-282x-anp-2020-0482 · Cited by 87
Nurses’ ability and willingness to work during pandemic flu
MARTIN, S. D. (2010) · Journal of Nursing Management · doi:10.1111/j.1365-2834.2010.01190.x · Cited by 83
Mental Health Status of Healthcare Professionals and Students of Health Sciences Faculties in Kuwait during the COVID-19 Pandemic
Alsairafi, Z. K., Naser, A. Y., Alsaleh, F. M., Awad, A. I., & Jalal, Z. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18042203 · Cited by 85
“Mental Health Status of HCPs In Japan and Singapore, during the Severe Acute Respiratory Syndrome (SARS) outbreak, fear and anxiety were prevalent among more than half of HCPs [42,43].”
Background
Nurses' perceptions of risk from emerging respiratory infectious diseases: A Singapore study
Koh, Y., Hegney, D. G., & Drury, V. (2012) · International Journal of Nursing Practice · doi:10.1111/j.1440-172x.2012.02018.x · Cited by 82
“[8] [9] [10] In particular, many studies report that HCWs perceived a high level of infection transmission and consequent adverse outcomes such as SARS infection and/or death.”
BackgroundInfluential
Prevalence of mental health problems and associated risk factors among military healthcare workers in specialized COVID ‐19 hospitals in Wuhan, China: A cross‐sectional survey
Pan, X., Xiao, Y., Ren, D., Xu, Z., Zhang, Q., Yang, L., Liu, F., Hao, Y., Zhao, F., & Bai, Y. (2020) · Asia-Pacific Psychiatry · doi:10.1111/appy.12427 · Cited by 79
“Koh et al. (2005) reported 68% of first-line healthcare workers experienced severe work-related pressure and 57.0% experienced psychological disturbance during the SARS outbreak.”
BackgroundInfluential
Nurses' and Physicians' Distress, Burnout, and Coping Strategies During COVID-19: Stress and Impact on Perceived Performance and Intentions to Quit
Lou, N. M., Montreuil, T. C., Feldman, L. S., Fried, G. M., Lavoie‐Tremblay, M., Bhanji, F., Kennedy, H., Kaneva, P. A., & Harley, J. M. (2021) · Journal of Continuing Education in the Health Professions · doi:10.1097/ceh.0000000000000365 · Cited by 82
The mental health of frontline health care providers during pandemics: a rapid review of the literature
Magill, E., Siegel, Z., & Pike, K. M. (2020) · Psychiatric Services · doi:10.1176/appi.ps.202000274 · Cited by 77
“health workers in under-resourced or inadequately resourced settings with less training also reported higher levels of mental distress (22, 25, 27, 30, 32, 37, 43, 54, 6769).”
BackgroundInfluential
Anxiety and Sleep Disturbances Among Health Care Workers During the COVID-19 Pandemic in India: Cross-Sectional Online Survey
Gupta, B., Sharma, V., Kumar, N., & Mahajan, A. (2020) · JMIR Public Health and Surveillance · doi:10.2196/24206 · Cited by 80
Will First-Responders Show Up for Work During a Pandemic? Lessons From a Smallpox Vaccination Survey of Paramedics
Mackler, N. J., Wilkerson, W. M., & Cinti, S. K. (2007) · Disaster management & response · doi:10.1016/j.dmr.2007.02.002 · Cited by 75
“A survey of more than 15,000 Singapore HCWs after the SARS outbreak revealed that 76% of respondents were afraid of falling ill with SARS. 9 However, 69.5% accepted the risk of getting SARS as part of their job.”
BackgroundInfluential
Health care worker burnout during the COVID-19 pandemic
Alsulimani, L. K., Farhat, A. M., Borah, R. A., Alkhalifah, J. A., Alyaseen, S. M., Alghamdi, S. M., & Bajnaid, M. J. (2021) · Saudi Medical Journal · doi:10.15537/smj.2021.42.3.20200812 · Cited by 75
Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review
Fiest, K. M., Leigh, J. P., Krewulak, K. D., Plotnikoff, K. M., Kemp, L. G., Ng-Kamstra, J. S., & Stelfox, H. T. (2021) · BMC Psychiatry · doi:10.1186/s12888-021-03090-9 · Cited by 74
“Recognition of service from the government was also indicated by physicians in China [108] and Singapore [53] as a positive buffer to experiencing negative psychological symptoms.”
BackgroundInfluential
A year in review: sleep dysfunction and psychological distress in healthcare workers during the COVID-19 pandemic
Pappa, S., Sakkas, N., & Sakka, E. (2021) · Sleep Medicine · doi:10.1016/j.sleep.2021.07.009 · Cited by 84
Mental health of clinical staff working in high-risk epidemic and pandemic health emergencies a rapid review of the evidence and living meta-analysis
Bell, V., & Wade, D. M. (2020) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-020-01990-x · Cited by 77
“disease experienced stigma from friends, family and the public (Bai et al., 2004; Goulia et al., 2010; Grace et al., 2005; Hewlett and Hewlett, 2005; Khee et al., 2004; Koh et al., 2005; Maunder et al., 2006; McMahon et al., 2016; Meyer et al., 2018; Nickell et al., 2004; Park et al., 2018; Poon et al., 2004; Smith et…”
Result
History for some or lesson for all? A systematic review and meta-analysis on the immediate and long-term mental health impact of the 2002–2003 Severe Acute Respiratory Syndrome (SARS) outbreak
Chau, S. W. H., Wong, O. W. H., Ramakrishnan, R., Chan, S. S. M., Wong, E. K.-Y., Li, P. Y. T., Raymont, V., Elliot, K., Rathod, S., Delanerolle, G., et al. (2021) · BMC Public Health · doi:10.1186/s12889-021-10701-3 · Cited by 81
“Many SARS patients and their family members, healthcare workers, and residents from SARS-hit neighbourhoods encountered discrimination in various aspects of their lives [37, 64, 101].”
Background
Factors mediating the psychological well-being of healthcare workers responding to global pandemics: A systematic review
Schneider, J., Talamonti, D., Gibson, B., & Forshaw, M. J. (2021) · Journal of Health Psychology · doi:10.1177/13591053211012759 · Cited by 80
Factors influencing emergency nurses’ ethical problems during the outbreak of MERS-CoV
Choi, J. S., & Kim, J. S. (2016) · Nursing Ethics · doi:10.1177/0969733016648205 · Cited by 68
“According to previous studies, what is more, nurses’ ethical problems during a pandemic might be affected by perceived risk and cognitions of social stigmatization.(8,9) Previous studies have explored ethical conflicts and problems experienced by nurses in clinical environments such as emergency care, end-of-life care…”
BackgroundMethodResultInfluential
COVID-19 risk management at the workplace, fear of infection and fear of transmission of infection among frontline employees
Nabe‐Nielsen, K., Nilsson, C. J., Juul-Madsen, M., Bredal, C., Hansen, L. O. P., & Hansen, Å. M. (2020) · Occupational and Environmental Medicine · doi:10.1136/oemed-2020-106831 · Cited by 68
Effects of work conditions and organisational strategies on nurses' mental health during the COVID‐19 pandemic
Li, T., Pien, L., Kao, C., Kubo, T., & Cheng, W. (2021) · Journal of Nursing Management · doi:10.1111/jonm.13485 · Cited by 68
“Social stigmatization was reported by high percentages of health care workers in Singapore during the SARS outbreak of 2003 and in Sierra Leone during the Ebola epidemic (Koh et al., 2005; McMahon et al., 2016).”
Background
Planning for Avian Influenza
Bartlett, J. G. (2006) · Annals of Internal Medicine · doi:10.7326/0003-4819-145-2-200607180-00133 · Cited by 68
“Forty-nine percent reported social stigmatization, and 31% reported ostracism by family members (22).”
Background
Psychological impact of COVID-19 on health workers in Ghana: A multicentre, cross-sectional study
Ofori, A. A., Osarfo, J., Agbeno, E. K., Manu, D. O., & Amoah, E. (2021) · SAGE Open Medicine · doi:10.1177/20503121211000919 · Cited by 66
Preparedness and the importance of meeting the needs of healthcare workers: a qualitative study on Ebola
Belfroid, E., van Steenbergen, J., Timen, A., Ellerbroek, P. M., Huis, A. M. P., & Hulscher, M. (2017) · Journal of Hospital Infection · doi:10.1016/j.jhin.2017.07.001 · Cited by 65
“They may have to work extra shifts and perform tasks that do not belong to their daily routine in a different department, and they may have to work in a multidisciplinary team they are not accustomed to [2].”
Occupational health responses to COVID-19: What lessons can we learn from SARS?
Koh, D. S. Q., & Goh, H. P. (2020) · Journal of Occupational Health · doi:10.1002/1348-9585.12128 · Cited by 71
“…I normally don't do 54% I had to work overtime 36% People close to me are worried for my health 87% People close to me are worried they might get infected through me 69% People avoid me because of my job 49% People avoid my family members because of my job 31% Note: Source: Koh et al. (2005)19.”
BackgroundSelf-citation
Obstetrics Healthcare Providers’ Mental Health and Quality of Life During COVID-19 Pandemic: Multicenter Study from Eight Cities in Iran
Vafaei, H., Roozmeh, S., Hessami, K., Kasraeian, M., Asadi, N., Faraji, A., Bazrafshan, K., Saadati, N., Aski, S. K., Zarean, E., et al. (2020) · Psychology Research and Behavior Management · doi:10.2147/prbm.s256780 · Cited by 66

Authors: Koh, D., Lim, M. K., Chia, S. E., Ko, S. M., Qian, F., Ng, V., Tan, B. H., Wong, K. S., Chew, W. M., Tang, H. K., Ng, W., Muttakin, Z., Emmanuel, S., Fong, N. P., Koh, G., Kwa, C. T., Tan, K. B.-C., & Fones, C.
Affiliations: National University of Singapore (SG)
National University Hospital (SG)
Singapore General Hospital (SG)
KK Women's and Children's Hospital (SG)
NHG Polyclinics (SG)
Corresponding author: Koh, David
Lim, Meng Kin
Chia, Sin Eng
Qian, Feng
Ng, Vivian
Fong, Ngan Phoon
ORCID: Koh, David
Chia, Sin Eng
Qian, Feng
Ng, Vivian
Tan, Ban Hock
Fong, Ngan Phoon
Koh, Gerald
Tan, Keson Beng-Choon
Venue: Medical Care
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2005-07
Volume: 43
Issue: 7
Pages: 676-682
ISSN: 0025-7079 (ISSN-L)
DOI: 10.1097/01.mlr.0000167181.36730.cc
OpenAlex: W2031239563
Cited by: 454
References: 21
Citations by year: 2026: 2 · 2025: 9 · 2024: 15 · 2023: 45 · 2022: 73 · 2021: 131 · 2020: 104 · 2019: 1 · 2018: 4 · 2017: 7 · 2016: 3 · 2015: 3 · 2014: 3 · 2012: 7
FWCI: 9.26
Type: journal article
Language: en
Open access: closed
Locations: Medical Care (publishedVersion)
PubMed (publishedVersion)
National University of Singapore (submittedVersion)
Topics: Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
Health Sciences › Health Professions › Emergency Medical Services › Disaster Response and Management
Health Sciences › Health Professions › General Health Professions › Healthcare professionals’ stress and burnout
Keywords: SARS, healthcare workers, risk perception, occupational anxiety, occupational stress, personal protective measures, social stigma, ostracism, work-life impact, infection control policy, bioterrorism preparedness
MeSH terms: Adaptation, Psychological, Adult, Disease Outbreaks, Emotions, Female, Health Personnel, Humans, Male, Surveys and Questionnaires, Singapore, Logistic Models, Workload, Severe Acute Respiratory Syndrome

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Risk Perception and Impact of Severe Acute Respiratory Syndrome (SARS) on Work and Personal Lives of Healthcare Workers in Singapore: What Can We Learn?

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