Introduction

Epidemics are characterized as involuntary transitory events of civilization¹. The first human beings, whose characteristics of social organization are distinct from today’s society, faced illnesses in the same way that today occurs. However, due to the fact that they are more inmates in their “tribes”, isolated from other groups, the diseases did not have the ability to spread. However, this changed with the advent of the Agricultural Revolution and the consequent sedentarization of man¹.

Currently, humanity faces the coronavirus disease (COVID-19), which has SARS-CoV-2 as the etiologic agent according to the International Virus Taxonomy Committee classification. This virus belongs to the genus β-coronaviruses, as well as SARS-CoV and MERS-CoV, which caused an epidemic in China in 2003 and similar respiratory conditions in 2012 in the Middle East, respectively. The first reported cases referring to SARS-CoV-2 occurred in Wuhan, Hubei province, China, dated December 2019², resulting in the declaration of a pandemic by the World Health Organization (WHO) in March 2020.

Worldwide, COVID-19 has a high incidence and mortality, especially in the Americas region, in which Brazil stands out³. The data in the country are tabulated using an epidemiological database, e-SUS NOTIFICA, to record cases of Influenza Syndrome (IS) suspected of COVID-19 in the population and among health professionals, including technicians and/or nursing assistants. are configured as the category that most falls ill by COVID-19⁴.

Studies show that the pandemic has caused negative consequences on workers’ health, such as fear of contamination, impact on lifestyle, sleep, changes in behavior (approaches), search for public information^5,6, in addition to increase in mental problems, such as anxiety, depression and stress, due to overwork, frustration, discrimination, isolation, lack of contact with family members, pressure and exhaustion^7,8.

Such aspects are intensified, among other factors, by ineffective strategies of social isolation, the lack of human resources and the precariousness in the offer of collective and Individual Protection Equipment (PPE). In this sense, it is necessary to understand how these professionals are adapting to these changes that impacted practices, social and family life.

This study aimed to identify and describe coping strategies and adaptive behaviors adopted by health professionals during the COVID-19 pandemic according to national and international scientific literature.

Methods

This is an integrative review carried out through the following steps: identification of the guiding research question, search in databases, identification of eligible publications, selection of publications, data extraction, analysis and synthesis of evidence.

To develop the guiding question of the research, descriptors were identified that derived from the guiding question: what are the coping strategies and adaptive behaviors adopted by health professionals during the COVID-19 pandemic in the national and international scenarios? PICo strategy was used, in which P (population) corresponded to health professionals; I (intervention/interest), coping strategies and adaptive behaviors; Co (context), the COVID-19 pandemic.

Literature search took place in June 2020 and was carried out by two researchers independently, with the possibility of a third researcher if there was disagreement in the selection of articles. The search expressions were prepared using Boolean operators AND and OR for the combination of the descriptors indexed in the Health Sciences Descriptors (DeCS), Medical Subject Headings (MESH) and Emtree (Embase Subject Headings), with their respective synonyms in English and Spanish (Chart 1).

Bibliographic survey was carried out in the Latin American & Caribbean Literature in Health Sciences (LILACS), International Literature in Health Sciences (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus and Embase databases. Subsequently, the materials were exported to the online systematic review application Rayyan QCRI of the Qatar Computing Research Institute⁹, as well as duplicate publications and others submitted to title and abstract reading by two independent researchers were excluded.

We chose to include quantitative and qualitative studies, complete, in Portuguese, English, and Spanish, published in 2020. It was also considered as exclusion criteria, literature reviews, letters, notes, editorials, comments and other types of publications other than scientific articles.

For article selection, the study should answer the guiding question of the review, making them eligible for full reading, later submitted to a qualitative and descriptive synthesis by means of a file containing authors, country and publication period, objective, study design and quantity of professionals studied.

Results and Discussion

Thus, 212 publications were found in the databases, of which, in order to meet the previously established inclusion criteria, 29 were excluded for being duplicates, 39 publications for being incomplete, five for being in other languages, 32 for having been published before 2020, 12 because they are letters, six because they are notes, four editorials, three comments and 20 because they fit into other types of publication other than scientific articles.

After reading all titles and abstracts, 30 publications were excluded for not meeting the guiding question of the research because they worked with norms and recommendations for researchers, mental health professionals, higher education and long-term care institutions in the COVID-19 pandemic context, techniques for diagnosing the disease, changes in the sleep status of health teams and patient safety with COVID-19. Thus, 32 eligible studies were selected to be read in full. Two were excluded for discussing other outbreak and epidemic scenarios, without mention of COVID-19, and implications of respiratory isolation for patients in mental health units; in the end, this made it possible to include 30 articles to be analyzed and discussed (Figure 1).

The articles included were published, mostly, in English (96.7%), in international journals, of which the International Journal of Environmental Research and Public Health (23.3%), JMIR Public Health and Surveillance (13.3%), and Journal of Hospital Infection (13.3%) stand out. Most of them were carried out on the international stage, especially in countries that since the beginning of the pandemic have already been considered its epicenter, such as China (16.7%), Italy (20%), the United States (6.7%) and India (6.7%) (Table 1).

Regarding the study design, predominantly cross-sectional research (73.3%) and quantitative approach were identified (50%). The study population was composed of health professionals who work in the front line to combat the pandemic, such as nurses, physicians, physiotherapists, nutritionists, dentists, pharmacists, in addition to medical residents, interns and other professionals from the health support sectors who contribute to health control actions in different institutions and health settings, public or private (Table 1).

It was verified as for the methods used in the studies, mainly the accomplishment of online surveys with application of questionnaires to the study population (83.3%) - validated, elaborated or adapted through Google Forms, SurveyMonkey, Kwiksurveys, shared through media social and email. Some questionnaires, in addition to the collection of sociodemographic data and related to the behaviors, practices and attitudes of health professionals during the COVID-19 pandemic, also assessed other variables through Generalized Anxiety Disorder-7 (GAD-7) tests, PMT constructs, Connor-Davidson Resilience Scale and China Perceived Stress Scale.

Regarding coping strategies for the management of COVID-19 and for professional practice, studies have shown, in general, that health professionals have a good knowledge of transmission, diagnosis, prevention, management and control measures of the disease. Additionally, the growth in using new health technologies through an application was identified; conducting courses and training for COVID-19 at the health institution itself or over the internet; adaptations to changes in service protocols and office environment, even with the weaknesses in the availability of effective protection measures at individual and collective levels by health systems.

As for health professionals’ adaptive behaviors during the pandemic, studies have identified negative consequences for mental health related to increased work overload, insecurity and stress regarding handling COVID-19 cases, risk of disease transmission to their families, as well as financial concern and with future professionals^{11,15,19,21,23,27,35,36,37,40}. On the other hand, self-confidence behaviors, fear control, resilience and seeking help were identified^12,20,28,30as good practices acquired.

In the light of the scientific literature, it was identified that the COVID-19 pandemic impacted, in general, the lives of thousands of health professionals around the world, which resulted in the modification and implementation of strategies to face the pandemic individually and collectively^{11,12,15,16,18,19,22,23,25,26,28,29,32,34,38}, as well as adapting practices, behaviors and experiencing new feelings and values^{11-16,18-21,24,27-31,33-38,40}.

Acquisition of knowledge related to COVID-19 was presented as a factor for the modification and implementation of new practices and specific measures for infection control with regard to the forms of transmission, clinical and epidemiological criteria for case diagnosis and management^{11,15,21,22,26,27,33,38,40}. Such knowledge is considered vital to reduce the chain of transmission of the virus among the population and among health professionals themselves^28,30.

As for disease prevention strategies, studies show the need to incorporate good practices into individual and collective daily lives in relation to the proper use of PPE, correct hand hygiene, distance practices and social isolation^{12,18,19,23,28,30,33}, including those related to environmental measures^{11,15,16,21,22,26}. On the other hand, it is identified that there is much to be done to promote effective protection measures²⁷, considering the challenges to obtain, availability and use of PPE^17,21,36.

Moreover, some studies have presented incorrect knowledge, decisions and practices related to COVID-19, either due to professional inexperience, lack of habit, or preparation or lack of understanding the importance of health safety principles^{12,13,19,23,24,29}. This highlights the need for continuing professional education as a strategy to identify existing needs, gaps and bottlenecks, in order to improve health professionals’ knowledge about COVID-19, promoting better and appropriate therapeutic and prevention practices^{12,25,27,28,30,36}.

Access and provision of theoretical and practical training related to COVID-19 were also pointed out by literature^{13,18,19,22,23,28,29,31,33,38,39,40}. Topics to be addressed were identified, such as actions and recommendations for pandemic control, combating misinformation, information and knowledge about the virus, organization and flow of patient demand, symptoms, immunity, testing and transmission, in order to ensure patient safety and minimize knowledge deficiencies^19,39.

The change and implementation of new institutional treatment and management protocols for COVID-19 control were evidenced in the studies as factors capable of promoting better decision-making, reducing stress among health teams and internal conflicts regarding disparate knowledge^{11,17,19, 20,36}.

On the other hand, literature addresses the search for updates by health professionals regarding COVID-19 management, independently, over the internet, on institutional and governmental sites^{13,23,28,29,30}, for scientific articles^29,38, and most of them through social media^13,23,30,33, like Twitter³⁹.

The regular search for knowledge through unofficial websites and media demonstrates the potential fragility of the information sources chosen by professionals. There is a need for journals to offer open access to publications related to the topic³⁸ and for official government agencies to invest resources in digital platforms and social media, in order to guarantee the dissemination of reliable news^19,29, including for the involvement and awareness of the general public^18,22,24,27, since this is a recent issue, with increasing discoveries and the need for evidence-based updates.

COVID-19 brings with it several challenges, but also opportunities for digital healthcare. In this sense, health innovation technologies, with emphasis on electronic technologies (eHealth), have been proposed as tools to assist the provision of care from the perspective of social distance, such as the free C19CC application. The application was deployed in outpatient care settings in different countries for remote tracking of patients with comorbidities and discharge management, in addition to assisting in telehealth care by infected doctors in quarantine³⁴.

Another proposal capable of contributing to the digital support for health education of health professionals was the creation of educational video content in the United States through the Revinax. App mobile app. The app was responsible for the remote training of users for the procedures during handling of COVID-19, capable of offering skills acquisition, new skills and review of infection-related content³².

In times of pandemic, some weaknesses in health services interfere with the implementation of coping strategies, such as the limited support of public health authorities for human, material, financial resources and inefficiency in protecting physical integrity in the workplace^17,21,40; this contributes to the increased risk of occupational exposure experienced by health professionals^21,26, in addition to insecurity with the professional and economic future^16,18.

Considering that health professionals are the main players in the front line in the fight against COVID-19 in the different scenarios of health services, literature shows the growth of new adaptive behaviors that interfere with physical and psychological changes¹⁸ either due to the lack of preparation to deal with cases, ignorance of the disease, or due to work overload^19,27,30,34.

The authors point out some feelings that could be listed through the questionnaires applied in the studies to professionals, such as concern and anguish about the disease, fear of contamination^{11,12,14-16,18,19,21,27-29,31,35,36,40}, high anxiety, intense feelings of anger and sadness, which, even if observed in a few cases, can directly impact the quality of care provided to patients^16,31.

Furthermore, feelings of concern, fear and fear of contaminating family members and/or close friends were also mentioned by the authors^11,19,20,36. This highlights the importance of the availability of alternative locations or temporary accommodation for health professionals to remain after activities that involve risk of contamination, in order to minimize the chain of COVID-19 transmission³⁶ and reduce associated psychological impacts.

On the other hand, it is emphasized that there were, to a lesser extent, good practices in relation to the COVID-19 pandemic; they were motivated by governmental measures that guaranteed reliability in response actions to fight the disease, as well as by the experience of professionals who collaborated for a more optimistic considering the moment experienced^{13,20,24,28,30,33,37}, less stress and anxiety³⁸, in addition to controlling fear¹².

The availability and correct use of PPE are described in the literature not only as important means of COVID-19 prevention and control, but also as factors that contribute to the emotional and psychological security of health professionals^20,38. However, when unavailable or used incorrectly, they can cause insecure behaviors^24,30, often driven by distrust and uncertainty in their protective capacity^18,19,40.

To assist in the development of a culture of resilience within the work environment, a study carried out in the United Kingdom, using digital learning services through evidence-based guidance and support related to health professionals’ psychological well-being, allowed, after its use, normalization of psychological responses during a crisis, encouragement to self-care and help behaviors¹⁴.

This highlights the importance and need for interventions aimed at improving health professionals’ resilience and mental health that involve: communication with family and friends²¹; strengthening protection measures; development of standards, workshops and health education that integrate control behaviors; setting goals and making decisions to alleviate the stressful experience of experiencing a pandemic; avoiding complicated and more serious psychological problems in the long run^11,20,35.

Conclusion

This review made it possible to identify coping strategies related to the knowledge acquired, growth in the use of new health technologies through applications, adaptations to changes in protocols, in addition to adaptive behaviors associated with practices, expression of feelings and negative values. Although less frequently, good practices have been identified that contribute to increased resilience and psychological well-being among health professionals.

As a limitation of this study, it is noteworthy to include only original articles to the detriment of other types of publication, which may have caused the exclusion of materials that addressed and contributed to the theme. It presents the importance of understanding and knowing coping strategies and adaptive behaviors to foster discussions of disease prevention and control practices in different health service settings, as well as interventions aimed at the self-care of frontline combat health professionals from COVID-19.

Acknowledgments

We would like to thank the Tuberculosis Study Group (TSG) at Universidade Federal de Rondônia (UNIR).

References

1. Liritzis I. Pandemics - from Ancient Times to Covid19. Same Thoughts. Mediterranean Archaeology & Archaeometry 2020;13(1):1-9. http://dx.doi.org/10.5281/zenodo.3724821

2. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The lancet 2020; 395(10223):497-506. http://dx.doi.org/10.1016/S0140-6736(20)30183-5

3. Organização Mundial da Saúde. Coronavirus disease (COVID-19). Situation Report – 168. Disponível em: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200706-covid-19-sitrep-168.pdf?sfvrsn=7fed5c0b_2 . Acessado em 07 de julho de 2020.

4. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Boletim Epidemiológico Especial Doença pelo coronavirus COVID-19. 27ª semana epidemiológica. Brasília (DF), 2020 jun 28 - jul 04. Disponível em: http://saude.gov.br/images/pdf/2020/July/08/Boletim-epidemiologico-COVID-21-corrigido-13h35.pdf Acessado em 14 de julho de 2020

5. Cimerman S et al. Deep impacto of COVID-19 in the healthcare of Latin America: the case of Brazil. Brazil J Infect Dis. 2020; 24 (2): 93-95. http://dx.doi.org/10.1016/j.bjid.2020.04.005

6. Wu K, Wei X. Analysis of psychological and sleep status and exercise rehabilitation of front-line clinical staff in the flight against COVID-19 in China. Med Sci Monit Basic Res. 2020; 11; 26: e924085. http://doi.org/10.12659/MSMBR.924085

7. Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry. 2020 Apr;7(4):300-302. http://dx.doi.org/10.1016/S2215-0366(20)30073-0

8. Kang L, Li Y, Hu S, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. The lancet 2020;7(3):14. https://dx.doi.org/10.1016/S2215-0366(20)30047-X

9. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan – a web and mobile app for systematic reviews. Systematic Reviews 2016;5(1):1-10. https://dx.doi.org/10.1186/s13643-016-0384-4

10. Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Med 2009; 6(7):e1000097. https://dx.doi.org/10.1371/journal.pmed.1000097

11. Ahmed M, Jouhar R, Ahmed N, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. International Journal of Environmental Research and Public Health 2020;17(8):1-11. https://dx.doi.org/10.3390/ijerph17082821

12. Barati M, Bashirian S, Jenabi E, et al. Factors associated with preventive behaviours of COVID-19 among hospital staff in Iran in 2020: an application of the Protection Motivation Theory. Journal of Hospital Infection 2020;105(3):430-433. https://dx.doi.org/10.1016/j.jhin.2020.04.035

13. Bhagavathula AS, Aldhaleei WA, Rahmani J, et al. Knowledge and Perceptions of COVID-19 Among Health Care Workers: Cross-Sectional Study. JMIR Public Health Surveill 2020; 6(2):1-9. https://dx.doi.org/10.2196/19160

14. Blake H, Bermingham F, Johnson G, et al. Mitigating the psychological impact of covid-19 on healthcare workers: A digital learning package. International Journal of Environmental Research and Public Health 2020;17(9):1-15. https://dx.doi.org/10.3390/ijerph17092997

15. Cagetti MG, Cairoli JL, Senna A, et al. COVID-19 Outbreak in North Italy: An Overview on Dentistry. A Questionnaire Survey. Int. J. Environ. Res. Public Health 2020;17(11):1-12. https://dx.doi.org/10.3390/ijerph17113835

16. Consolo U, Bellini P, Bencivenni D. Epidemiological aspects and psychological reactions to COVID-19 of dental practitioners in the Northern Italy districts of modena and reggio emilia. Int. J. Environ. Res. Public Health 2020;17(10):1-17. https://dx.doi.org/10.3390/ijerph17103459

17. Delgado D, Quintana FW, Perez G, Liprandi AS, Ponte-Negretti C, Mendoza I, Baranchuk A. Personal safety during the covid-19 pandemic: Realities and perspectives of healthcare workers in Latin America. Int J Environ Res Public Health. 2020 Apr 18;17(8):2798. https://dx.doi.org/10.3390/ijerph17082798

18. De Stefani A, Bruno G, Mutinelli S, et al. COVID-19 outbreak perception in Italian dentists. Int. J. Environ. Res. Public Health 2020;17(11):1-7. https://dx.doi.org/10.3390/ijerph17113867

19. Dost B, Koksal E, Terzi Ö, et al. Attitudes of Anesthesiology Specialists and Residents toward Patients Infected with the Novel Coronavirus (COVID-19): A National Survey Study. Surgical Infections 2020;21(4):349-355. https://dx.doi.org/10.1089/sur.2020.097

20. Huang L, Wang Y, Liu J, et al. Factors associated with resilience among medical staff in radiology departments during the outbreak of 2019 novel coronavirus disease (COVID-19): A cross-sectional study. Med Sci Monit 2020; 26(e925669):1-10. https://dx.doi.org/10.12659/MSM.925669

21. Jin YH, Huang Q, Wang YY, et al. Perceived infection transmission routes, infection control practices, psychosocial changes, and management of COVID-19 infected healthcare workers in a tertiary acute care hospital in Wuhan: A cross-sectional survey. Military Medical Research 2020;7(1):1-13. https://dx.doi.org/10.1186/s40779-020-00254-8

22. Khader Y, Al Nsour M, Al-Batayneh OB, et al. Dentists’ awareness, perception, and attitude regarding COVID-19 and infection control: A cross-sectional study among Jordanian dentists. JMIR Preprints 2020; 6(2): 1-18. https://dx.doi.org/10.2196/preprints.18798

23. Khan S, Khan M, Maqsood K, et al. Is Pakistan prepared for the COVID-19 epidemic? A questionnaire-based survey. J Med Virol 2020; 92: 824-832. https://dx.doi.org/10.1002/jmv.25814

24. Kumar J, Katto MS, Siddiqui AA, et al. Knowledge, Attitude, and Practices of Healthcare Workers Regarding the Use of Face Mask to Limit the Spread of the New Coronavirus Disease (COVID-19. Cureus 2020; 12(4): 1-8 https://dx.doi.org/10.7759/cureus.7737

25. Lai X, Wang X, Yang Q, et al. Will healthcare workers improve infection prevention and control behaviors as COVID-19 risk emerges and increases, in China?. Biomed Central 2020,9(83): 1-9. https://dx.doi.org/10.1186/s13756-020-00746-1

26. Lima DS, Leite Filho JAD, Gurgel MVSA, et al. Recomendações para cirurgia de emergência durante a pandemia do COVID-19. J. Health Biol. Sci 2020;8(1):1-3. https://dx.doi.org/10.12662/2317-3076jhbs.v8i1.3176.p1-3.2020

27. Moro M, Vigezzi GP, Capraro M. 2019-novel coronavirus survey: Knowledge and attitudes of hospital staff of a large Italian teaching hospital. Acta Biomed 2020; 91(3):29-34. https://dx.doi.org/10.23750/abm.v91i3-S.9419

28. Olum R, Chekwech G, Wekha G, et al. Coronavirus Disease-2019: Knowledge, Attitude, and Practices of Health Care Workers at Makerere University Teaching Hospitals, Uganda. Frontiers in Public Health 2020;8(181):1-9. https://dx.doi.org/10.3389/fpubh.2020.00181

29. Parikh PA, Shah BV, Phatak AG, et al. COVID-19 Pandemic: Knowledge and Perceptions of the Public and Healthcare Professionals. Cureus 2020;12(5):1-13. https://dx.doi.org/10.7759/cureus.8144

30. Prescott K, Baxter E, Lynch C, et al. COVID-19: how prepared are front-line healthcare workers in England?. J Hosp Infect 2020; 105(2): 142-145. https://dx.doi.org/10.1016/j.jhin.2020.04.031 0195-6701

31. Ramaci T, Barattucci M, Ledda C, et al. Social stigma during COVID-19 and its impact on HCWs outcomes. Sustainability 2020; 12(9):1-13. https://dx.doi.org/10.3390/su12093834

32. Ros M, Neuwirth LS. Increasing global awareness of timely COVID-19 healthcare guidelines through FPV training tutorials: Portable public health crises teaching method. Nurse Education Today 2020;91(104479):1-6. https://dx.doi.org/10.1016/j.nedt.2020.104479

33. Saqlain M, Munir MM, Rehman SU, et al. Knowledge, attitude, practice and perceived barriers among healthcare workers regarding COVID-19: a cross-sectional survey from Pakistan. J Hosp Infect 2020; 105(3): 419-423. https://dx.doi.org/10.1016/j.jhin.2020.05.007

34. Schinköthe T, Gabri MR, Mitterer M, et al. A Web- and App-Based Connected Care Solution for COVID-19 In- and Outpatient Care: Qualitative Study and Application Development. JMIR Public Health and Surveillance 2020; 6(2): e19033. https://dx.doi.org/10.2196/19033

35. Shacham M, Hamama-Raz Y, Kolerman R, et al. COVID-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in Israel. Int. J. Environ. Res. Public Health 2020; 17(8): 1-7. https://dx.doi.org/10.3390/ijerph17082900

36. Singh H, Sharma S. Concerns of Frontline Doctors in India during COVID-19: A Cross-Sectional Survey. Indian Journal of Public Health 2020; 64(Suppl 2): 237-239. https://dx.doi.org/10.4103/ijph.IJPH_472_20

37. Sun D, Yang D, Li Y, et al. Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China. Epidemiology and Infection 2020; 148(e96):1-6. https://dx.doi.org/10.1017/S0950268820001090

38. Taghrir MH, Borazjani R, Shiraly R. COVID-19 and iranian medical students; A survey on their related-knowledge, preventive behaviors and risk perception. Archives of Iranian Medicine 2020;23(4):249-254. https://dx.doi.org/10.34172/aim.2020.06

39. Wahbeh A, Nasralah T, Al-Ramahi M, El-Gayar O. Mining Physicians' Opinions on Social Media to Obtain Insights Into COVID-19: Mixed Methods Analysis. JMIR Public Health Surveill 2020;6(2):e19276. https://dx.doi.org/10.2196/19276

40. Zhang M, Zhou M, Tang F, et al. Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. J Hosp Infect 2020; 105(2): 183-187. https://dx.doi.org/10.1016/j.jhin.2020.04.012