Structure of the perception of health professionals regarding the quality of health services in the context of COVID‐19

Abstract Background The health emergency caused by COVID‐19 revealed the shortcomings of health services (HS), but little is known about how this has impacted the mental health of health professionals (HP) when perceiving these difficulties. Methods Data were collected through an online survey administered to HP in Lima (Peru) between May and July 2020. A questionnaire was applied to identify perceived quality of health services (PHQS). A network analysis was performed, and the centrality measures of the variables were calculated and plotted. Results A total of 507 HP completed the survey. In the network analysis of PHQS, four clusters were identified: (A) “empathy” and “recognition of competencies,” (B) “logistical support,” “protection,” “personal early diagnosis,” and “early family diagnosis”; C) “professional competence with regard to their treatment and treatment for their family,” “equipment for their treatment and treatment for their family,” “professional competence with regard to their treatment and treatment for their family,” and “institutional support for them and their family”; and D) “fear of being infected or infecting their family,” “fear of dying or death of a family member,” “knowledge stability,” “job burnout,” and “role change.” The variables of PHQS with the greatest centrality were “equipment for their treatment,” “equipment for the treatment of their family,” and “early family diagnosis.” Conclusions The structure of the PHQS of HP describes direct and indirect influences of different variables in the context of COVID‐19.

Epidemiología, Prevención y Control de Enfermedades, s. f.). Peru adopted the health recommendations against the pandemic issued by the World Health Organization (WHO) early; therefore, the high numbers of infections and deaths reported imply a lack of efficacy of these strategies (Díaz Cassou et al., 2020); the general population had difficulty complying with the measures because of the precariousness, inequity, and fragmentation of HS, an economy whose informal sector supports 70% of the national economy (PERUCÁMARAS: Cámara Nacional de Comercio, Producción, Turismo y Servicios, 2020), families living in overcrowded conditions (11.7%), and households without hygienic services (29.2% for metropolitan Lima alone) (Instituto Nacional de Estadística e Informática, 2020).
For HP, the extraordinary conditions in which they worked during the pandemic were confounding factors, for example, increased workloads, shortages of drugs or specific vaccines, a lack of personal protective equipment, and the feeling of not receiving enough support from health authorities (Cuba, 2021). This context, added to the impact on quality of life, explains why the mental health of the HP who faced COVID-19 on the front line (Pearman et al., 2020;Shanafelt et al., 2020;Vizheh et al., 2020) was affected, leading to a deterioration in their clinical understanding capacities and/or decision-making skills (Siddiqui et al., 2021). Consequently, the COVID-19 pandemic must be considered a powerful and persistent stressor, whose effects on the mental health of HP stem from (Ambrosetti et al., 2021;Amerio et al., 2021;Nobari et al., 2021) among other factors, the discomfort experienced as a result of precarious working conditions and feelings of being abandoned by health authorities who did not comply with the duty to protect them (Charney et al., 2020;Crocker et al., 2023;Editorial eClinicalMedicine, 2020;Fernández-Arana et al., 2022;Lin et al., 2020;Olórtegui-Yzú et al., 2023;Organización Panamericana de la Salud, 2022;Young et al., 2021).
This study is part of a project aimed to evaluate various aspects of the mental health of HP during the pandemic, developed in the city of Lima, Peru; some of the findings of the project have been recently published. In the first study, the relationship between mental health problems (anxiety, depression, and perceived stress) and the care of patients with COVID-19 and early adverse events (ACEs) in HP was evaluated (Fernández-Arana et al., 2022). A total of 542 health professionals completed the survey. Caring for patients with COVID-19 was significantly associated with depression and anxiety. Moreover, when caring for patients with COVID-19 was combined with a history of early sexual abuse, its effect on the risk of anxiety increased (OR = 7.71, p = .010). Mental health problems were associated with female gender in almost all the analyses and with most ACEs. In a second study carried out with the same HP population, the relationship between mental health problems (anxiety, depression, and PS) and their perceptions about the quality of health services (PQHS) in the context of the COVID-19 pandemic was established . The most relevant unfavorable PQHS associated with anxiety were "HP competence with regard to their treatment", as well as "institutional support for themselves and their families" in the event of becoming infected; the most relevant unfavorable PHQS associated with depression were "equipment for their treatment and their fami-lies" if infected, "institutional support for themselves and their families" if infected, "fear of HP and/or family menbers being infected or dying", and "HP' recognition of their competencies" (p < .001); and most relevant unfavorable PHQS associated with PS were "institutional support for themselves and their families" if infected and "inestability of knowldge".
The objective of this study was to establish, through a network analysis, the structure of the relationships between the PHQS by HP in the context of the COVID-19 pandemic.   Table 1). This questionnaire was developed by the authors based on other studies on this topic (Charney et al., 2020;Crocker et al., 2023;Editorial eClinicalMedicine, 2020;Lin et al., 2020).

Data analysis
The network analysis was performed in RStudio® using the packages IsingFit, qgraph, and igraph. The network was estimated with the IsingFit function. Measures of centrality of the variables (strength and influence) were calculated and plotted using the centralityTable and TA B L E 1 Grouping and assignment of variables of perceived quality of health services (PHQS) of health professionals (HP) in the context of the pandemic.

PHQS Direct variable Abbrev Questions
Recognition of the concerns and competencies of HP

Ethical aspects
The study procedures were carried out in accordance with the eth-

General
The survey was answered by 507 HP, whose average age was 49.5 years (minimum 23 years and maximum 87 years). A total of 62.7% were women, with a mean age of 47.7 years; for men, the average age was 52.5 years (p < 0.05) (Fernández-Arana et al., 2022).
Doctors and nurses accounted for 56.8% and 15.0%, respectively, of the respondents, followed by obstetric professionals (11.6%). These three groups accounted for 88.4% of the total respondents. Married professionals or those cohabiting accounted for 59.5% of the respondents. A total of 38.3% of those surveyed worked directly with patients with COVID-19 (Fernández-Arana et al., 2022).
Regarding the PHQS of HP not infected with COVID-19, the two items most frequently reported were "fear of infecting their family" and "fear of being infected" (92.5% and 89.0%, respectively). These items were followed in frequency by "knowledge instability" and "fear of a family member dying" (80.5% and 72.0%, respectively). Notably, 69.0% reported "job burnout" (Olórtegui-Yzú et al., 2023).

Network analysis
The associations between the variables corresponding to PHQS and from which the network analysis was performed are shown in Table 2.
In the network analysis of the PHQS, four clusters were identified, Sp, empathy; Se, recognition of competencies; Ep, protection; D, early diagnosis; Df, early family diagnosis; Ea, logistical support; P, professional competence with regard to their treatment; Et, equipment for their treatment; Pf, professional competence with regard to treatment for their family; Etf, equipment for the treatment of their family; Cf, fear of infecting their family; C, fear of getting infected; M, fear of dying; Mf, fear of a family member dying; I, knowledge stability; Te, job burnout; Ta, concern for the family; A, institutional support for themselves and their family; Tn, role change.

F I G U R E 2
Measures of centrality (influence) for each perceived quality of health services (PHS) of HCPs. Sp, empathy; Se, recognition of competences; Ep, protection; D, early diagnosis; Df, early family diagnosis; Ea, logistical support; P, professional competence with regard to their treatment; Et, equipment for their treatment; Pf, professional competence with regard to treatment for their family; Etf, equipment for the treatment of their family; Cf, fear of infecting the family; C, fear of getting infected; M, fear of dying; Mf, fear of family member dying; I, knowledge stability; Te, job burnout; Ta, concern for the family; A, institutional support for themselves and their family; Tn, role change.
to avoid infecting their families. In line with our findings, a study in Bangladesh showed the difficulties HP encountered performing their duties while wearing inadequate personal protective equipment (PPE) in hospitals. In addition, they had to meet their family responsibilities despite the risk of infection (Mehedi & Ismail Hossain, 2022).
Another study carried out in the United Kingdom (Nyashanu et al., 2020) highlights how the shortage of PPE prevented HP from being able to fully comply with their hospital duties and deteriorated relationships with colleagues. In addition, these perceptions represented by Cluster B are strongly linked to the confidence that HSs will provide early diagnosis services for both HP and their families (strongly In Peru, as in other countries, hospitals had to convert operating rooms and general rooms into intensive care units (ICUs) and use anesthetic ventilators, portable ventilators, and older ventilators from laboratories or teaching simulation areas. However, in many hospitals, these resources were quickly depleted, as was the supply of oxygen (Pons-Òdena et al., 2020). In these circumstances, physicians must decide whether to allocate or reallocate these resources during shortages (Chu et al., 2020). This explains why HP, given this shortage of ventilators and oxygen, perceived that they and their families will not receive adequate care if they are infected. In addition, the constant change in and adaptation of equipment made it difficult to adequately train colleagues on correct use (Chu et al., 2020;Pons-Òdena et al., 2020).
On this basis, it is understandable why the perceptions of HP regarding "equipment for their treatment," "equipment for their family," and "early family diagnosis" are those that in the analysis of centrality have the greatest strength and influence (Figures 2 and 3). A study carried out in Iran described that the concern of HP for their health and the health of their relatives, in particular elderly individuals, was directly related to the need to comply with caring for patients with minimal PPE in hospitals (Eftekhar Ardebili et al., 2021).
Cluster D shows the importance of the perceptions of HP in relation to the fear of infection and subsequent death of themselves and/or their relatives and their work performance. The influence of "concern for the family" is highlighted as a relevant factor that affects concentration at work and has a close relationship with job burnout and concern about providing services outside of their role to meet HS needs. These factors were coupled with an instability of information that constantly changes and a lack of real knowledge about the behavior of COVID-19.
These findings coincide with the results of a study in Turkey (Alsulimani et al., 2021) that reported that 46% of the HP studied had job burnout closely related to the perception of being pressured to work in patient care services due to COVID-19. Another study in Bangladesh (Hossain et al., 2021) (Chang et al., 2020) observed that the fear of infection in HP traumatized them, preventing them from carrying out their work in a solvent manner.

F I G U R E 3 FIGURE 3
Measures of centrality (strength) for each perceived quality of health services (PHS) of HCPs. Sp, empathy; Se, recognition of competencies; Ep, protection; D, early diagnosis; Df, early family diagnosis; Ea, logistical support; P, professional competence with regard to their treatment; Et, equipment for their treatment; Pf, professional competence with regard to treatment for their family; Etf, equipment for the treatment of their family; Cf, fear of infecting the family; C, fear of getting infected; M, fear of dying; Mf, fear of family member dying; I, knowledge stability; Te, job burnout; Ta, concern for the family; A, institutional support for themselves and their family; Tn, role change.
This study has several limitations. First, it was a cross-sectional study based on an online questionnaire distributed to HP. Generalization of the conclusions is not possible because we did not have a means of approximating the entire population of HP. A longitudinal design is needed to provide definitive evidence of the resilience of health workers against mental health problems related to COVID-19.
Second, the participants were heterogeneous and direct conclusions could not be applied to any professional group, whether they were doctors, nurses, midwives, or others. Third, the participants were from Lima and the surrounding region; therefore, our findings cannot be generalized to the less affected regions of Peru or to professionals from other countries due to cultural differences and differences in health systems. Fourth, this study was based on a self-administered questionnaire, and it was not possible to verify mental health problems through structured interviews. Fifth, this study did not differentiate between preexisting mental health symptoms and new symptoms related to COVID-19 care.

CONCLUSIONS
The results of this study, beyond the understandable effects on the mental health of HP in the context of a health emergency such as the COVID-19 pandemic, highlight the importance of PHQS related to the precariousness of HSs, both in budgetary as well as administrative, technological, and assistance aspects, which could affect the adaptability and resilience of workers to these contingencies.
The network analysis shows us how the PHQS of the HP are grouped, related, and hierarchical, allowing us to identify the qualitative impact of each subgroup on their adaptability and efficiency in their job performance, in the context of the COVID-19 pandemic.
Therefore, it is necessary for HP to be able to express their con-

CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
Data available on request from the authors.

PEER REVIEW
The peer review history for this article is available at https://publons. com/publon/10.1002/brb3.3140