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A Survey on the Mental Health Status of Social Workers Under Long-term Stress of COVID-19 and the Exploration of Associated Factors: A Case Study of Chaoyang District, Beijing
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摘要:目的
了解COVID-19疫情防控常态化期间, 社工焦虑、抑郁、睡眠障碍发生情况并分析其影响因素。
方法采用分层整群抽样法, 于2021年11月—2022年3月期间选取北京市朝阳区酒仙桥、望京、太阳宫、十八里店、孙河5个街道的全部社工为研究对象(社工组), 并以该5个街道对应社区医院且具有相同年龄范围的在职一线医护人员(医护组)、社区居民(居民组)为对照人群。社工组、医护组、居民组比例为1∶1∶1。采用问卷星平台, 向社工、医护人员、社区居民微信群发放电子问卷展开调查。比较3组焦虑、抑郁、睡眠障碍筛查阳性率, 并采用多因素Logistic回归和决策树分析社工焦虑、抑郁、睡眠障碍的影响因素。
结果共回收问卷954份, 其中62份不合格予以剔除, 最终纳入892份(93.5%)有效问卷进行数据分析。其中社工组372份(41.7%), 医护组262份(29.4%), 居民组258份(28.9%)。社工组焦虑、抑郁、睡眠障碍筛查阳性率分别为15.3%、22.0%、48.1%, 较医护组(7.6%、10.3%、30.5%)和居民组(7.0%、8.5%、29.5%)明显升高(P均＜0.001)。多因素Logistic回归显示, 家庭负担(OR=1.80, 95% CI: 1.09~2.96)、中文版压力知觉量表(Chinese perceived stress scale, CPSS)评分(OR=1.34, 95% CI: 1.24~1.45)是社工焦虑的独立影响因素, CPSS评分(OR=1.29, 95% CI: 1.20~1.39)、社会支持评定量表(social support rating scale, SSRS)评分(OR=0.96, 95% CI: 0.92~1.00)是社工抑郁的独立影响因素, 有精神疾病家族史(OR=4.91, 95% CI: 1.27~18.94)、CPSS评分(OR=1.20, 95% CI: 1.14~1.27)、SSRS评分(OR=0.95, 95% CI: 0.91~0.98)是社工睡眠障碍的独立影响因素。决策树分析结果与多因素Logistic回归分析结果基本一致, 家庭负担、CPSS评分、SSRS评分是影响社工心理健康的重要变量, 其中CPSS评分与社工焦虑、抑郁、睡眠障碍均呈强关联。
结论在COVID-19疫情防控常态化时期, 相较于医护人员和社区居民, 社工表现出更高水平的心理健康问题。压力知觉、社会支持为社工心理健康的重要影响因素, 尤其以压力知觉的影响为著。
Abstract:ObjectiveTo study the prevalence of depression, anxiety, and insomnia among social workers during the prolonged battle against the COVID-19 pandemic and explore the associated risk factors.
MethodsUsing a stratified cluster sampling method, we selected all social workers in the five streets of Chaoyang District, Beijing(Jiuxianqiao, Wangjing, Taiyanggong, Shibalidian, Sunhe) from November 2021 to March 2022 as the study population(social worker group), and the frontline medical staffs(medical professional group) of the same age range of the corresponding community hospitals of the same five streets, and the community residents(resident group) as the control population. The ratio of the social worker group, medical professional group, and resident group was 1∶1∶1. The Sojump platform was used to send electronic questionnaires to the wechat groups of social workers, healthcare workers, and community residents to carry out the survey. The screen positive rates for anxiety, depression, and sleep disorders were compared among the 3 groups. Multifactorial Logistic regression and decision tree were used to analyze the influencing factors of anxiety, depression, and sleep disorders among social workers.
ResultsA total of 954 questionnaires were collected, of which 62 were disqualified and excluded. Finally, 892 valid questionnaires(93.5%) were included for data analysis. Among them, there were 372 questionnaires(41.7%) from the social worker group, 262(29.4%) from the medical professional group, and 258(28.9%) from the resident group. The prevalences of anxiety, depression, and sleep disorders among social workers group were found to be 15.3%, 22.0%, and 48.1%, respectively, which were significantly higher than those in the medical professional group(7.6%, 10.3%, and 30.5%) and the resident group(7.0%, 8.5%, and 29.5%), all P < 0.001. Multiple Logistic regression showed that family burden(OR=1.80, 95% CI: 1.09-2.96) and Chinese perceived stress scale(CPSS) score(OR=1.34, 95% CI: 1.24-1.45) were independent influencing factors for anxiety among social workers; CPSS score(OR=1.29, 95% CI: 1.20-1.39) and social support rating scale(SSRS) score(OR=0.96, 95% CI: 0.92-1.00) were independent influencing factors for depression among social workers; family history of mental illness(OR=4.91, 95% CI: 1.27-18.94), CPSS score(OR=1.20, 95% CI: 1.14-1.27), and SSRS score(OR=0.95, 95% CI: 0.91-0.98) were independent influencing factors for sleep disorders among social workers. The results of decision tree analysis were consistent with those of multiple Logistic regression analysis. Family burden, CPSS score, and SSRS score were important variables affecting the mental health of social workers, among which CPSS score was strongly associated with anxiety, depression, and sleep disorders among social workers.
ConclusionsSocial workers exhibited significant levels of anxiety, depression, and sleep disorders during the long-term pandemic prevention, with CPSS being the most significant influencing factor.
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Keywords:
- COVID-19 /
- social-workers /
- anxiety /
- depression /
- sleep disorders
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种植义齿因具有美观、舒适、损伤小、咀嚼效率高等优点被广大口腔科医师和患者接受。目前全世界应用的种植系统达一百多种, 其中瑞士的ITI纯钛螺纹种植体和北京莱顿生物材料公司生产的BLB钛合金柱状种植体应用较广泛。以往的研究证实, 这两种种植系统都能取得良好的修复效果[1-2]。但是人体内植入金属材料常常在磁共振成像(magnetic resonance imaging, MRI)检查中形成伪影, 影响临床诊断[3]。本研究对ITI和BLB种植体及其上部烤瓷冠修复体在3.0T MRI检查中的伪影进行比较。
材料和方法
材料
选取体积大致相等的ITI纯钛螺纹种植体和BLB钛合金柱状种植体各1枚, ITI种植体直径为4.1 mm, 长度为12 mm, 材料为经机械加工的四级纯钛(4级ISO5832/1), 结构采用螺纹柱状设计, 喷砂酸蚀处理表面; BLB种植体直径为4 mm, 长度为11 mm, 材料为钛合金TC4, 含铁(Fe)≤0.30、碳(C)≤0.10、氮(N)≤0.05、氢(H)≤0.015、氧(O)≤0.20、铝(Al)5.5~6.8、钒(V)3.5~4.5, 柱状非螺纹设计, 表面为羟基磷灰石涂层。制作体积相同的金铂合金(含金86%)烤瓷冠和镍铬合金烤瓷冠各1个, 并使之可分别就位于ITI种植体和BLB种植体上。
对象和方法
选取健康志愿者1名作为受试者, 女性, 年龄32岁, 经检查其口腔卫生良好, 无龋齿, 无缺牙, 未见金属和树脂等充填体。受试者签署书面知情同意后, 先将ITI种植体和BLB种植体固定于其下颌骨双侧第一磨牙对应的皮肤上行颅脑MRI检查; 再将金铂合金烤瓷冠和镍铬合金烤瓷冠分别黏固于ITI种植体和BLB种植体上, 进行MRI检查。采用3.0T磁共振机(西门子, verio), 以标准头线圈进行头部扫描, 扫描条件:TSE/EPI序列, 重复时间:6600 ms, 回波时间:100 ms, 视野240 mm×240 mm, 层厚:4 mm, 层间距:0.15 mm, 重建矩阵:180×180。
结果
志愿者在两次MRI扫描过程中, 均无明显发热、局部受力等不适感觉。第1次MRI扫描结果显示, 被检ITI种植体和BLB种植体结构不能分辨, 而由大致呈三角形的异常信号代替, 说明有明显伪影产生, 而ITI种植体比BLB种植体产生的伪影小, 面积分别为2.7和4.0 cm2(图 1)。将金铂合金烤瓷冠和镍铬合金烤瓷冠分别黏固在ITI种植体和BLB种植体上行第2次MRI扫描, 结果显示行冠黏固后, 志愿者下颌骨两侧的伪影面积都明显增大, 但是ITI种植体和金铂合金烤瓷冠修复体产生的伪影仍然比BLB种植体和镍铬合金烤瓷冠修复体产生的伪影小, 面积分别为4.9和7.3 cm2(图 2)。
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图 2 金铂合金烤瓷冠和镍铬合金烤瓷冠分别就位于ITI种植体和BLB种植体后在轴位TSE/EPI序列磁共振中的成像和伪影箭头a示ITI种植体和金铂合金烤瓷冠修复体产生的伪影; 箭头b示BLB种植体和镍铬合金烤瓷冠修复体产生的伪影讨论
在头面部MRI检查中, 3.0T超高场强磁共振机比以往的1.5T磁共振仪信号更强, 图像质量更高, 优势十分明显, 在临床上运用范围日益增大[4], 但其超高场强也会加剧金属植入物产生的伪影对图像质量的影响[5]。因此患者常被放射科医师告知要求拆除口腔金属修复体, 口腔种植体和上部冠修复体的拆除会给患者造成较大的生理和心理创伤及经济损失。因此, 研究如何减少口腔种植体及上部冠修复体在MRI中形成的伪影影响可有效解决种植修复与MRI检查的矛盾。目前常用的种植体系统根据材料不同可分为:钛及钛合金、316-L不锈钢、铸造钴铬钼合金、生物陶瓷、有机高分子材料等。钛及其合金因质轻、弹性模量低, 对震动的减幅力大, 硬度、极限抗张强度大、屈服强度和疲劳强度大, 成为最有前景的口腔种植材料之一[6], 以纯钛ITI种植系统和钛合金BLB种植体系统为代表。本研究对这两种种植系统在MRI检查中产生的伪影影响展开探讨。
从结果中可以看出, 尽管ITI种植体的体积比BLB种植体略大, 但是前者产生的伪影面积仍比后者小。这种差异的产生可能与两种种植系统的材料类型相关。已有研究证实, MRI中伪影的产生与金属修复体的材料密切相关, 依金属材料的磁化率由小到大可分为抗磁性、顺磁性和铁磁性三类, 金属磁化率越高, 产生的伪影越大。BLB种植体的主要成分为TC4, 含铁(Fe)≤0.30, 铁为铁磁性材料, 即使在种植体中含量较小, 但进入磁场后可使磁力线高度集中在铁磁性金属上, 严重破坏磁场的均匀性, 在图像中产生明显的伪影。而ITI种植体材料为纯钛, 纯钛磁化率较小, 对MRI检查的影响也较小[7]。
种植体植入后, 需靠上部结构恢复缺失牙的形态, 以行使功能和恢复美观。本研究以镍铬合金烤瓷冠和金铂合金烤瓷冠作为研究对象, 分别就位于BLB种植体和ITI种植体上, 模拟完整的种植修复方式。结果显示, BLB种植体和ITI种植体戴冠后, 二者产生的伪影面积都比戴冠前大, 并且前者产生的伪影面积比后者大。这是由于戴冠后, 两组修复体的体积都增大, 使静磁场不均匀的区域增加, 参与失相位的质子数也会增加, 二者共同导致伪影面积增大, 与以往研究中金属的体积与伪影面积大小呈正相关关系的结论相一致[8]。另外, 冠修复体材料的成分也是产生伪影的重要影响因素。镍铬合金烤瓷冠内含镍56.0%、铬26.0%、钼10.0%、铌1.0%、铁2.5%、钽1.5%(重量百分比)。镍和铁都是铁磁性金属, 且含量较高, 明显影响MRI成像的准确性。而金铂合金烤瓷冠中, 主要成分含金86%、铂11%、锰1%, 磁化率均较低, 对MRI成像的影响较小[9]。
综上, ITI种植系统和BLB种植系统, 以及上部冠修复体镍铬合金烤瓷冠和金铂合金烤瓷冠都对MRI有不同程度的影响, 采用纯钛种植体和贵金属烤瓷冠修复, 在MRI中产生的伪影较小。这一结论对种植修复治疗有重要指导意义, 鉴于患者今后行颅脑MRI检查的可能性, 口腔科种植医师在行修复时应该综合考虑以下两个因素:第一, 在修复体材料选择方面, 纯钛在减小伪影对磁共振图像影响方面表现出突出优势, 是种植体的最佳材料。而对于上部修复体, 全瓷冠因不含任何金属元素, 理论上对MRI检查影响最小[10]; 其次为贵金属烤瓷冠, 其内冠所含的金属大部分为非铁磁性材料, 对MRI影响较小[11]; 镍铬合金烤瓷冠无论是修复效果还是对MRI的影响都不尽如人意, 不宜用于口腔种植修复[12-13]。第二, 在固位方式的选择方面, 种植体与基台的连接方式主要有螺丝固位和黏接固位两种, 采用螺丝固位方式的修复体拆除其上部结构相对容易, 并且可在行MRI检查后, 再次将上部修复体重新就位并固定, 因此是较理想的固位方式。总之, 口腔科医师应综合考虑上述因素, 合理选择材料和进行结构设计, 尽量减小口腔种植体和修复体对MRI影像的影响, 避免因拆除修复体给患者带来的损伤和经济损失。
作者贡献：张函负责研究设计、论文撰写；马万欣、刘宏新、孟凡锐、张丹萍、刘春宇负责多中心数据收集；高媛主要承担数据分析；邢颖、刘璐负责指导论文修订。利益冲突：所有作者均声明不存在利益冲突 -
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图 1 社工精神心理状态的决策树模型
A.焦虑；B.抑郁；C.睡眠障碍
Figure 1. Decision tree model for the mental health status of social workers
A.anxiety; B.depression; C.sleep disorders
表 1 3组人口学信息与心理健康水平比较
Table 1 Demographic information and mental health comparisons between 3 groups
指标 社工组(n=372) 医护组(n=262) 居民组(n=258) P值 性别[n(%)] ＜0.001 男 102(27.4)* 52(19.8)* 102(39.5) 女 270(72.6) 210(80.2) 156(60.5) 年龄[M(P25, P75)，岁] 38.5(33, 43)* 37.5(31, 44.3)* 39(33, 46) 0.032 焦虑[n(%)] 57(15.3)#* 20(7.6) 18(7.0) ＜0.001 抑郁[n(%)] 82(22.0)#* 27(10.3) 22(8.5) ＜0.001 睡眠障碍[n(%)] 179(48.1)#* 80(30.5) 76(29.5) ＜0.001 与医护组比较，# P＜0.05；与居民组比较，* P＜0.05 
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表 2 社工组有/无焦虑、抑郁、睡眠障碍人群临床资料比较
Table 2 Clinical data comparisons on among social worker groups with and without anxiety, depression and sleep disorders
指标 焦虑(n=57) 无焦虑(n=315) P值 抑郁(n=82) 无抑郁(n=290) P值 睡眠障碍(n=179) 无睡眠障碍(n=193) P值 性别[n(%)] 0.158 0.481 0.362 男 20(35.1) 82(26.0) 25(30.5) 77(26.0) 53(29.6) 49(25.4) 女 37(64.9) 233(74.0) 57(69.5) 213(73.4) 126(70.4) 144(74.6) 年龄[M(P25, P75)，岁] 38(34，43) 39(33，44) 0.746 37(32.8, 42.5) 39(34，44) 0.037 38(33，43) 39(34，43.5) 0.633 独居[n(%)] 2(3.5) 10(3.2) 0.895 3(3.7) 9(3.1) 0.802 7(3.9) 5(2.6) 0.472 文化程度[n(%)] 0.175 0.231 0.897 高中及以下 1(1.8) 22(7.0) 2(2.4) 21(7.2) 10(5.6) 13(6.7) 大专及本科 56(98.2) 287(91.1) 78(95.1) 265(91.4) 166(92.7) 177(91.7) 研究生及以上 0(0) 6(1.9) 2(2.4) 4(1.4) 3(1.7) 3(1.6) 工作年限[n(%)] 0.656 0.831 0.291 ＜5年 24(42.1) 136(43.2) 37(45.1) 123(42.4) 72(40.2) 88(45.6) 5~10年 23(40.4) 110(34.9) 27(32.9) 106(36.6) 63(35.2) 70(36.3) ＞10年 10(17.5) 69(21.9) 18(22.0) 61(21.0) 44(24.6) 35(18.1) CPSS评分[M(P25, P75)，分] 33(29，37) 25(20，28) ＜0.001 32(29，37) 24(20，28) ＜0.001 29(27，32) 22(17.5，26) ＜0.001 CD-RISC评分[M(P25, P75)，分] 43(36，55) 62(50，74) ＜0.001 47(37，56) 64(50，75) ＜0.001 50(42，62) 67(56，81) ＜0.001 SSRS评分[M(P25, P75)，分] 34(30，40) 42(36，47) ＜0.001 34(29，40) 42(37，47) ＜0.001 37(31，42) 45(39，49) ＜0.001 工作负担[n(%)] 0.014 0.017 ＜0.001 轻度 0(0) 10(3.2) 1(1.2) 9(3.1) 3(1.7) 7(3.6) 中度 19(33.3) 158(50.2) 29(35.4) 148(51.0) 67(37.4) 110(57.0) 重度 38(66.7) 147(46.7) 52(63.4) 133(45.9) 109(60.9) 76(39.4) 经济负担[n(%)] ＜0.001 ＜0.001 ＜0.001 轻度 2(3.5) 84(26.7) 7(8.5) 79(27.2) 21(11.7) 65(33.7) 中度 20(35.1) 142(45.1) 28(34.1) 134(46.2) 79(44.1) 83(43.0) 重度 35(61.4) 89(28.3) 47(57.3) 77(26.6) 79(44.1) 45(23.3) 家庭负担[n(%)] ＜0.001 0.001 0.001 轻度 13(22.8) 163(51.7) 26(31.7) 150(51.7) 67(37.4) 109(56.5) 中度 30(52.6) 118(37.5) 38(46.3) 110(37.9) 81(45.3) 67(34.7) 重度 14(24.6) 34(10.8) 18(22.0) 30(10.3) 31(17.3) 17(8.8) 共患慢性疾病[n(%)] 30(52.6) 104(33.0) 0.005 42(51.2) 92(31.7) 0.001 82(45.8) 52(26.9) ＜0.001 有精神疾病家族史[n(%)] 11(19.3) 16(5.1) ＜0.001 14(17.1) 13(4.5) ＜0.001 23(12.8) 4(2.1) ＜0.001 CPSS(Chinese perceived stress scale)：中文版压力知觉量表；CD-RISC(Connor-Davidson resilience scale)：心理弹性量表；SSRS(social support rating scale)：社会支持评定量表
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表 3 社工焦虑、抑郁、睡眠障碍影响因素的多因素Logistic回归分析结果
Table 3 Influencing factors in multifactor Logistic regression analysis on anxiety, depression, and sleep disorders among social workers
指标 β SE Wald χ2 OR(95% CI) P值 焦虑 常量 -11.31 1.38 67.28 - ＜0.001 家庭负担 0.59 0.26 5.30 1.80(1.09~2.96) 0.021 CPSS评分 0.29 0.04 50.24 1.34(1.24~1.45) ＜0.001 抑郁 常量 -7.87 1.53 26.37 - ＜0.001 CPSS评分 0.26 0.04 44.47 1.29(1.20~1.39) ＜0.001 SSRS评分 -0.04 0.02 4.81 0.96(0.92~1.00) 0.028 睡眠障碍 常量 -4.44 1.26 12.51 - ＜0.001 有精神疾病家族史 1.59 0.69 5.34 4.91(1.27~18.94) 0.021 CPSS评分 0.18 0.03 41.50 1.20(1.14~1.27) ＜0.001 SSRS评分 -0.06 0.02 10.31 0.95(0.91~0.98) 0.001 -：不适用；CPSS、SSRS：同表 2
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