Increased outbreaks of infectious diseases in recent years, including Severe Acute Respiratory Syndrome (SARS) in 2003, Novel Influenza A/H1N1 in 2009, and Middle East Respiratory Syndrome (MERS) in 2012, have raised concerns about the potential of a global pandemic. The emergence of Corona Virus Disease-2019 (COVID-19) brought this potential to realization (Fernandez et al., 2020) and caused a tremendous public health crisis (Que et al., 2020; Sperling, 2021).

Healthcare workers (HCWs) are on the front lines of the fight against the crisis of such infectious outbreaks (Abolfotouh et al., 2017). They often risk contracting pathogens (Temsah et al., 2020). Therefore, during the past and current infectious outbreaks, frontline HCWs became infected, and many have lost their lives (Chakravorty et al., 2020; Jalili et al., 2021). COVID-19 infections and deaths among HCWs follow that of the general population worldwide, and over 150,000 infections and 1,400 deaths were reported until 2020 (Bandyopadhyay et al., 2020). According to a recent Iranian study, COVID-19 has killed about 10,000 HCWs (Jalili et al., 2021).

Participating in frontline work and receiving such negative information appears to be significant risk factors for psychological distress and problems (Goulia et al., 2010). High levels of concern have been reported in many studies (Alsubaie et al., 2019) in both frontline and non-frontline HCWs (Sahashi et al., 2021). It has significantly impacted them professionally and personally (Moseley et al., 2020). Understanding HCWs’ concerns and how to support them is crucial, not only from a moral perspective but also to ensure that health services remain on track (Borek et al., 2022). The HCWs’ concerns mean facing challenges, fears, and anxieties (Heidarijamebozorgi et al., 2021).

Many frontline HCWs’ are concerned about well-reported deaths, according to media reports in the United Kingdom (Chakravorty et al., 2020). They are frequently concerned about their health and the health of their families, concerned about how they function, and fear being stigmatized (Goulia et al., 2010). A survey of over 10,000 HCWs during the SARS outbreak (2003) reported that many respondents experienced social stigmatization. Nearly half (49%) and 31%, respectively, believed that “people avoid me because of my employment” and “people avoid my family members because of my job.” For instance, some parents of school-aged children prohibited their kids from playing with or being close to HCWs’ kids. A significant portion of HCWs (69%) also thought that “those close to me are concerned they might contract the virus from me” (Koh et al., 2005).

These are only part of the concerns of HCWs during pandemics. Various studies reported that during the outbreak of pandemics, widespread concerns are created among health workers, which becomes a big challenge for health systems in crisis periods (Abolfotouh et al., 2017; Khademipour et al., 2017; Berkhout et al., 2021).

The novelty of the diseases, the lack of prior experience, and the potential that HCWs were not fully informed about the management difficulties by the pertinent authorities during their teaching campaign all could be attributed to a high level of concern (Alsubaie et al., 2019).

Higher job stress, social isolation, and health fears have all been related to HCWs’ concerns and psychological distress around the outbreaks (Goulia et al., 2010; Sheikhbardsiri et al., 2022). Unrecognizing emotions and concerns may prevent patient-centered care, neglect patients’ psychological issues, avoid bonding with patients, and inhibit the quality of care. It also could affect the HCWs’ sense of well-being and may lead to distress, disengagement, job conflict, and burnout (Barello et al., 2020). In an extended crisis such as the pandemic, the sustainability of the healthcare response entirely depends on its capability to protect the health of responders and the HCWs (Muller et al., 2020). However, even when supplied for free or at a low cost, the support uptake by HCWs has remained limited (Berkhout et al., 2021). For an appropriate epidemic response, it is vital to understand the concerns, behaviors, and knowledge of HCWs. The concerns may affect HCWs’ overall effectiveness and must be addressed by including organization policies in outbreak planning (Alsubaie et al., 2019).

Limited studies focus on HCW’S perception of concerns and worries in the past (Wong et al., 2008; Goulia et al., 2010; Abolfotouh et al., 2017) and current pandemics (Koh et al., 2005; Chaudhary et al., 2020; Kinariwala et al., 2020; Sperling, 2021) among different groups of HCWs. In these studies, questionnaires have been used as a data collection tool. However, there is some ambiguity regarding their creditability.

In Singapore, a study evaluated how HCWs perceived the risk and its effects on their work and personal life. A three-part questionnaire has applied, including individual characteristics, 88 questions about the perceived risk of infection, the perceived impact of the SARS pandemic on personal and professional life, and the impact of events scale (Koh et al., 2005). After 3 years of an avian influenza pandemic, Wong et al. (2008) from the same country used a modified version of that questionnaire to study concerns, perceived impact, and preparedness in HCWs (Wong et al., 2008). In MERS outbreaks in Saudi Arabia, the level of concern among HCWs was assessed with Wong’s et al. (2008) instrument (Abolfotouh et al., 2017). Based on retrieved studies, research in Greek is the only article on past outbreaks that report Cronbach’s α score. In this study, Goulia et al. (2010) designed the questionnaire based on the information in the literature about the perspectives and opinions of experts on infectious disease outbreaks (Goulia et al., 2010).

With the emergence of COVID-19, HCWs’ concerns and worries have become the focus of some researchers again. A modified version of Goulia et al.’s (2010) instrument without validity assessment has been used to survey worries and concerns among HCWs in COVID-19 in Japan (Sahashi et al., 2021). Researchers have applied a modified version of Wong’s et al. (2008) scale to study concerns, perceived impact, and preparedness of oral HCWs. In this study, Cronbach’s α score has been reported (Chaudhary et al., 2020). An instrument with no psychometric report was applied to study the concerns and fears of Indian dentists regarding professional practice (Kinariwala et al., 2020).

This brief review of applied questionnaires to study concerns of HCW shows no clear, sufficient, and substantial evidence on the rigorous process of designing and psychometric evaluating of used questionnaires. There is no valid and reliable tool to evaluate HCWs’ concerns in an infectious disease outbreak. More objectively, among those already built instruments, no one validated for the Iranian context can evaluate the healthcare workers’ concerns. Thus, we seek to contribute by filling this gap and offering an instrument to healthcare workers’ concerns in infectious outbreaks, given the relevance and urgency of the matter. Hence, this study aimed to develop and psychometrically evaluate a scale to measure HCWs’ concerns in infectious outbreaks.

This study aimed to design and psychometrically evaluate a scale to measure HCWs’ concerns in infectious outbreaks. The initial scale was developed based on data obtained from extensive reviews of existing literature on HCWs’ concerns in infectious outbreaks and a qualitative study. The findings of this study confirmed that the validity and reliability of the final HCWCIOS were as expected. HCWCIOS featured 36 items and six factors: inadequate preparedness, lack of knowledge, risk perception, affected social relations, work pressure, and absenteeism.

The first factor of HCWCIOS was inadequate preparedness. Emergency preparedness involves a broad range of skills, abilities, and knowledge to prepare for and respond to catastrophes, threats, and pandemics. Understanding the readiness and preparation of HCWs to handle emergencies like the COVID-19 pandemic and deliver safe and effective treatment during these times is lacking (Chua et al., 2021). In a qualitative study, Borek et al. (2022) with the issue of HCWs’ concerns in the COVID-19 pandemic, stated that HCWs experienced substantial stress and anxiety due to the pandemic’s inadequate preparation, which was followed by requests for reflection and learning from the experience.

The second factor of this scale was the lack of knowledge. HCWs might need more knowledge regarding pandemics. As a result, individuals could not fully comprehend the risk or danger involved, which could affect their ability to stop the virus’s spread. Related studies conclude that less experienced HCWs are less knowledgeable, have lower levels of self-control and resilience, and experience greater levels of stress than more experienced HCWs who also have greater expertise (Chigwedere et al., 2021; Jamebozorgi et al., 2021). According to Malekshahi Beiranvand and Hatami Varzaneh (2018) the HCWs faced difficulties during COVID-19, including a lack of specialized expertise, inadequate readiness, and access to practical skills for managing and controlling the disease. One of the stressors identified among HCWs during the COVID-19 pandemic was a lack of knowledge and experience (Yusefi et al., 2022).

Risk perception was the third factor on the scale, with six items. Risk perception is essential in making the proper decisions during a pandemic crisis and can be viewed as the driving force behind preventive behaviors (Cori et al., 2020). According to the findings of the research done in the United States, because it was recognized that COVID-19 could result in severe effects other than death, such as serious infections and self-quarantine, the association between risk perception of COVID-19 and death due to COVID-19 has a stronger relationship with protective activities (Bruine De Bruin and Bennett, 2020). However, a cross-sectional study in Asian and European regions found no connection between awareness of the influenza pandemic risk and taking protective behaviors during the outbreak (Sadique et al., 2007). Studies showed that considering a pandemic’s perceived risk and setting standards for assessing performance can be beneficial for preventive planning, and appropriate educational interventions could be implemented (Molavi-Taleghani et al., 2020; Arefi et al., 2022).

Another factor of the designed tool was affected social relations. Several incidents of stigmatization of HCWs have emerged throughout this pandemic worldwide. In Mexico, for example, it was discovered that doctors and nurses utilize bicycles because they were allegedly denied access to public transportation and were the targets of physical assaults (Bagcchi, 2020). Healthcare professionals’ social relations studies demonstrated that HCWs’ families are psychologically impacted due to the pandemic (Lau et al., 2005; Amakiri et al., 2020). HCWs endure social stigmatization despite being praised by the media as heroes and suffer extreme anxiety and concern for their safety and the well-being of their family, friends, and coworkers. Although HCWs are more prone to seek peer psychological assistance, they also gain from being aware of the availability of official psychological support (Duffy et al., 2022). To tackle the COVID-19-related social stigma, the World Health Organization (WHO) emphasizes fostering a culture that encourages honest communication between individuals and HCWs (Bagcchi, 2020).

Work pressure was another factor. Pandemics placed extreme demands on HCWs. When pressure is high, they have had to manage a more significant number of patients with high mortality rates. They have had difficulties providing care while adhering to strict infection control procedures and not always wearing enough personal protective equipment. As a result of their redeployment into new positions, teams, or wards, many have been operating in unfamiliar settings without the established social support of their peers (Billings et al., 2021). Some studies have depicted that the unique demands of world crises and high-stress levels placed HCWs at additional risk for mental health problems (Lai et al., 2020; Greene et al., 2021).

The last but not most minor factor of HCWCIOS was absenteeism. During the SARs outbreak, several reports revealed HCWs in Toronto and Hong Kong either shied away from physical examinations of ill patients or refused to work with them because the risk they posed was too significant. At the height of China’s SARS outbreak, at least one hospital struggled to sustain services due to absenteeism, among which some were driven by concerns about getting sick (Shiao et al., 2007). More than 80% of HCWs in New York City were willing and/or able to report to work during a mass casualty or environmental disaster. However, only 57–68% would be willing to do so during a SARS or smallpox outbreak, according to a recent survey assessing their readiness for duty during a catastrophic disaster (Qureshi et al., 2005). Fears for one’s safety and the responsibilities of the family are frequently the leading causes of potential absenteeism during a pandemic, and the absenteeism rate doubles when a family member is infected (Seale et al., 2009).

The present research used a robust methodological and statistical approach to provide a valid tool for HCWs’ concerns in infectious outbreaks.

A 36-item HCWCIOS has good psychometric properties and is suitable for measuring HCWs’ concerns during a pandemic.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Supplementary material.

The studies involving human participants were reviewed and approved by the Ethics Committee of Lorestan University of Medical Sciences, Khorramabad, Iran (IR.LUMS.REC.1399.007). The patients/participants provided their written informed consent to participate in this study.

SY: conceptualization, methodology, data curation, writing – original draft preparation, review and editing, supervision, and project administration. MK: conceptualization, methodology, writing – original draft preparation, and review and editing. FE: formal analysis and methodology. TC: data curation and methodology. ES: formal analysis, writing – original draft preparation, review and editing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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