The results of the present study showed that in September, 2009, when there were significant public and hospital staff concerns about a new A/H1N1 influenza pandemic outbreak, more than half of our hospital's HCWs (56.7%) reported they worried about the pandemic, their degree of worry being moderately high. The most frequent concern was for infection of family and friends and the consequences of the disease on their health. The perceived risk for being infected was considered moderately high and more than half agreed to some degree that being infected with the A/H1N1 influenza would have a major consequence on their health. Few HCWs (6.6%) had restricted their social contacts and fewer (3.8%) felt isolated by their family members and friends because of their hospital work, while a low percentage (4.3%) would take a leave to avoid infection. However, worries and degree of worry were significantly associated with intentional absenteeism, restriction of social contacts, and psychological distress. Perceived sufficiency of information about several aspects of the A/H1N1 influenza was moderately high, and the overall information about the A/H1N1 influenza was considered clear. Although more than half agreed to some degree that the ward/department they worked was well prepared for the pandemic, a significant proportion (44.4%) expressed a disagreement (at least somewhat) in this respect, with nurses presenting the lower rates of agreement. Finally, perceived sufficiency of information for the prognosis of the infection was the variable most closely independently associated with the degree of worry about the pandemic.
It has been well established that HCWs experienced significant stress during infectious epidemics [5
]. Reports of the psychological impact of SARS on hospital staff indicated that high levels of distress were common [5
]. In Singapore, over 27% of HCWs had a GHQ-28 score >5 and approximately 20% of the doctors and nurses were suffering from PTSD [24
]. In one Toronto hospital, 29% of respondents scored above the threshold for "emotional distress" on GHQ-12 [17
], while in Taiwan, 5% of staff members suffered from an acute stress disorder [7
]. Studies on HCWs' concerns about the avian influenza pandemic have also shown that 71.6% had significant concerns and had perceived the pandemic as having adverse impacts on their personal life and work [10
]. Despite, however, the large epidemiological literature on the A/H1N1 influenza pandemic, there is little information available regarding the worries, concerns or the psychological impact that the pandemic might have on HCWs. To the best of our knowledge, at the time of reporting, this is the first study investigating the acute concerns and worries of hospital staff about the A/H1N1 influenza pandemic and their associations with psychological distress.
Our results showed that more than half of HCWs experienced moderately high levels of worry about the pandemic, with auxiliary staff being more worried than all other groups and nurses being more worried than medical staff. On the other hand, our findings also showed that 20.7% of HCWs presented scores indicating mild to moderate psychological distress, rates similar to those found in a previous study, at times when there was no infectious exposure, when 18.1% of HCWs presented scores indicating mild to moderate psychological distress [25
]. In another study of 275 HCWs in the same hospital one year before the infectious outbreak, we found that 21.8% presented scores indicative of mild or moderate psychological distress (unpublished data). These findings indicate that psychological distress is a common experience in HCWs, as also has been suggested by studies in the UK, which have shown that among doctors and nurses, between 28 and 32% scored above the threshold for "emotional distress" in GHQ-12 [26
]. However, despite the fact that HCWs' psychological distress was not elevated in the present study, their degree of worry about the pandemic was an independent correlate of psychological distress (Table ), indicating that HCWs concerns about the pandemic might contribute to psychological distress. The cross-sectional design of our study prevent us from answering questions about causality, since it is plausible, for instance, that people who are already distressed for reasons not measured in this study are more likely to worry about A/H1N1 influenza pandemic. Work satisfaction was also associated with psychological distress (Table ) but it was not correlated to the degree of worry about the pandemic (Table ), indicating that the association of work dissatisfaction with psychological distress could be attributed to the chronic stress and burnout that are common in hospital settings and leading contributors to work dissatisfaction [29
] rather than the HCW's concerns about the pandemic.
Consistent with the results of previous studies in SARS-affected hospitals [17
], nurses and medical staff presented high rates of psychological distress. Although by definition, both medical staff and nurses have greater contact with patients, medical staff expressed the lower degree of worry (Table ), possibly because they mostly regarded themselves as sufficiently informed (Table ). A greater proportion of nurses and auxiliary staff also worried about the A/H1N1 influenza pandemic compared to medical staff, and their degree of worry was also greater than that of doctors (Table ). Auxiliary staff expressed the highest level of worry, while being a nurse and/or auxiliary staff was significantly associated with psychological distress. In addition, auxiliary staff considered the consequences of the infection for their health to be greater (Table ). These findings indicate that assessing and intervening for the psychological impact of the infectious outbreak on HCWs, especially on nurses and auxiliary staff, is of particular importance in planning for the current and future outbreaks of infectious diseases. Hospital policies should also take into account auxiliary staff's concerns and worries, and since we found that perceived sufficiency of information was associated with lower degree of worry, hospital managers should try to provide for auxiliary staff's information needs, in order to provide a favourable working environment in times of extreme public health-related concerns, such as the current A/H1N1 influenza pandemic.
Nurses constitute the largest hospital occupational group and are directly and intensively involved in patient care, experiencing a greater risk of contagion in cases of infectious diseases. It is therefore not surprising that nurses reported the higher percentages when asked whether, for a disease that they might contract, they would prefer as much information as possible, while they also felt their department was less well prepared for the A/H1N1 influenza pandemic, compared to the other staff groups (Table ). Other studies have also found that in a pandemic of influenza, medical and nursing staff were significantly less likely than ancillary and support staff to consider their ward/department sufficiently prepared for the pandemic [32
]. Our results and the results of the aforementioned studies indicate that hospital and department managers and directors should consider the opinions of nurses and medical staff with respect to the proper ward/department preparation for a pandemic, if they are to offer the most favourable working conditions possible for HCWs in times of extreme distress, such as the current and future infection pandemics.
Consistent with the results of other studies reporting that distress can be amplified in the face of lack of clear information that is common in the initial period of disease outbreaks [33
], in our study perceived sufficiency of information about the A/H1N1 influenza prognosis was independently associated with reduced degree of worry (Table ).
HCWs across a range of professions tended to feel motivated to work during the A/H1N1 influenza pandemic, as indicated by the high sense of duty expressed and by the low proportion of HCWs reporting that they would take a leave to avoid infection (4.3%). In addition, although fear of stigmatization, in the form of being avoided by family and friends, was observed to be a prominent aspect of many HCWs' experience during SARS [5
], this was not the case in the present study, where only 3.8% felt that family and friends avoided them because of their hospital work, and only 6.6% had restricted their social contacts themselves. This is not surprising, since the stigmatization reactions of the public to SARS was founded on the fact that the infection was limited to hospitals, whereas the A/H1N1 infection is a community spread infection for which the risk of infection is fairly evenly distributed across the population. Nevertheless, studies in other countries have shown variable rates of intentional absenteeism due to contagious diseases [12-14,32], depending on the kind of the infection, the different time periods the studies took place, the different survey questions, and the cultural differences or religious beliefs. Our results indicated that most HCWs surveyed considered that it was not possible to avoid their duties in an emergency situation due to the pandemic and they would continue working despite the potential risks (Table ), a finding consistent with the view that HCWs consider it unethical to abandon their professional responsibilities in order to protect themselves or their families [32
The main methodological limitation of the present study lies in the response rate. An accurate estimation of the response rate was difficult, because the number of staff who could have been contacted during the 4-week period the study took place is difficult to estimate, given that in September many Greek employees are on vacation. However, the response rate of this study (46.9%) is comparable to other studies investigating HCWs' concerns and distress about infectious outbreaks (for example, 47% in the study of Nickell et al [17
], 41.1% in the study of Styra et al [6
], or 23.3% in the study of Maunder et al [5
]). In addition, comparison of the characteristics of the study sample with the total hospital employees suggested that the study sample is representative of HCWs in our hospital. For example, nurses comprise 46.4% of the hospital staff and 44.6% of the study sample. Despite this, however, we cannot refute the criticism that an underlying response style might have led to our results. We also cannot exclude the possibility that particularly concerned or distressed HCWs were under-represented, as such subjects might be on leave because of their worries about the pandemic and thus unable to join the study. Further methodological limitations are the potential for bias caused by socially acceptable answering resulting in possible underestimated intentional absenteeism rates. Gathering information regarding psychological distress by self-report is a further limitation. Finally, as mentioned earlier, questions about causality cannot be resolved by cross-sectional surveys, and therefore future prospective studies are needed to confirm our findings and to investigate the causal paths of the associations reported regarding HCWs concerns and worries about A/H1N1 influenza pandemic, psychological distress, perceived information and intended behaviour.