Determining the Effect of Covid-19 Disease on Family Physicians` Social and Daily Activities in Kayseri/Türkiye Ocena efekta Kovida-19 na društvene i dnevne aktivnosti porodičnih lekara u Kajzeriju

Objective: We aimed at determining the effects of Cov -id-19 disease on family physicians` (FPs) daily work and life. Methods: We searched for GPs who had Covid-19 by making inquiries in the Medical Chamber, Association of GPs in Kayseri, and local health authorities. Our study pe riod covers the first year of the Covid-19 pandemic in Tür kiye (March 11 th , 2020 – March 11 th , 2021). The descriptive characteristics, we looked into, were the use of preventive measures, location of family health centers, the transmission route of Covid-19, the symptoms they experienced, FP’s gen eral health status, and additionally details of isolation, diag -nosis, and hospitalization procedures. Results: A total of 85 FPs (18.2% of all FPs in the Kay seri region) had Covid-19 in the first 12 months of the Co -vid-19 pandemic in Kayseri/Türkiye. FPs who gave consent to participate in our study made up 60.8% of Kayseri`s FPs. Washing hands, keeping distance, using face masks, and fre quent indoor ventilation were the most frequently used mea sures (>75%). More than 2/3 of FPs stuck to the preventive measures. The most frequent symptoms experienced by the FPs were muscle and joint pain, weakness, and fever (more than 1/5 of FPs, respectively 35.4%, 30.4%, 29.1%). The transmission sites were mostly Family Health Centers. Conclusion: About 1/6 of FPs were infected with Co -vid-19. Almost all of them were working in the urban area. The mean hospitalization stay was 7.7 days and in more than 50% the symptoms of fever and cough were detected. The disease transmission was the most prevalent at the workplace and the most common concern of FPs was the protection of their families.


Introduction
Covid-19 was pronounced an epidemic, an 'International Public Health Emergency', in January, 2020.On March 11 th , 2020 it was pronounced a pandemic since it was detected in 113 countries 1 .On December 10 th , 2021 the number of confirmed Covid-19 cases reached 267.184.623 and there were 5.277.327Covid-19 related deaths reported 1 .
The prevalence of the confirmed Covid-19 cases was 3.46-28.9%in the first six months of the pandemic in Chinese health care workers (2).The corresponding figures in UK, USA, and Spain were 14.5%, 12.9%, and 11.6% respectively (3-5).The number of confirmed Covid-19 cases in Turkish health care workers was 29.865 (10.9%) in September 2020 and 52 (0.17%) of them died 6 .
The Ministry of Health (MoH) in Türkiye started tracking Covid-19 on January 10 th , 2020, and founded the Covid-19 Tracking Committee on January 22 nd , 2020.The first Covid-19 case was detected on March 11 th , 2020.According to the guidelines, published by the Turkish MoH, common signs of Covid-19 infection included fever, cough, and dyspnea.The uncommon symptoms were headache, sore throat, runny nose, muscle and joint pain, extreme weakness, newonset loss of smell and taste, and diarrhea.Although confirmed cases included those who were asymptomatic, there were also those with severe conditions like pneumonia, acute respiratory distress, kidney failure, and even death 7 .
The management of detection, diagnosis, ambulatory and hospital care of the Covid-19 patients in the very early period of the pandemic was managed by the secondary or tertiary healthcare institutions.Additionally, smartphone applications were used, both to detect and manage Covid-19 in infected people.Initially, the role of family physicians was to detect new cases, and possible contacts, follow up on nonhospitalized patients at home by phone calls, referring severe cases to hospitals.Although Family Health Centers (FHC) and GPs were regarded as the site of the first contact, GP's role was limited in the management of the Covid-19 cases.GP's role in the delivery of general preventive health services and management of acute and chronic diseases in family health centers was limited due to the novel situation (8).FHCs were primarily focused on diagnostic procedures and ambulatory follow-up during the course of the Covid-19, in accordance with the frequently updated guidelines published by the MoH.
As of September 2020, the number of healthcare workers who lost their lives due to Covid-19 reached 85. Forty-one (48.2%) of them were physicians (9).By the end of the first Covid-19 pandemic year, the MoH announced that health workers were overcome by the burden of the disease, and the total number of healthcare workers with positive PCR tests, since the beginning of the pandemic, exceeded 120,000.This figure exceeded 10% of the total number of healthcare work-
The mortality rate from Covid-19 in family physicians was 14%, or more precisely 14,92% according to the public institutional announcement given respectively by the MoH and Turkish Medical Association (TMA).The estimated number of GPs who were infected with Covid-19 was 3593 11 .
According to the survey conducted by the Turkish Thoracic Society (TTS), the incidence of Covid-19 infections in healthcare workers was 13.9% in the first three months of the pandemic.This incidence was 17 times higher than in the general population, and according to the TTS`s report, the incidence of Covid-19 in healthcare workers was 46 times higher than in the general population, and 52,3 % of healthcare workers were positive for SARS-CoV-2.On the other hand, the radiographic confirmation rate of SARS-CoV-2 was 11,4%.The incidence of asymptomatic healthcare workers, who were registered as SARS-CoV-2 positive was 79,5% thus indicating that monitoring SARS-CoV-2 symptoms in healthcare workers was ineffective 12 .
In this study, we aimed at determining the effect of Covid-19 on the daily work and social life of family physicians in Kayseri/Türkiye and to determine the incidence of Covid-19 related symptoms, preventive measures, diagnostic procedures, and hospitalization incidence.We believe that the descriptive results of this study may be useful in the future management of the Covid-19 pandemic.

Materials and method
The participants of this descriptive cross-sectional study are physicians from primary health care institutions in Kayseri: family health centers, subunits of the district health directorate, and GPs working at university and state hospitals.This sample consists of all GPs who were infected with Covid-19 and recovered completely.The institutional consent for this study was given by the Scientific Research Platform of the General Directorate of Health Services of the MoH (13.10.2020-T20_56_23).Additionally, ethical approval was received from Erciyes University Clinical Research Ethics Committee (18.11.2020-591).All GPs in Kayseri who had Covid-19 and completely recovered in the period from pandemic onset (March 11 th , 2020) and 12 months onward were included in this study.
The questionnaire included questions about GP's workplace, the preventive methods they used, the route of infection, how they were diagnosed, the symptoms they experienced, the course of the isolation period, and the effect of Covid-19 on their work, and social life.The personal experiences of the GP researchers were used to make the questionnaire.
Although information (confirmed cases, recovered cases, cases in emergency services, e.t.c) about Covid-19 was O N L I N E F I R S T published daily, there were no announcements about the local figures 13 .Due to this, we planned to call all 100 FHCs in Kayseri to track the GPs who had Covid-19.Additionally, we requested information from the Association of Family Physicians/Kayseri.We also obtained the information from the local health authority of Kayseri.After determining the total number of GPs who had Covid-19 and recovered completely, we visited each of these GPs at their workplace.During these visits, they were asked whether there were GPs working in the same unit or other healthcare institutions who had newly detected Covid-19.Additionally, all social media platforms were checked to find out whether there were Covid-19 cases among GPs.Final information about the number of GPs who had and recovered from Covid-19 was checked in the Presidency of the Kayseri Medical Chamber and Health Directorate.
The GPs included in the study were called beforehand and informed about the study and then visited.During the visit, the purpose, design, and implementation of the study were explained and their consent was received.Data were collected from the questionnaire.It consisted of forty questions concerning the demographic characteristics of family physicians (age, gender, work and tenure, work experience, etc.), existing chronic diseases, drugs they used for acute and chronic disorders, nutritional supplements they were using before they were infected with Covid-19, testing information, duration of isolation, from whom they got the infection, how Covid-19 was diagnosed, which test was the first tool for diagnosis, Covid-19 related signs, and symptoms, and if they infected any of their household members or workplace partners.Additionally, they were asked if they transmitted Covid-19 to anybody else, their treatment protocol, changes in their lifestyle, or their income.The details about hospitalization due to Covid-19 were also noted.The duration of filling out the questionnaire was about 15 minutes.GPs not available at the moment and who could not fill in the questionnaire, were visited the next day.We planned phone calls to GPs with whom we failed to make face-to-face conversations.Phone calls were made with 30 (37%) GPs.
The descriptive variables of preventive measures, signs, and symptoms of Covid-19, existing chronic diseases, and drugs used for any reason were compared between ambulatory and hospitalized GPs with the Chi-square test.The SPSS 18 statistical software was used for data analysis.
The transmission of the Covid-19 from the GP to any of the household members was 41,8% and to any of co-workers 13,9%.58,2% GPs reported they didn`t transmit the disease to anybody.The fear from Covid-19 was reported in 54,8% of females and 43,8% of males.There were several concerns we found: the fear of infecting a family member, dying from Covid, to have dyspnea.Thirty-two (40,5%) of the GPs reported that someone in their house was infected with Covid-19 from someone outside their home.GPs who were infected with Covid-19 preferred the method of isolation (self or household members` isolation) at their home to protect their household (n=50, 63,3%).A total of 8 (10,2%) GPs either transferred themselves or their household members to another place.
There were 51 (64,5 %) GPs who were satisfied with the health service they received.72 (91,1%) GPs stated they had no concerns about the loss of income.The leading concerns of GPs were: their substitution with another GP and possible problems their patients could encounter during this period.The rationale for these concerns was the frequent calls from their patients during the GP`s isolation period.In addition to these concerns, 69 (87,3%) GPs reported they spent extra money during their isolation period.

Discussion
The primary aim of the study was to determine both the prevalence and related factors to Covid-19 in 466 GPs in 100 family health centers (FHC) in Kayseri.During our study period, 85 (18%) GPs had Covid-19 in the first year of the pandemic and most of them were males.According to the data announced by the Ministry of Health (MoH) on March 10 th , 2021 (the last day of recruitment for our study) the total number of citizens who were infected with Covid-19 was 2.835.989(4.1% of the general population) 13 .Covid-19 prevalence in GPs was four times higher than in the general population.The major contribution this study may have is recruiting almost all GPs in Kayseri and trying to determine the related factors for Covid-19 infection.
Although the highest reported rate of Covid-19 in healthcare workers was 24.1% globally, we found that the rate of GPs who were infected with Covid-19 was 18.0% of all GPs in Kayseri.The Covid-19 infection prevalence in China, USA, UK, and Spain was 3,46-28,9%, 12.9%, 14.5%, and 11.6% respectively 6,14,15,16 .In Türkiye, in the second part of 2020, Covid-19 infection prevalence among all healthcare workers was 10.9% but the mortality for all healthcare workers was 0.17% 6 .Thus we may conclude that the Covid-19 prevalence in GPs was almost 25-50% higher than in other countries in Europe and USA.This significant difference may be attributed to a relatively high number of GP consultations (the number of daily consultations: 44.7) 17 .
The frequency of Covid-19 infection was more prevalent in male GPs aged 40-49.We think that neither the period of employment in healthcare nor the period spent in GP`s FHC is related to hospitalization for Covid-19.We also tried to detect the independent variables influencing the effect of Covid-19 on the GP's daily work and life.More than 2/3 of GPs were employed for more than twenty years and about 60% of them were males.About 90% of GPs were working in the urban area (88% of the city population lives in urban areas).The ratio of the central districts (Melikgazi, Kocasinan, and Talas) population to the general Kayseri population was 80.76% 18 .The frequency of chronic diseases was about 1/3 in males and more than ½ in females and more than 1/3 of GPs were using medications for their chronic diseases in our study group (Table 1, 2).About 1/3 of GPs had to be hospitalized and the average length of hospitalization was 6 (2-20) days.
The frequency of preventive measures for Covid-19, in our study sample, in descending order is shown in Table 3.Among these measures hand washing, distancing, using face masks, indoor ventilation, avoiding social activities, use of hand disinfectant, and avoiding public transportation constituted about 2/3 to ¼ of preventive measures GPs used against Covid-19 infection.Hand washing was the unique preventive measure that was performed by all GPs in our study sample.In a systematic review published in September, 2020 in India, it was shown that paying attention to social distancing was the most effective intervention in delaying the peak of the pandemic 24 .Although there are several studies about which Učestalost preventivnih mera protiv Kovida-19, u našoj studiji, opadajućim redom je prikazana u tabeli 3. Među ovim merama, pranje ruku, održavanje distance, korišćenje zaštitnih maski, provetravanje prostorija, izbegavanje društvenih aktivnosti, upotreba dezinficijenasa za ruke i izbegavanje javnog transporta činilo je 2/3 do 1/4 preventivnih mera koje su primenjivali PL u borbi protiv Kovid-19 infekcije.Pranje ruku je bila jedinstvena preventivna mera koju su koristili svi PL u našoj studiji.U sistematičnom pregledu objavljenom u septembru 2020, u Indiji, pokazano je da je održavanje socijalne distance najefikasniji način u odlaganju vrha pandemije 24 .Mada ima nekoliko studija o tome koja je preventivna The frequency of preventive measures for Covid-19, in our study sample, in descending order is shown in Table 3.Among these measures hand washing, distancing, using face masks, indoor ventilation, avoiding social activities, use of hand disinfectant, and avoiding public transportation constituted about 2/3 to ¼ of preventive measures GPs used against Covid-19 infection.Hand washing was the unique preventive measure that was performed by all GPs in our study sample.In a systematic review published in September, 2020 in India, it was shown that paying attention to social distancing was the most effective intervention in delaying the peak of the pandemic (24).Although there are several studies about which preventive measure against Covid-19 is the most effective, we may conclude that GPs in our study sample were using most of the preventive measures very frequently.More than 95% of GPs in our study were using the four most significant preventive measures (hand washing, wearing face masks, distancing, and room ventilation).Non-abiding to preventive measures was relatively low in preventive measure against Covid-19 is the most effective, we may conclude that GPs in our study sample were using most of the preventive measures very frequently.More than 95% of GPs in our study were using the four most significant preventive measures (hand washing, wearing face masks, distancing, and room ventilation).Non-abiding to preventive measures was relatively low in GPs and we think that the cause of Covid-19 infections in GPs was mostly due to frequent encounters with active Covid-19 patients.Recently, the positive effect of frequent indoor ventilation to prevent Covid-19 infection was found to be the most effective measure, and more than 95% of our study participants were performing indoor ventilation.In a systematic review, published in the Lancet in May, 2021, it was stated that there is consistent, strong evidence that Covid -19 is spread by airborne transmission 25,26 .The use of face masks has shown great potential to prevent respiratory virus transmission, including Covid-19 27.When we checked the source of the disease transmission, we found that the transmission at workplace was 83% in women and 70% in men.Similarly, in a study conducted in Istanbul between April 1 st and May 15 th , 2020, 67% of infected healthcare workers were infected at their workplace 28 .
In our study group, 2/3 of Covid-19 diagnoses were made after Covid-19-related symptoms were experienced.PCR test was the leading diagnostic test (79.7%).About half of the recovered requested a control test.PCR test is used as the primary diagnostic test globally 29 .Similar to other national and international reports, the major concern of healthcare workers infected with Covid-19 was transmitting the disease to their household members.This concern was reported as the cause of anxiety, depression, and burnout 30 .In our study group about ¾ of GPs either used isolation at home or transferred themselves or their household members to another place.This may prevent their family from getting Covid-19.In a study of healthcare workers in İstanbul, it was reported that 83.7% of them were afraid of transmitting Covid-19 to their household members 31 .In addition to transmitting Covid-19 to their families, healthcare workers also reported they were anxious about transmitting Covid-19 to their colleagues in healthcare facilities 32 .In our study, about 2/3 of GPs performed self-isolation to prevent their family members from getting infected with Covid-19.Similar preventive measures were found for the USA healthcare workers, as well 30 .

Figure 1 .Figure 1 .
Figure 1.Comparison of the four most frequent symptoms of Covid in GPs in Kayseri, Iran, and Spain.Slika 1. Poređenje četiri najčešća simptoma Kovida kod PL u Kajzeriju, Iranu i Španiji Figure 1.Comparison of the four most frequent symptoms of Covid in GPs in Kayseri, Iran, and Spain.