Impact of COVID-19 on Environmental Services Workers in Healthcare Settings: A Scoping Review.

BACKGROUND: In the wake of the Coronavirus Disease 2019 (COVID-19) pandemic, demand for deep cleaning and environmental services workers grew exponentially. Although there is extant literature examining the impact of the COVID-19 pandemic on healthcare workers, less emphasis has been paid to environmental services workers who play an equally important frontline role. AIM: To examine the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on environmental services employees working in healthcare settings.
METHODS: Scoping review methodology. A search strategy was developed, in consultation with a medical information specialist, employing various combinations of the keywords [(environmental services worker OR health attendant OR housekeeping) AND (COVID OR coronavirus OR pandemic OR epidemic)]. Five bibliographical databases were searched from database inception through 5 July 2022: OVID Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Database.
RESULTS: A total of 24 studies were included. The studies were generally cross-sectional in design. Seroprevalence studies highlight significantly higher rates of COVID-19 infections among environmental services workers (housekeeping, cleaning and janitorial staff) compared to other clinical and non-clinical staff in the same institution. In addition, based on qualitative interviews, environmental services employees also experienced greater psychological stress working during the pandemic.
CONCLUSIONS: Environmental services workers appeared to be a particularly vulnerable group to increased work stress and also COVID-19 infections during the pandemic. Health systems need to do more to support these workers. Further research could investigate specific policy and procedural changes to benefit this underrecognized group in the greater healthcare workforce.

Introduction

It is well recognized that regular disinfection, housekeeping and cleaning are essential for the daily operations of any healthcare facility. Environmental services workers are the unsung heroes who perform these arduous tasks despite often long hours and limited renumeration [1].

During the Coronavirus Disease 2019 (COVID-19) pandemic, with the emerging threat of the highly transmissible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and related variants, demand for deep cleaning and environmental services workers grew exponentially [2]. At the time of writing, there are more than 555 million COVID-19 cases and 6.3 million COVID-related deaths worldwide [3]. Besides vaccines, the importance of hygiene and personal protective measures (e.g. mask wearing and disinfecting) in stemming the transmission of COVID-19 is critical, but adds to the burden of these workers [4]. Preliminary evidence also showed that the virus could survive on surfaces for up to three days, although surface transmission is now thought to be a minor mode of transmission [5].

Although there is extant literature examining the impact of the COVID-19 pandemic on healthcare workers [6,7], less emphasis has been paid to environmental services workers who play an equally important, if not greater role, in the modus operandi of a well-functioning hospital. Therefore, this scoping review aimed to map the literature in this area and identify gaps for future research.

Methods

This scoping review protocol was guided by recommendations from Arksey & O’Malley’s framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [8,9]. A search strategy was developed, in consultation with a medical information specialist, employing various combinations of the keywords [(environmental services worker OR health attendant OR housekeeping) AND (COVID OR coronavirus OR pandemic OR epidemic)]. Five bibliographical databases were searched from database inception through 5 July 2022: OVID Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Database. The full search strategy for the individual databases were available in Supplementary Material 1. Grey literature was not searched.

The key research question was: what is the impact of COVID-19 pandemic on environmental services workers in healthcare settings?

For this scoping review, all study designs (case series, randomized controlled trials and observational cohort studies) were included in the initial search. Studies needed to have data specifically pertaining to environmental services workers, housekeeping staff or sanitary workers etc. Overlapping data studies, reviews, commentaries, and letters to editors without original data were excluded to improve the included literature’s quality. Full texts were obtained for all articles of interest and their reference lists were hand-searched to identify additional relevant papers. Conflicts were resolved by discussion and consensus amongst four study investigators (Q.X.N., C.Y.L.Y., C.E.Y. and Y.L.L.).

Relevant quantitative and qualitative data was extracted by three study investigators (C.Y.L.Y., C.E.Y. and Y.L.L.) and cross-checked by a fourth (Q.X.N.) for accuracy.

Results

The study selection and abstraction processes are illustrated in Figure 1 . The database search found 1529 records, from which 127 duplicates were removed. A further 1357 articles were removed after title and abstract screening and 21 articles were removed after review of full-texts. Finally, 24 articles were included in the scoping review [[10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33]]. The characteristics and salient findings of the included studies are summarised in Table 1, Table 2, Table 3 , grouped broadly as SARS-CoV-2 seropositivity studies, outbreak investigations and studies on mental health.

Figure 1

PRISMA flowchart illustrating the study selection process.

Table 1

Characteristics of SARS-CoV-2 seropositivity studies included in this scoping review (arranged alphabetically by first author’s last name)

Author, Year	Country	Study Design	Study Population and Sample Size (n)	Key Findings
Akinbami, 2021 [10]	United States	Cross-sectional study	Environmental services workers, n=114 (hospital) and n=69 (nursing home)	Environmental services workers in the hospital and nursing home were at elevated risk of SARS-CoV-2 seropositivity, with 2.6 (95% CI 0.6 to 7.5) and 13.0 (95% CI 6.1 to 23.3) percent seropositive respectively.
Al-Kuwari, 2021 [11]	Qatar	Cross-sectional study	Housekeeping staff, n=530	Non-clinical staff including housekeeping had a higher attack rate (46.8%) and higher prevalence of rt-PCR positivity (47,1%, 248 out of 526) than clinical staff (p<0.001).
Baker, 2021 [12]	United States	Cross-sectional study	Environmental services workers, n=35	Environmental services workers had a slight increased likelihood of SARS-CoV-2 seropositivity, though with a wide confidence interval (crude OR 1.6, 95% CI 0.4 to 4.6).
Barry, 2021 [13]	Saudi Arabia	Retrospective analysis	Housekeeping staff, n=146	Housekeeping staff had the highest infection rate (17.1%, 25 out of 146) compared to other healthcare workers. Most infections appeared to have been acquired in the community.
Cruz-Arenas, 2021 [14]	Mexico	Cross-sectional study	Janitorial staff, n=11	Security staff (62.5%, 5 out of 8) and janitorial staff (45.4%, 5 out of 11) had the highest IgG seroprevalence amongst all healthcare professionals working at a “non-COVID” hospital.
Darvishian, 2022 [15]	Iran	Cross-sectional study	Janitors and building superintendents, n=349	Janitors and building superintendents have the lowest prevalence of SARS-CoV-2-specific IgG or IgM antibodies (9.5%, 33 out of 349).
Das, 2022 [16]	India	Cross-sectional study	Ward boys and cleaners, n=97	Of the healthcare workers in the hospital, IgG seroprevalence was the highest amongst ward boys and cleaners (29.9%, 29 out of 97).
Eyre, 2020 [17]	United Kingdom	Prospective cohort study	Porters and cleaners, n=323	Over a 3-month period, porters and cleaners had the highest seroprevalence (18.6%, 60 out of 323) and greatest risk of COVID-19 infection compared to other healthcare professionals (adjusted OR 2.06, 95% CI 1.34 to 3.15, P=0.001).
Goenka, 2020 [18]	India	Cross-sectional study	Housekeeping, n=226	Housekeeping staff had the highest SARS-CoV-2-specific IgG seroprevalence (26.1%, 59 out of 226) and highest odds of seropositivity (adjusted OR 4.90, 95% CI 2.04 to 11.74, p<0.001).
Jacob, 2021 [19]	United States	Cross-sectional study	Environmental services workers, n=122	Environmental services workers had slight increased likelihood of seropositivity compared to other healthcare professionals (adjusted OR 1.5, 95% CI 0.8 to 3.1).
Mishra, 2021 [20]	India	Cross-sectional study	Housekeeping and sanitation staff, n=186	Housekeeping and sanitation staff had the highest seroprevalence (6.99%, 13 out of 186) compared to other healthcare workers.
Musa, 2021 [21]	Egypt	Prospective cohort study	Patient transporters and cleaners, n=37	Patient transporters and cleaners had the highest seroprevalence (45.9%, 17 out of 37) and likelihood of SARS-CoV-2 infection compared to other healthcare professionals (OR 5.94, 95% CI 2.08 to 16.96).
Oliveira, 2021 [22]	Brazil	Cross-sectional study	Cleaners, n=93	Among healthcare professionals working in a dedicated COVID-19 facility, a positive SARS-CoV-2 serology, cleaners appeared to be more likely to be infected with COVID-19 (crude OR 2.44, 95% CI 1.26 to 4.73, p=0.006).
Pınarlık, 2021 [23]	Turkey	Retrospective analysis	Janitorial staff, n=66	In the multivariate analysis, being a janitorial staff was independently associated with an increased risk of SARS-CoV-2 infection (adjusted OR 2.24, 95% CI 1.21 to 4.14, p=0.011). Most infections were likely acquired in the community.
Rosser, 2021 [24]	United States	Retrospective analysis	Environmental services, food service, patient transport staff, n=335	In the multivariable regression analysis, environmental services, food service and patient transport staff had significantly higher likelihood of seropositivity (OR 2.64, 95% CI 1.33 to 4.80, p<0.001). This was not observed for other occupations in the academic medical health system.
Shepard, 2021 [25]	United States	Retrospective analysis	Environmental services workers (56.12% females, average age 43.18 years), n=335	In an academic medical centre, there was a significantly greater prevalence of COVID-19 rt-PCR test positivity among environmental services workers (5.96%) compared to clinicians (1.93%; P<0.0001) and nurses (1.46%; P<0.0001).
Shields, 2020 [26]	United Kingdom	Cross-sectional study	Housekeeping staff, n=29	In a large hospital trust, the seroprevalence of SARS-CoV-2 antibodies was highest among housekeeping staff (34.5%, 10 out of 29 tested positive), compared to other asymptomatic healthcare workers.
Wattal, 2021 [27]	India	Cross-sectional study	Sanitary workers, n=203	In a tertiary medical hospital, sanitary workers were at significantly higher risk of SARS-CoV-2 IgG seropositivity (OR 3.946, P<0.001) than other asymptomatic healthcare workers.
Zuñiga, 2022 [28]	Chile	Cross-sectional study	Janitorial staff, n=8606	In regions with low and medium SARS-CoV-2 seroprevalence, doctors, nurses, allied health professionals and janitorial and other support staff were all at increased risk of infection. The likelihood of seropositivity for janitorial staff in low and medium seroprevalence regions were, OR 1.12 (95% CI 0.68 to 1.85) and OR 1.37 (95% CI 1.07 to 1.74) respectively.

Abbreviations: 95% CI, 95% confidence intervals; COVID-19, Coronavirus Disease 2019; OR, odds ratio; PPE, personal protective equipment; rt-PCR, reverse transcriptase polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Table 2

Characteristics of outbreak investigations included in this scoping review (arranged alphabetically by first author’s last name)

Author, Year	Country	Study Design	Study Population and Sample Size (n)	Key Findings
Barani, 2021 [29]	India	Outbreak investigation	Housekeeping staff, n=120	In the wake of a COVID-19 cluster in a tertiary care cancer hospital, 2.5% of the housekeeping staff tested rt-PCR positive (3 out of 120) and they showed the highest secondary attack rate (3.3 per 100 persons) among all the healthcare workers.
Girgis, 2022 [30]	Egypt	Outbreak investigation	Housekeepers, n=118	In the wake of a hospital COVID-19 outbreak, 7.6% of the housekeeping staff were infected (9 out of 118), and they had the highest risk of rt-PCR positivity (risk ratio 5.08, 95% CI 1.4 to 1.84) compared to other hospital staff.

Abbreviations: 95% CI, 95% confidence intervals; COVID-19, Coronavirus Disease 2019; rt-PCR, reverse transcriptase polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Table 3

Characteristics of studies on mental health of environmental services workers (arranged alphabetically by first author’s last name)

Author, Year	Country	Study Design	Study Population and Sample Size (n)	Key Findings
Jordan, 2022 [31]	United States	Qualitative study; semi-structured telephone interviews	Environmental services workers (69% females; average age 51 years), n=16	The COVID-19 pandemic worsened the existing stressors facing environmental services workers, and there is a need for more support (training, education and adequate PPE) and recognition for these frontline workers.
Latha, 2022 [32]	India	Cross-sectional study	Housekeeping, n=64	Based on self-reported DASS-21 and IES-R scores, Hospital housekeeping staff endorse high levels of depressive, anxiety and stress symptoms during and post-lockdown. Housekeeping staff had the highest levels of anxiety and this worsened post-lockdown.
Tamene, 2022 [33]	Ethiopia	Qualitative study; key informant interviews and one-on-one in-depth interviews	Environmental services workers, n=19	There were concerns regarding a lack of sufficient and appropriately-sized PPE in the workplace; poor renumeration; increased work fatigue; and lack of experience and training dealing with potential hazards.

Abbreviations: DASS-21, depression, anxiety and stress scale 21; IES-R, impact of event scale revised; PPE, personal protective equipment.

There were six studies from the United States [10,12,19,24,25,31], six studies from India [16,18,20,27,29,32], two studies from the United Kingdom [17,26], two from Egypt [21,30], one each from Brazil [22], Chile [28], Ethiopia [33], Iran [15], Mexico [14], Qatar [11], Saudi Arabia [13] and Turkey [23].

The seroprevalence studies, with the exception of a single study from Iran [15], consistently reported that environmental services workers (housekeeping, cleaners and janitorial staff) were at a significantly elevated risk of having contracted COVID-19 compared to other healthcare workers in the same institution [[10], [11], [12], [13], [14],[16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]]. The quality of these cross-sectional studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for analytical cross-sectional study [34] by consensus among three study investigators (Q.X.N., C.Y.L.Y. and C.E.Y.). The studies had generally low-to-moderate risk of bias, with shortcomings in the response rate reporting and sample size (further details in Supplementary Material 2).

One cross-sectional, quantitative study looked at the level of anxiety, depressive and stress symptoms experienced by healthcare workers, including housekeeping staff during and after a lockdown situation [32]. Two qualitative studies conducted individual interviews with environmental services workers and specifically examined their thoughts, feelings and concern during the pandemic [31,33]. The studies all found high levels of stress and anxiety among environmental services workers during the pandemic. Of note, compared to doctors and nurses, non-clinical workers (e.g. housekeeping and security staff) endorsed significantly higher prevalence of anxiety during and after the lockdown and after adjustment for possible confounders [32]. Based on self-reported depression, anxiety, and stress scale 21 (DASS-21) scores, the mean score for anxiety among housekeeping staff was 4.8 during the lockdown and 7.2 post lockdown. In contrast, doctors had a lower mean anxiety score of 4.22 during the lockdown and 5.6 post lockdown, and nurses had a lower mean anxiety score of 4.0 during the lockdown and 7.0 post lockdown [32]. These studies collectively highlighted a clear need for more support (areas of deficit include psychological support, staff training, infection control education and adequate PPE supply) and recognition for these frontline workers [[31], [32], [33]].

Discussion

COVID-19 has been an unprecedented global pandemic of unparalleled scale, and it has caused a serious strain for health systems and greatly increased the demands on healthcare workers. Based on the available studies, environmental services workers appeared to be a particularly vulnerable group to increased work stress and also COVID-19 infections during the pandemic.

Seroprevalence studies highlight higher rates of COVID-19 infections among environmental services workers (housekeeping, cleaning and janitorial staff) compared to other clinical and non-clinical staff. In a prospective cohort study conducted in a teaching hospital in the UK, over a 3-month period, porters and cleaners were found to have the highest seroprevalence (18.6%, 60 out of 323) and greatest risk of COVID-19 infection compared to other healthcare professionals (adjusted OR 2.06, 95% CI 1.34 to 3.15, P=0.001) [17]. Similarly, in a study conducted in the wake of a COVID-19 outbreak in a university cardio-thoracic hospital in Cairo, Egypt, housekeeping staff were the most affected out of all hospital staff, with 7.6% (9 out of 118) of them eventually contracting the infection; they had the highest risk of rt-PCR positivity (risk ratio 5.08, 95% CI 1.4 to 1.84) [30].

This observed difference could be due to a combination of knowledge, training and socioeconomic factors. Although the studies did not control directly for income or education attainments, occupation is a surrogate for socioeconomic status. As COVID-19 could be acquired in both healthcare (albeit less likely [13,23]) as well as community settings, environmental services workers could have poorer knowledge and compliance to PPE use and they tend to gather frequently during mealtimes as highlighted by a number of studies [11,24,30], and this group could also live in more crowded housing conditions that might expose them to the virus [13]. Several international studies have found that COVID-19 further exacerbated income and socioeconomic inequalities [[35], [36], [37]], and this could have adversely impacted the housing and living conditions of these employees. These have been identified as risk factors for COVID-19 transmission in other contexts. Workers living in dormitories and close quarters were particularly predisposed to COVID-19 outbreaks [38].

Environmental services workers are a vital part of the wider public health workforce as they positively impact the health and wellbeing of staff and patients through their work. Hence, due consideration and appreciation should be given to this population. Due to possibly increased staff turnover during the pandemic, infection control training should be provided (and reiterated) for these staff members. They should also be educated and receive reminders on potential sources of nosocomial and fomite transmission. In addition, across hospital systems, cost-cutting to hospital environmental services has been associated with an increased risk of nosocomial infections for these employees [39]. As aforementioned, the majority of the infections were thought to have been acquired in the community, suggesting potential social inequalities, which need to be addressed.

For workers who have been infected and are returning to work, psychoneuroimmunity prevention measures (e.g. good ventilation in the workplace and availability of PPE) may also help with possible psychiatric symptoms and facilitate smooth return to work [40].

Apart from these physical needs and issues, the qualitative studies also reflect that environmental services employees experienced greater psychological stress working during the pandemic, due to increased demands, fear of contagion of the virus and staff shortages [31]. Health systems can consider additional measures to support these workers, who are at times underappreciated and underprivileged [41]. They should be entitled to paid sick leave benefits to stay home if feeling unwell. Their work and stories could be elevated and recognized and we should also consider tapping on technology and innovation to complement their work and ease their burden.

Conclusions

Environmental services workers had increased work stress and heightened risk of COVID-19 infections during the pandemic, even more so than other healthcare staff. There is a paucity of studies specifically focusing on and addressing the impact of the COVID-19 pandemic on the lived experiences of these employees. Further research should also investigate policy and procedural changes to benefit this underrecognized group in the greater healthcare workforce.

Author’s statement

Ethical approval

Not applicable. No human participants involved. This was a systematic review of published studies.

Acknowledgments

None.

Funding

This research did not receive any specific grant funding from agencies in the public, commercial or not for profit sectors.

Authorship contributions

Qin Xiang Ng and Julian Thumboo conceived the original idea. Qin Xiang Ng, Chun En Yau, Clyve Yu Leon Yaow and Yu Liang Lim carried out the study, investigation, and the relevant data analysis and interpretation. Xiaohui Xin, Kok Yong Fong and Julian Thumboo contributed to the data analysis and interpretation. Kok Yong Fong and Julian Thumboo supervised the study. All authors contributed to the writing and proofreading of the final manuscript. The final manuscript was approved by all authors.

Data availability statement

No datasets were generated or analysed during the current study.

Declaration of Competing Interest

None.