Wellbeing at Work before and during the SARS-COV-2 Pandemic: A Brazilian Nationwide Study among Dietitians

This study aimed to evaluate the perceptions of dietitians’ wellbeing at work before and during the SARS-COV-2 pandemic in Brazil. This cross-sectional study was performed using a previously validated instrument to investigate the wellbeing of dietitians at work in Brazil. The questionnaire on the wellbeing of dietitians was composed of 25 items (with a 5-point scale), characteristics, and questions about the SARS-COV-2 period. The application was carried out with GoogleForms® tool from 26 May to 7 June 2020. The weblink to access the research was sent via email, messaging apps, and social networks. Volunteers were recruited nationwide with the help of the Brazilian Dietitians Councils, support groups, as well as media outreach to reach as many dietitians as possible. Volunteers received, along with the research link, the invitation to participate, as well as the consent form. A representative sample of 1359 dietitians from all the Brazilian regions answered the questionnaire—mostly female (92.5%), Catholic (52.9%), from 25 to 39 years old (58.4%), with a partner (63.8%), and with no children (58%). Most of the participants continue working during the pandemic period (83.8%), but they did not have SARS-COV-2 (96%), nor did their family members (80.7%). The wellbeing at work before SARS-COV-2 was 3.88 ± 0.71, statistically different (p < 0.05) from during the pandemic, with the wellbeing of 3.71 ± 0.78. Wellbeing at work was higher before the pandemic for all the analyzed variables. Analyzing variables separately before and during the pandemic, dietitians with partners, children and a Ph.D. presented higher scores for wellbeing at work. Professionals receiving more than five times the minimum wage have higher scores. During the pandemic, better wellbeing was observed for dietitians working remotely.


Introduction
The world is facing the unexpected SARS-COV-2 pandemic with several consequences for economic, social, mental, environmental, and health aspects. The SARS-COV-2 brought not only the risk of death from the viral infection but also unbearable psychological pressure on people in the world [1]. According to the World of Health Organization (WHO), until June 7, 2020, 6,799,713 cases of SARS-COV-2 were registered and there have been 397,388 deaths in the world [2]. Americas represent almost half of the registered cases (n = 3,234,875 cases; 47.6%) and deaths (n = 179,394 deaths; 45%) in the period. These numbers could be underestimated due to the lack of medical diagnosis at the beginning of the pandemic. Some countries face a few diagnostic tests. In South America, Brazil is

Participants and Ethics
Dietitians from the entire country were recruited to participate in the study. Researchers wanted to trace the wellbeing at work before and during the SARS-COV-2 of this population group in Brazil. Ethical approval was obtained for this study by the Ethics Committee University of Brasília (protocol No. 54822316.1.00000030). The study was conducted according to the guidelines laid down in the Declaration of Helsinki and followed the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals.
The sampling size was calculated based on data from the Brazilian Federal Dietitians Council that presents 129,134 registered dietitians [20], considering an error (e) of 3% and a level of significance (α) of 5% [21]. The minimum estimated representative sample size would be of 1059 participants. The inclusion criteria were to be a dietitian and living and working in Brazil.

Statistical Analysis
Researchers extracted data from the GoogleForms ® tool and analyzed using Statistical Package for the Social Sciences-SPSS 24.0 (version 24, SPSS Inc., Chicago, IL, USA). Exploratory and confirmatory analyses were conducted to determine the psychometric quality of the wellbeing at work instrument. We used the Kaiser-Meyer-Olkin (KMO), and Barlett's sphericity test. For consistency, Cronbach's alpha was used. Descriptive analyses were used to determine the measures of central tendency and dispersion of the sample. We compared means of the sample through paired t-tests (wellbeing before and during SARS-COV-2) and Analysis of Variance (ANOVA) with Tukey post-hoc.

Results
A representative sample of 1359 dietitians from all the 26 Brazilian states and the Federal District and regions answered the questionnaire. Figure 1 shows the distribution of the dietitians and participants by Brazilian regions.
A representative sample of 1359 dietitians from all the 26 Brazilian states and the Federal District and regions answered the questionnaire. Figure 1 shows the distribution of the dietitians and participants by Brazilian regions. The participants were mostly female (92.5%), Catholic (52.9%), aged from 25 to 39 years old (58.4%), with a partner (63.8%), and with no children (58%) ( Table 1). Most of the participants continued working during the pandemic period (83.8%), but had not been diagnosed with SARS-COV-2 (96%) before answering the questionnaire, nor did their family members (80.7%).  The participants were mostly female (92.5%), Catholic (52.9%), aged from 25 to 39 years old (58.4%), with a partner (63.8%), and with no children (58%) ( Table 1). Most of the participants continued working during the pandemic period (83.8%), but had not been diagnosed with SARS-COV-2 (96%) before answering the questionnaire, nor did their family members (80.7%). Dietitians with less than 1 MW family income are mostly graduates (35.9%) or present specialization/residency (56.4%). However, dietitians with more than 20 MW as a family income have a master's and Ph.D. (52.2%). Of 144 dietitians with Ph.D., 95.1% work in the teaching area (universities). Table 2 shows data from the wellbeing at work before and during the pandemic period compared by participants' characteristics. The instrument presented a KMO of 0.957 and a significant (0.000) Barlett's sphericity test. For internal consistency, the wellbeing at work instrument presented a Cronbach's alpha of 0.952. In the communalities, the extraction item was below 0.500 for questions 12 (social relations with my colleagues positively influence my work) and 25 (I consider my workload adequate), and they were not considered for the final score of wellbeing at work. The maintained questions from the instrument were divided into four factors. Factor 1 is related to exterior perception with questions 2, 4, 6, 7, 11 and 15 (Appendix A), factor 2 is concerned about the perception in itself (questions 1, 3, 5, 8, 13, 14, 18 and 21), factor 3 is the task perception (questions 19, 20, 22, 23 and 24), and factor 4 is the perception from the dietitians' category (questions 9, 10, 16 and 17). Cronbach's alpha was also calculated for each factor: factor 1, 0.871; factor 2, 0.881; factor 3, 0.881; factor 4, 0.884 (Supplementary File, Table S1). In general, wellbeing at work before SARS-COV-2 was 3.88 ± 0.71, statistically different (p < 0.05) from during the pandemic, with the wellbeing of 3.71 ± 0.78. A comparison between before the pandemic and during the pandemic showed statistical differences for all variables (worse during the pandemic period) (p < 0.05).
Gender and number of workplaces did not influence wellbeing at work before and during the pandemic period. Individuals with a partner and with children had a better perception of wellbeing at work than the ones with no partner or children. Before and during the pandemic, master's and Ph.D. individuals presented better wellbeing at work than graduates, and Ph.D. dietitians presented better wellbeing than dietitians with a master's degree ( Table 2).
For both periods, individuals that work in teaching present better wellbeing at work compared to the other areas of dietitians' practice (clinic, foodservice administration, public health, and others). Before the pandemic period, individuals with family monthly income >5 MW present higher wellbeing at work than the ones up to 5 MW (Table 2). During the pandemic period, the results were a little different, showing differences among individuals up to 3 MW, from 3 to 5 MW and >5 MW, with increasing wellbeing perception with higher family income. Before the pandemic, the time from the undergraduate completion differed from up to 10 years to >15 years. During the pandemic, the higher time from undergraduate completion (>15 years) presented a higher mean of wellbeing at work than the lowest time of completion (≤2 years).
Before the pandemic period, individuals adept in Catholicism and Spiritism had a better perception of wellbeing at work than Protestants. During the pandemic, Catholics did not differ from Protestants, agnostics, or Spiritism followers. However, individuals following the Spiritism religion presented a better perception of wellbeing at work than Protestants ( Table 2).
Dietitians that tested positive for SARS-COV-2 (n = 55) were predominantly working in-person (78.2%, n = 43), without or with adaptations (58.2%, n = 32; 20%, n = 11, respectively). Participants who reported not being working during the pandemic period (n = 220) have a job, but they are unable to work in-person or remotely. The wellbeing values were considered for this group of workers because they answered the questions and effectively have a job. There is no difference among perceptions of wellbeing at work between dietitians who had SARS-COV-2 and the ones that did not have, similarly to the results from the ones that had any family member test positive for SARS-COV-2.
When separating the wellbeing at work by factors (Table S1) and comparing by participant's characteristics, factors 1 and 4 presented the lowest means before and after the pandemic, being lower and statistically different (p < 0.05) during the pandemic. Factor 1 relates to exterior perception and factor 4 to the category perception. Higher scores occurred for the perception of itself and the perception of the task, before and during the pandemic.

Discussion
As the world grapples with the impact of the SARS-CoV-2 pandemic, health care workers face extraordinary challenges daily, in different contexts and conditions [22]. The media reports that health care professionals are hugely concerned for the health and wellbeing of their patients, their families, and themselves, facing pandemic issues [22,23]. However, the Brazilian government did not recognize dietitians as part of the health professionals facing the SARS-COV-2 pandemic [14]. These changes in life and work and the lack of recognition and support have a significant impact on their wellbeing, as shown by our results. Among Brazilian dietitians, there was a worse perception of wellbeing at work during the pandemic compared to the period before the pandemic for all variables (p < 0.05) ( Table 2). In general, dietitians' wellbeing at work was positive (above 2.5), which is the midpoint of the scale. The items that obtained the best scores were those that investigate the perception of the importance of the profession for themselves and society. The average scores were above 4.40 before the SARS-COV-2 pandemic and 4.20 during it. The items with the lowest scores and which need to be improved are related to compensation and technological support to perform the tasks assigned to the dietitian. Probably, wage improvement could come through professional qualification, as higher wages were linked to more years of study in our research. Besides, there is a need for an increase in the number of class entities (unions and councils) to fight for better wages of this professional category. In Brazil, even before the SARS-COV-2 pandemic, the country had high unemployment rates [24], a situation worsened by the pandemic, which made it difficult for workers to maintain their family income. Part of the dietitians' work is in the foodservice area (schools, commercial and institutional restaurants), and most of these are closed or changed the policies of production due to the food safety and workers' safety conditions.
Wellbeing at work before SARS-COV-2 was 3.88 ± 0.71, statistically different (p < 0.05) from during the pandemic (3.71 ± 0.78). Usually, these conditions would place health care professionals in a situation defined by threat and fear, both of which have been shown to have a detrimental effect on their ability to offer compassionate and person-centered care to their patients [22,25]. In these circumstances, there are high levels of conflict within teams and workplace adversity, leading to a working environment which is perceived as hostile, abusive, and unrewarding [26,27]. As a consequence, workplace adversity can be correlated with a decreased quality of care [28]. In April 2020, the Brazilian Health Ministry requested the registration of all health professionals, including dietitians, to reinforce the fight against SARS-CoV-2, in addition to the usual work of individuals [29]. This reinforcement is to assist managers of the Unified Health System (SUS) in coping with SARS-CoV-2, based on the work capacity of these professionals. It focuses on those who were available to go to the Brazilian states with the greatest need to strengthen health teams [29]. This fact also caused concern in several dietitians who were afraid to work facing SARS-COV-2 patients for various reasons. According to the Brazilian Health Ministry, from the 90,245 Brazilian registered dietitians to reinforce the fight against SARS-CoV-2, 33,624 were willing to work facing SARS-COV-2 [30]. These professionals were registered in the category to receive payment for their work to confront SARS-COV-2. However, the Brazilian Ministry registered other health care professions in a voluntary (unpaid) category of workers, and no dietitian volunteered until 28 April 2020 [30]. It was not stated, but it seems that the dietitians that were willing to work facing SARS-COV-2 were doing it to help the family income, which can potentially worsen their perception of wellbeing at work. Given the unknown and uncontrollable nature of the SARS-COV-2, some health care professionals need to stay away from their home and loved ones, possibly affecting emotional aspects and the relationship with their work [23].
In the pandemic situation, the protection measures for these professionals get worse due to the limitations of social distance. In some cases, this risk is higher, such as in hospitals, emergency services, outpatient clinics, vaccination clinics, screening lines, and other health care settings. In this environment, these professionals are even more exposed when their duty includes providing some assistance to infected people with SARS-COV-2. In foodservices, where these professionals do not work directly with individuals adequately tested for the new coronavirus, they face the same environment with asymptomatic individuals or those in the incubation phase of the disease [31].
Our sample was mostly composed of females ( Table 1). The female hegemony among dietitians is common, as shown by other studies in different countries [8,9,13,[32][33][34]. Female hegemony in the profession can represent repercussions on career, social prestige, and income [12]. A study showed that dietitians were mostly women and that, although the labor market has grown, the new jobs were mostly (86%) part-time, not only because women need to conciliate career and family care, but also because these positions get lower payment [35]. However, according to our data, gender did not influence wellbeing at work before nor during the pandemic period.
According to a research conducted by the Dietitians Federal Council in 2016/2017 with 1104 dietitians in Brazil, most of them are young, between 25 and 44 years old (81%), a higher percentage than our study (68.3%). Previous studies showed that 73% of the Brazilian dietitians are postgraduates [12,16,36], similar to our data (77.8%, n = 1058). Before and during the pandemic, master's and Ph.D. individuals presented better wellbeing at work than graduates ( Table 2). Most Ph.D. dietitians work in the teaching area, and for both periods, individuals that work in teaching present better wellbeing at work compared to the other areas of dietitians' practice (clinic, foodservice administration, public health, and others). All schools, including universities, faced changes in how they conducted work. Professors had to search for technological tools and strategies in order to work during the pandemic period, impacting their perception of wellbeing at work, as shown by the lower mean during the pandemic. Undergraduate courses in the health area need practical classes and time inside the hospitals, and it is difficult to return to these activities in-person. The other work areas for dietitians did not present statistically different wellbeing, even for professionals that work in the clinical area and can be inside hospitals.
Before the pandemic period, individuals with family monthly income > 5 MW presented higher wellbeing at work than the ones up to 5 MW (Table 2). During the pandemic period, wellbeing perception increased with higher family income. These data are confirmed by other studies, indicating that lower wages decrease satisfaction at work [13,16,[37][38][39]. During the pandemic period, most family members are isolated at home, increasing expenses with bills (water, energy, food, and others). This can influence the difference between the categories of family income compared to the period before the SARS-COV-2. According to the official data [24], unemployment increased in all Brazilian regions with SARS-COV-2, but mainly in the northeast region (from 13.6% in 2019 to 15.6% in 2020), followed by the North (from 10.6% to 11.4%) and the southeast region (from 11.4% to 12.4%), also impacting family income. It is noteworthy that the north and northeast regions were the ones presenting the largest proportional increase in official cases of SARS-COV-2 in Brazil until June 7, 2020 [40].
The Brazilian government published two provisional measures [41,42] during the pandemic changing the work relationship between employers and employees. Employers can reduce employees' salaries during the SARS-COV-2 crisis, and rules were established for remote work and the suspension of some administrative measures related to safety at work. These legislative measures enable up to a 70% salary reduction and precarious work relationships, reflected by a lower perception of wellbeing at work during the pandemic.
Two characteristics influence wellbeing at work before and during the pandemic: marital status, and children. Dietitians with partners (63.8%) and with children (42%) had higher wellbeing before and during the pandemic. VanderWeele [43] discusses in his article that studies associate marriage with higher life satisfaction and happiness. This association can be related to better mental and physical health and longevity. With time, marriage is associated with a better relationship with others, including work partners, which can influence work wellbeing. VanderWeele [43] also highlights that marriage and family are vital to wellbeing. Despite this study evaluating wellbeing in life, not in the workplace, it could potentially explain higher scores of wellbeing in our study for dietitians with children and partners. Wilcox [44] discusses in his book that marriage is also associated with financial status and education. A meta-analytic study [45] suggested that people who are employed present better life, family, and marital satisfaction. Our study was only conducted with dietitians that have a job, because the instrument is related to wellbeing at work. Therefore, it is not possible to compare this with studies of unemployment. However, they show better wellbeing for people with partners, family, and education, such as our findings for wellbeing at work [46]. Ryff and Heidrich [46] stated that work and education experiences explain differences in the purpose of life. Higher levels of education are associated with happiness and satisfaction and strongly affect income [47]. As already discussed, dietitians with more education and income presented better scores for wellbeing before and during the pandemic.
Regarding religion, worldwide, 15% of people are agnostic [48], higher than in our study (5.2%), but closer to the Brazilian statistics of 8% (IBGE, 2010). Even though research has shown that religion brings higher subjective wellbeing because of social support and meaning in life, wellbeing at work was not lower among agnostic dietitians [49]. Sedikides [50] stated that religion is important for most people's psychological conditions and subjective wellbeing. There are pieces of evidence that suggest that spirituality is a protective factor for health and psychological problems [51,52]. A study conducted by Ferreira, Pinto e Neto [52] with university students from Portugal, Mozambique, Angola, and Brazil showed that churchgoers present better spiritual wellbeing and better life satisfaction. During the pandemic, churches and temples were closed in many cities and states, and this can explain the lower wellbeing in our study for all the religions during the pandemic.
Dietitians that tested positive for SARS-COV-2 (n = 55) were predominantly working in-person (78.2%, n = 43), without or with adaptations (58.2%, n = 32; 20%, n = 11, respectively). Despite the need for adaptations, people working remotely during the pandemic had better wellbeing at work than the ones that are working in person. Probably, this is due to the possibility of a greater sense of security at home, and being near the family.
The new coronavirus pandemic arrived in Brazil at a time of economic stagnation, problems with the health and social protection systems, difficulties among the food security programs, accelerated increase in poverty, and, especially, extreme poverty, and a significant increase in the homeless population. Since March 2020, Brazil has accumulated a fall in gross domestic product (GDP) [53], and this retreat, partially caused by social isolation, has significantly increased formal and informal unemployment, in addition to precarious labor relations. This new scenario will directly impact dietitian's work and wellbeing, not only their work conditions, incomes, and uncertainties, but also the feeling of helplessness when facing hunger in the country.
At the same time, the pandemic can bring a search for new strategies for better conditions for health professionals in hospitals and clinics. New routines and behaviors for food production can be developed, not thinking only of food safety inside the production area, but also the attitudes of consumers. Dietitians have the potential to show the importance of their work, to avoid contaminations in foodservices, and bring more discussion about eating habits and immunity.
Dietitians are health professionals at the front line for the population's nutritional assistance. They work at all levels of complexity in the health care system, and may potentially reduce the risks of disease worsening, and contribute to the recovery of patients affected by Sars-Cov-2. The different spheres (population, governments, and other health professionals) must recognize the relevance of these professionals for public health in the country.

Conclusions
These data are essential to evaluating dietitians' perceptions of wellbeing at work and potentially helping to understand the main challenges supporting them to emerge from the pandemic as a different type of health care practitioner. The instrument presented an excellent KMO and internal consistency as a whole or by its factors. For all the participants' characteristics, wellbeing decreased during the pandemic, not showing specific influence among the analyzed variables. The hypothesis that the SARS-COV-2 pandemic period influences the wellbeing of Brazilian dietitians was confirmed. However, when evaluating wellbeing separately, before and during the pandemic, dietitians with partners, children, Ph.D. and receiving more than five MW presented higher wellbeing scores at work. During the pandemic period, dietitians working remotely also showed higher wellbeing. Regardless of the period, it is notable that, for dietitians' wellbeing at work to improve, better compensation for and recognition of the profession is necessary, as well as the conditions for their activities to be carried out. Health policymakers should discuss the role of health professionals as a multidisciplinary team, highlighting the importance of each category for the health system. Much improvement has happened in the health system in Brazil to integrate professionals but, as discussed, dietitians still feel unrecognized for their work. This study can open doors for more research and discussion in the field of wellbeing at work for health professionals, as well as a clear understanding of the factors that influence dietitians' wellbeing before and during the SARS-COV-2 pandemic, helping these professionals to recover after this period. Therefore, the data could help to explore the areas that most affected (before and during the pandemic period) wellbeing at work, favoring professional valorization. Further studies should be conducted after the pandemic period to evaluate the perceptions of dietitians' wellbeing at work due to the potential changes in the work environment and conditions in Brazil, and also in other countries, allowing comparisons netweem them.  data from the research participants, in order to allow the analysis of trends in responses according to personal and work characteristics. Please complete the questionnaire with this data, ensuring that none of this information will be used to identify any research participants.
Qual o estado brasileiro de residência atual?/What is your resindency state in Brazil?
Quantas pessoas vivem na sua casa incluindo você? Counting with you, how many persons live in the house? 7.
O trabalho como nutricionista é importante para mim/My work as a dietitian is important for me 2.
Percebo que minha profissão é valorizada onde trabalho/I realize that my profession is valued where I work 3.
Considero que exerço um trabalho importante para a sociedade/I comsider my work important for society 4.
Sou recompensado(a) por minha competência como nutricionista/I am rewarded for my competence as a dietitian 5.
Sou admirado(a) por meus colegas pelo trabalho que faço/I am admired by my colleagues for my work 6.
Tenho liberdade para executar minhas atividades com meu estilo pessoal/I am free to carry out my activities in my personal style 7.
Tenho a infraestrutura material necessária para a execução do meu trabalho/I have the necessary material infrastructure to carry out my work 8.
Tenho a possibilidade de me desenvolver profissionalmente/I have the possibility to improve professionally 9.
Sinto-me realizado(a) profissionalmente/I feel professionally fulfilled 10. Sinto-me seguro(a) com a possibilidade de continuar trabalhando como nutricionista/I feel safe with the possibility of continuing to work as a dietitian