Level of anxiety and depression among healthcare workers in Saudi Arabia during the COVID-19 pandemic

Study design and settings

An online cross-sectional survey study was conducted to test the research hypothesis. This design was employed to recruit a convenience sample of healthcare professionals who work for public healthcare facilities and the Dr. Sulaiman Al Habib Medical Group, the largest private healthcare provider in Saudi Arabia. That medical group operates eight tertiary private hospitals located in different geographical areas in Saudi Arabia. A convenience sample was considered to be the most appropriate sampling design during the early stage of the pandemic as it is efficient, simple to implement and the principal investigator is employed in Al Habib medical group.

Study population

This study included females and males, who were Saudi or non-Saudi healthcare workers working in public or private such as Dr. Sulaiman Al Habib Medical Group. Study selection was based on the following inclusion criteria: (1) healthcare worker aged ≥ 21 years old; (2) living in Saudi Arabia at the time of the study; (3) the healthcare worker was responsible for providing direct patient care in an inpatient or outpatient healthcare setting: and (4) spent at least six months in the current clinical unit.

Ethical consideration

The researchers obtained ethical approval to conduct the study from the Institutional Review Board at Dr. Sulaiman Al Habib Medical Group (IRB log Number: RC20.03.79). Participation in the study was voluntary and the participants were ensured through the online explanatory letter that the information gathered for the study would be kept confidential and would only be used for the study’s purposes. Online informed consent was obtained from all the participants and they were able to download and save the consent.

Sample

The sample size was calculated using G*Power; considering the sample size parameters, moderate effect size, 5% significance level, and 80% power, it was determined that 300 participants would be a sufficient sample size (Faul et al., 2007). A total of 500 healthcare workers were invited to participate in the study, and 326 submitted the completed questionnaires, resulting in a response rate of 65.2% (Fig. 1). All of those who consented to participate in the study, submitted their completed questionnaires. The response rate was computed through determining the IP addresses.

An online link to the anonymous survey was developed through the Qualtrics platform and distributed among healthcare workers in Saudi Arabia. Participants received the online survey through social media channels (WhatsApp, Facebook, Twitter, LinkedIn, Snapchat and Instagram) and emails of staff at Dr. Sulaiman Al Habib Medical Group. The online survey was open for respondents to complete from April 26, 2020 to May 10, 2020. This was done to allow sufficient time for healthcare workers to participate in the study taking into consideration their overwhelming busy schedules during the COVID-19 pandemic.

Instruments

The Zung Self-Rating Depression Scale (SDS) and Generalized Anxiety Disorder Scale-7 (GAD-7) has previously been used in English to measure depression and anxiety levels among healthcare workers. The tools were in the English language as English is the official language used in all hospitals in Saudi Arabia. In addition, the sample included Arabic and non- Arabic speakers. The GAD-7 is a self-rated scale and consists of 7 items ranked using a Likert scale (Spitzer et al., 2006). Previous studies have shown that the GAD-7 scale has adequate reliability and validity (Rutter & Brown, 2017). The scale score ranges from 1 to 21, and it is classified as mild (5–9), moderate (10–14), or severe (15–21) (Spitzer et al., 2006) based on the total mean score. Scores of ≥ 10 are considered a reasonable cut-point for identifying probable cases of GAD.

The SDS is a tool used to screen depression in different populations. It consists of 20 items ranked on a 4-point Likert scale. The SDS scale score ranges from 20 to 80, with the scores classified as no depression (20 to 49), mild depression (50 to 59), moderate depression (60 to 69), and severe depression (>70) (Zung, 1967). The scale has shown adequate validity and reliability with an alpha value of 0.84 (Dunn & Sacco, 1989; Zung, 1967).

In the current study, the researchers added an additional part to the questionnaire regarding the socio-demographic characteristics of the respondents. These included gender, age, marital status, economic status, nationality, type of healthcare facility, profession, working facility, working area, and number of years of working experience. The socio-demographic part also included whether the respondents had become involved with testing and treating patients with COVID-19 and the level of severity of the COVID-19 cases they dealt with.

Data analysis

Data were summarized using counts, percentages, medians, and first and third quartiles. Bivariate and multivariable analyses were performed to investigate if the study’s two outcomes (anxiety and depression scores) were associated with socio-demographics factors. The distributions of the outcomes were assessed using the Shapiro–Wilk test for normality; it was found that both scores were not normally distributed (p-value <0.0001 for anxiety and p-value = 0.036 for depression). Therefore, the non-parametric Wilcoxon rank sum, Mann–Whitney U test, or Kruskal-Wallis was used in the bivariate analyses with the categorical independent variable. The non-parametric Spearman correlations were used for the depression scores and were log-transformed to stabilize the variance, after adding a constant of 1 to each participant’s anxiety score due to 0 values on this scale. Then, generalized linear models were used to assess the combined effect of the socio-demographics variables. The best model was found in two steps: first, a full model included the log-transformed outcome and all the predictors. Then, significant predictors (p-value <0.05) or those close to significance (p-value <0.08) from the full model were included in a reduced model. An F-test of overall significance was used to indicate whether the reduced model provided a better fit to the data then the full model. Because anxiety might be a sign of depression, the anxiety score was included as a covariate in the model with the depression score as the outcome. The level of significance was set at 5%. All analyses were performed using SAS 9.4 statistical software.

Socio-demographic characteristics

A total of 326 healthcare workers completed the survey. The socio-demographic characteristics of the participants are shown in Table 1. The majority of the respondents were Saudi Arabian nationals (94.8%), and more than half of the participants were female (58.6%). Half of the respondents were younger than 30 (50.0%) and almost half of respondents were married (49.4%). The economic status of the respondents were: poor (2.1%), good (43.9%), very good (42%), and excellent (12%). Most of the participants worked in a public hospital (89.9%); the remaining (5.2%) worked in the private sector. It was found that 40.5% of the respondents worked in a secondary or a tertiary hospital, 26.7% worked in a specialized hospital, and 20.9% worked in a primary healthcare center. More than half of the participants were physicians (34.7%) and nurses (21.8%) working in different areas of the hospital with an average of 7.35 ± 6.08 years of experience. The working areas of the participants included the emergency room (ER) (14.1%), ward (24.2%), intensive care unit (ICU) (7.7%), labs (10.4%), and other areas (43.6%). Almost half (46.3%) of the healthcare workers were not involved with treating or testing patients with COVID-19. The rest of the participants had dealt with, on average, 7.67 ± 9.78 patients with COVID-19. The majority of the COVID-19 cases were considered mild (53.1%). Moreover, almost half (46.3%) of all the respondents did not report the level of severity of the COVID-19 cases they dealt with, as they reported having not cared for these patients.

The bivariate analyses revealed that a number of socio-demographic variables were significantly associated with anxiety or depression (Table 1). Gender was significantly associated with anxiety (median score 6.0 (3.0, 9.0) for males and 7.0 (5.0, 11.0) for females, p = 0.008) and with depression (median score 39.0 (32.0, 48.0) for males and 43.0 (36.0, 50.0) for females, p = 0.007). Economic status was significantly associated with anxiety: (poor median score 16.0 (9.0, 17.0), good 7.0 (5.0, 10.0), very good 46.0 (4.0, 9.0), and excellent 7.0 (3.0, 14.0); p = 0.006) and with depression (poor median score 45.0 (40.0, 66.0), good 44.0 (37.0, 50.0), very good 39.0 (33.0, 47.0), and excellent 40.0 (30.0, 51.0); p = 0.003). The type of working facility was also associated with anxiety (primary healthcare center median score 6.5 (3.0, 10.5), secondary or tertiary hospital 7.0 (5.0, 10.0), specialized hospital 7.0 (5.0, 12.0), polyclinic 5.0 (4.0, 4.0), lab 3.0 (1.0, 6.0), and other 7.5 (6.0, 10.0), p = 0.023) and with depression symptoms (primary healthcare center 42.5 (34.0, 50.0), secondary or tertiary hospital 40.5 (34.0, 48.0),), specialized hospital 44.0 (38.0, 51.0), polyclinic 38.0 (33.0, 43.5), and other 34.0 (31.0, 36.0), p = 0.007). The anxiety scores of the healthcare workers involved with COVID-19 were higher (not involved in COVID-19 cases, 6.0 (4.0, 10.0), diagnosis 7.0 (4.0, 9.0), treatment 9.0 (5.0, 11.0), nursing care 9.0 (6.5, 15.0), and 7.0 (5.0, 10.0); p = 0.031) in comparison to depression scores (not involved in COVID-19 cases 40.0 (33.0, 48.0), diagnosis 42.5 (34.5, 50.0), treatment 43.0 (33.0, 50.0), nursing care 46.0 (43.0, 51.5), and other 40.5 (36.0, 47.0); p = 0.153). The number of patients with COVID-19 that the healthcare workers dealt with was significantly correlated with the anxiety scores, yet the correlation was weak (correlation coefficient = 0.123, p =0.026), but was not significantly correlated with the depression scores (correlation coefficient = 0.066, p = 0.232).

Level of anxiety and depression

The level of anxiety was categorized as mild, moderate, and severe. Scores of ≥ 10 on GAD-7 needed further evaluation to confirm GAD diagnoses. A total of 234 (72.5%) respondents had anxiety. It was found that 141 (44.1%) of the respondents had mild anxiety, 53 (16.2%) had moderate anxiety, and 40 (12.2%) had severe anxiety (Fig. 2). A total of 80 (24.4%) respondents had depression. Of those respondents, 71 (21.7%) had mild depression, seven (2.1%) had moderate depression, and two (0.6%) had severe depression (Fig. 2).

Association between the socio-demographic characteristics and anxiety and depression

The results of the generalized linear models were applied to explain the association between the socio-demographic characteristics and the anxiety and depression scores, respectively, as shown in Table 2. In the multivariable analyses with anxiety as the outcome, the F-test of overall significance (F (21,294) =1.04, p = 0.418) indicated that the reduced model, including age (p = 0.005), gender (p = 0.005), type of working facility (p = 0.001), and the number of cases dealt with (p = 0.010), was the best fit for the data. The analysis model suggests that the <30 age group (Beta = 0.556, p = 0.037) and the 30–39-year age group (Beta = 0.623, p = 0.019) were predicted to have significantly more anxiety than the ≥ 50 age group. The female respondents were more anxious (Beta = 0.241, p = 0.005) than the male respondents. The analysis also suggests that healthcare providers who worked in a primary healthcare center (Beta = −0.315, p = 0.008) and labs (Beta = −0.845, p = 0.0001 were predicted to have significantly less anxiety than those working in specialized hospitals. Anxiety significantly increased with the growing number of COVID-19 cases (Beta = 0.013, p = 0.009).

In the multivariable analyses with depression as the outcome, the F-test of overall significance (F(28,293) = 1.14, p-value = 0.31) indicated that the reduced model, including anxiety level (p < 0.0001) and socio-economic status (p =0.001), was the best fit for the data. The good socio-economic status group was predicted to be significantly more depressed (Beta = 0.067, p = 0.003) than the very good socio-economic status group. The analysis model found that the respondents’ anxiety GAD-7 score was significant (Beta = 0.030, p < 0.001), indicating that the anxiety level of the respondents predicted significantly higher levels of depression.

Limitations

This study has some limitations. It used a cross-sectional study design, convenience sampling, surveys were distributed online, and it included frontline and non-frontline healthcare workers. Therefore, caution should be taken when generalizing the results to all healthcare workers in Saudi Arabia. In addition, important variables were not examined, such as experience with previous pandemics, as we considered the time to fill out the survey during the high workload of the healthcare workers during the pandemic.

Implication for practice

This cross-sectional design does not support changes in clinical practice. It is strongly recommended, however, to encourage screening healthcare providers for anxiety and depression at times of pandemics. With special consideration for female healthcare workers, being younger than 30, ranging in age from 30 to 39, working in a specialized hospital, and dealing with a higher number of COVID-19 cases as they were associated with anxiety. In addition, it’s encouraged to screen healthcare workers with good socio-economic economic for depression.

Implication for research

This study has the potential to become a longitudinal study for tracking the prevalence of and factors related to levels of anxiety and depression in healthcare workers. Moreover, a psychological assessment for anxiety and depression should be conducted at another point during the pandemic. Additional studies should be conducted to target frontline healthcare workers in Saudi Arabia with a consideration of supporting those who are not directly caring for COVID-19 patients. In addition, qualitative studies should be conducted on healthcare providers working in primary healthcare centers, labs, and specialized hospitals to explore the impact of COVID-19 on anxiety and depression among healthcare workers.