Research - International Journal of Medical Research & Health Sciences ( 2021) Volume 10, Issue 4
Factors Influencing Stress Perception among Healthcare Workers during the Coronavirus Pandemic: A Multi-centric Cross-sectional Study
Moroj A Aldarmasi1* and Amal H Alghamdi22The Saudi Joint Program for Preventive Medicine, Ministry of Health, Jeddah, Saudi Arabia
Moroj A Aldarmasi, Community Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, Email: maldarmasi@kau.edu.sa
, DOI: 0
Abstract
Introduction: Pandemics increase the susceptibility of psychological illnesses among Healthcare Workers (HCWs). We aimed to estimate the stress level and identify factors influencing stress among healthcare workers during the Coronavirus-19 (COVID-19) pandemic.
Methods: A multi-centric cross-sectional study was performed between November 2020 and January 2021 in Jeddah, Kingdom of Saudi Arabia, involving four governmental hospitals. HCWs volunteered to participate in an electronic self-administered questionnaire, which used the 10-item perceived stress scale to assess stress.
Results: A total of 413 responses were received. Only 377 were eligible for this study. The mean stress score was 20 (SD=5). Most of the HCWs reported moderate stress levels (82%), compared to low or high-stress levels (10%) and (8%), respectively. Significant predictors for high-stress perception were determined using multivariate analysis. Our study determined that female, frontline, younger age groups and working long hours per day resulted in higher stress development.
Conclusions: This study indicated that overall, HCWs who worked during the COVID-19 pandemic were moderately stressed. Occupational stress management strategies need to be implemented to decrease stress to help manage COVID-19 related psychological problems and future pandemicrelated problemsy.
Keywords
COVID-19, Healthcare workers, Mental health, Stress, Pandemic, Jeddah
Introduction
In 2019, the novel Coronavirus Disease (COVID-19) originated in Wuhan, China which has become a global public health emergency [1]. The World Health Organization (WHO) announced COVID-19 to be a pandemic and stated that it poses a high health risk to countries with weak healthcare systems [2]. Naturally, the pandemic has led to concern among many people and has resulted in changes in the cognitive well-being of individuals worldwide [3].
Healthcare Workers (HCWs) are facing critical situations when managing COVID-19 patients [4]. Around 152,888 HCWs have been infected with COVID-19 since the onset of the disease, accounting for approximately 4% of the total cases [5]. HCWs are susceptible to a high risk of infection, mental illnesses, and psychological distress [1,4]. Many factors contribute to the mental burden of HCWs; these include the increasing number of cases, absence of medical supplies, depletion of personal protection equipment, overwhelming workload, and perception of insufficient assistance [4]. Furthermore, HCWs may be worried about spreading the virus to their families, friends, or colleagues [1].
Prior research has indicated that survivors of acute infectious diseases are at risk of developing stress, anxiety, depression, and posttraumatic stress disorder [6-8]. HCWs have been found to experience significant psychological distress as a result of fear of contagion, concern for their relatives, stigmatization, and job-induced stress [9-12]. Moreover, a review revealed that many socio-demographic factors, such as age, gender, place of work, and occupation, and psychological factors, such as lack of social support and self-efficacy, were associated with an increase in insomnia, distress, anxiety, and depression among HCWs [13]. Another study revealed that the perception of stress was not associated with the HCWs’ age or education level but was associated with their gender [14]. Interestingly, older people and those with longer work experience were found to have less stress and increased mental resilience [9,15]. The position in the hospital, e.g., nurse, doctor, or another HCW position, was not found to be associated with the perceived stress levels [14].
Increasing evidence suggests that COVID-19 could be a risk factor for stress among HCWs [13]. Therefore, we employed a cross-sectional study to address the gap of the psychological effects of COVID-19. We aimed to estimate the stress level and identify factors influencing the perception of stress among HCWs working in Jeddah, KSA, during the COVID-19 pandemic.
Materials and Methods
Study Design
The present cross-sectional study included HCWs working in four Ministry of Health (MOH) hospitals in Jeddah during the COVID-19 pandemic. The participants were recruited from November 2020 to January 2021. The hospitals were selected according to their geographical distribution. All HCWs within the four MOH hospitals were informed of the aim and objectives of the study, and an electronic questionnaire was distributed through the internal communications department. The survey consisted of an introduction to explain the purpose of the study, a consent form, and a selfquestionnaire. It was administered through web-based software, known as SurveyMonkey (http://www.surveymonkey. com), which provides a secure, password-protected, and anonymous online exchange. A reminder email was sent two weeks after sending the initial email. The study included male and female HCWs, including physicians, dentists, nurses, pharmacists, allied medical professionals, administration staff, and quality managers, who were above the age of 20 years. HCWs who had a psychiatric disease and those who were not working during the pandemic were excluded.
Questionnaire
In the first section of the survey, the participants were asked to provide the following information: age, gender, number of children, people they were living with, nationality, education level, work experience (years), job title, monthly income, the extent of direct interaction with COVID-19 patients, working hours per day, shift type, personal diagnosis of COVID-19, presence of a preexisting disease, and smoking status. The second section assessed the participants’ perception of stress. The 10-item Perceived Stress Scale (PSS) is most commonly used for assessing the perception of stress. The PSS was used in the present study to assess the extent of stress experienced by HCWs over the last month. This scale adopts a five-point Likert scale response format (from 0=never to 4=very often). PSS scores were obtained by reverse scoring the participants’ responses (0=4, 1=3, 2=2, 3=1, and 4=0) to four positively stated items (items 4, 5, 7, and 8). The total score was calculated as the sum of the scores for 10 items and ranged from 0 to 40. Higher scores were considered to indicate higher perceived stress. Scores of 0-13 indicated low perceived stress, 14- 26 indicated moderate perceived stress and 27-40 indicated high perceived stress [16]. This scale was provided in English and Arabic. The Arabic version was validated in another study [17]. Variables included in statistical analyses were identified from the literature and assessed for suitability in Saudi Arabia.
Ethical Approval
The initial approval for conducting the study was obtained from the Research and Studies Department at the Directorate of Health Affairs in Jeddah on September 14, 2020. The final approval was obtained on March 09, 2021 (approval number, A01004).
Statistical Analysis
An OpenEpi calculator was used to calculate the sample size. The margin of error was 5%, and the Confidence Interval (CI) was 95%. The HCW population size was 15,049 as per the MOH statistics [18]. The potential response rate was considered to be 50%.
Data were collected, coded, and analyzed using SPSS Statistics 26 (IBM). Continuous variables are presented as means and Standard Deviations (SDs), while categorical variables are presented as frequency distributions and percentages. The prevalence of different stress levels is presented as percentages. The association of perceived stress among HCWs with other variables was examined using an independent Student’s t-test and one-way Analysis of Variance (ANOVA) with a post-hoc Tukey HSD test. The correlation of perceived stress with age and work experience (years) was assessed using the Pearson correlation. Multilinear regression analysis was used to predict the PSS score and the outcome variable from independent variables when the p-value was <0.25 in bivariate analysis. A 95% CI was used throughout the study, and p-values <0.05 were considered statistically significant.
Results
Of the 413 respondents, 36 were excluded as they had a psychiatric illness. Consequently, a total of 377 respondents were eligible for the present study. The mean age of the participants was 36 years (SD=7, range=24-63 years). Their mean working experience was 11 years (SD=7, range=0-39 years). The participants’ mean PSS score was 20 (SD=5). Most participants (82%) reported experiencing a moderate level of stress in the previous month, while only a few reported experiencing a low (10%) or high (8%) level of stress. The other socio-demographic variables are discussed in Table 1. Gender, number of children, nationality, direct interaction with COVID-19 patients, and working hours per day had a significant association with the participants’ PSS score. However, no significant association was observed between the PSS score and other demographic variables (Table 2).
| Variable | Item | Number (%) |
|---|---|---|
| Gender | Female | 245 (65%) |
| Male | 132 (35%) | |
| Marital status | Single | 92 (24.4%) |
| Married | 257 (68.2%) | |
| Widowed | 4 (1.1%) | |
| Divorced | 24 (6.4%) | |
| Having Children | Yes | 252 (66.8%) |
| No | 125 (33.2%) | |
| Living with | Family | 355 (94.2%) |
| Friend | 2 (0.5%) | |
| Alone | 20 (5.3%) | |
| Nationality | Saudi | 350 (92.8%) |
| Non-Saudi | 27 (7.2%) | |
| Highest level of education | Secondary school | 4 (1.1%) |
| Diploma | 69 (18.3%) | |
| Bachelors | 169 (44.8%) | |
| Postgraduate studies | 135 (35.8%) | |
| Job title | Physician | 150 (39.8) |
| Dentist | 16 (4.2%) | |
| Nurse | 82 (21.8 %) | |
| Pharmacist | 9 (2.4%) | |
| Allied health personnel | 74 (19.6%) | |
| Other | 46 (12.2%) | |
| Monthly Income | Less than 1100 euro | 10 (2.7%) |
| From 1100 to 2200 euro | 73 (19.4%) | |
| From 2201 to 4500 euro | 189 (50.1%) | |
| From 45001 to 6500 euro | 65 (17.2%) | |
| More than 6500 euro | 40 (10.6%) | |
| Smoking status | Yes | 95 (25.2%) |
| No | 261 (69.2%) | |
| Ex-smoker | 21 (5.6%) | |
| Current dealing with COVID-19 patients directly | Yes | 214 (56.8%) |
| No | 163 (43.2%) | |
| Working hours per day | Less than 8hours | 14 (3.7%) |
| 8 hours | 238 (63.1%) | |
| 9 hours -12 hours | 107 (28.4%) | |
| More than 12 hours | 18 (4.8%) | |
| Usual shift type | Morning shift | 248 (65.8%) |
| Evening shift | 11 (2.9%) | |
| Night shift | 6 (1.6%) | |
| Mixed | 112 (29.7%) | |
| Diagnosed to have COVID-19 infection based on lap result | Yes | 55 (14.6%) |
| No | 322 (85.4%) | |
| Presence of a preexisting disease | Yes | 77 (20.4%) |
| Diabetes | 18 (25.71%) | |
| Hypertension | 33 (47.14%) | |
| Asthma | 20 (28.57%) | |
| Obesity | 18 (25.71%) | |
| Other | 20 (27.14%) | |
| No | 300 (79.6%) |
| Variable | Item | Mean score | SD | Statistical test | p-value |
|---|---|---|---|---|---|
| Gender | Female | 20.7 | 4.6 | t=3.2 | 0.001 |
| Male | 19.1 | 4.7 | |||
| Marital status | Single | 20.88 | 4.5 | F=1.1 | 0.339 |
| Married | 19.87 | 4.5 | |||
| Widowed | 19.07 | 4.2 | |||
| Divorced | 20.38 | 6.8 | |||
| Having Children | Yes | 19.7 | 4.8 | t= -2.3 | 0.019 |
| No | 20.9 | 4.4 | |||
| Living with | Family | 20.09 | 4.6 | F=0.34 | 0.708 |
| Friend | 20.5 | 0.7 | |||
| Alone | 21 | 5 | |||
| Nationality | Saudi | 18.12 | 5.4 | t= -2.3 | 0.02 |
| Non-Saudi | 20.3 | 4.6 | |||
| Highest level of education | Secondary school | 20.29 | 5.4 | F=0.21 | 0.887 |
| Diploma | 19.76 | 5.2 | |||
| Bachelors | 20.29 | 4.4 | |||
| Postgraduate studies | 20.14 | 4.8 | |||
| Job title | Physician | 20.25 | 4.4 | F=1.2 | 0.285 |
| Dentist | 20.09 | 3.5 | |||
| Nurse | 20.51 | 5.3 | |||
| Pharmacist | 23.14 | 4.8 | |||
| Allied health personnel | 19.62 | 4.7 | |||
| Other | 19.41 | 5 | |||
| Monthly Income | Less than 1100 euro | 21.01 | 4.1 | F=0.26 | 0.904 |
| From 1100 to 2200 euro | 19.9 | 5.4 | |||
| From 2201 to 4500 euro | 20.31 | 4.7 | |||
| From 45001 to 6500 euro | 19.84 | 3.9 | |||
| More than 6500 euro | 20.07 | 4.6 | |||
| Smoking status | Yes | 20.07 | 4.7 | F=1.15 | 0.318 |
| No | 20.29 | 4.7 | |||
| Ex-smoker | 18.68 | 4.6 | |||
| Current dealing with COVID-19 patients directly | Yes | 20.7 | 4.5 | t=2.6 | 0.009 |
| No | 19.4 | 4.9 | |||
| Working hours per day | Less than 8hours | 20.82 | 4.5 | F=2.7 | 0.041 |
| 8 hours | 19.71 | 4.6 | |||
| 9-12 hours | 20.59 | 5 | |||
| More than 12 hours | 22.62 | 3.8 | |||
| Usual shift type | Morning shift | 19.82 | 4.5 | F=2.6 | 0.48 |
| Evening shift | 21.19 | 3.4 | |||
| Night shift | 16.86 | 4.1 | |||
| Mixed | 20.94 | 5.2 | |||
| Diagnosed to have COVID-19 infection based on lap result | Yes | 19.4 | 4.6 | t= -1.3 | 0.176 |
| No | 20.3 | 4.7 | |||
| Presence of a preexisting disease | Yes | 20.8 | 4.5 | t=1.3 | 0.846 |
| No | 19.98 | 4.7 |
There was a mild correlation between the PSS score and age (R= -0.21, p<0.001) and a low correlation between the PSS score and work experience (years) (R= -0.19, p<0.001). The scatter diagram for both the comparisons showed a negative linear correlation (Table 3).
| Variable | Correlation Coefficient | p-value |
|---|---|---|
| Age | -0.21 | <0.001 |
| Work experience in year | -0.19 | <0.001 |
A stepwise multilinear regression model was used to predict statistical significance. Age (95% CI= -0.192- 0.064, p<0.0001), gender (95% CI= -2.60-0.679, p=0.001), direct interaction with COVID-19 patients (95% CI = -2.20-0.347, p=0.007), and working hours per day (95% CI=0.078-1.533, p=0.030) were significant independent predictors for a higher perception of stress. These factors accounted for 3.14% of the variance in the PSS score (F=10.16, p<0.001, R2=0.099, and adjusted R2=0.089) (Table 4).
| Unstandardized Coefficients B | Standardized Coefficients Beta | p-value | 95% C.I. for Odds Ratio | ||
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Age | -0.128 | -0.193 | 0 | -0.192 | -0.064 |
| Gender | -1.64 | -0.167 | 0.001 | -2.60 | -0.679 |
| Dealing directly with COVID-19 patients | -1.27 | -0.134 | 0.007 | -2.20 | -0.347 |
| Working hours per day | 0.805 | 0.108 | 0.03 | 0.078 | 1.533 |
| Constant | 26.95 | - | 0 | 23.49 | 30.41 |
| R Square=0.099 | Adjusted R Square=0.089 | ||||
Discussion
The COVID-19 pandemic has instigated mental health issues as a result of powerlessness, fears of being infected and of infecting others, anxiety, distress, and depression at an individual level. At a community level, the rate of psychiatric illnesses is similar to that observed during the severe acute respiratory syndrome epidemic. HCWs are considered to be at the highest risk of experiencing distress and mental health problems during disease outbreaks [2,19-21]. The present study aimed to assess stress levels and identify factors influencing the perception of stress among HCWs working in Jeddah, Kingdom of Saudi Arabia, during the COVID-19 pandemic. Our findings provide the first step toward understanding the factors that negatively influence mental health within Jeddah.
Most HCWs reported having a moderate stress level in the present study. These results are in line with those of previous studies from China, India, Iraq, Egypt, and Al Madinah Al Munawwarah [22-26]. The high prevalence of perceived stress among HCWs may be explained by the severe strain imposed by COVID-19 on health services and the resultant highly stressful working environment [23]. Furthermore, a previous study reported HCWs and frontline workers to have a higher stress level than the general public because of their direct interaction with COVID-19 patients [27].
In the present study, females were found to have higher perceived stress levels than males; this finding is consistent with previous findings [24,26,27]. Although another study revealed a higher stress level among males, females usually exhibit more reactivity in neural networks than males, resulting in an arousal response to fear [14,28]. Other variables related to significantly higher stress levels included young age, direct interaction with COVID-19 patients, low working experience, and working for more than 12 hours per day. These predictors were similar to those reported by Khalf, et al. and Luan, et al.; these findings could be explained by fatigue caused by work overload and the high physical and mental demands of healthcare services [24,27].
There were no significant differences in the participants’ PSS scores based on the following factors: marital status, people they were living with, job title, monthly income, shift type, presence of a preexisting disease, personal diagnosis of COVID-19, and smoking status. Furthermore, participants who were older and had more years of work experience had more stable mental health, were less distracted under stress, and were relatively free of neurotic anxiety. This may be due to the reduced working hours of senior HCWs and their greater experience in handling critical situations than junior HCWs [24]. We found that a higher prevalence of stress among HCWs was a common problem across all four hospitals; these findings are in line with those of previous studies published before the COVID-19 pandemic [29,30].
Certain limitations should be considered when interpreting the present findings. The present study was cross-sectional and was restricted to a single city; therefore, the results cannot be generalized. Moreover, our findings do not reflect the changes in the participants’ stress levels overtime during the COVID-19 pandemic. Conducting longitudinal research with an appropriate sample size will help understand the stress experienced on a broader scale and may reveal significant differences in other variables related to the perception of stress. We recommend that future studies should assess more independent variables, such as the type of home (private or rented), the distance between work and home, and other vital signs of HCWs (such as their weight, body mass index, and blood pressure). Despite these limitations, the present results provide essential information to address the gap between the factors influencing the psychological effects of COVID-19 and the mental health status of HCWs.
Conclusion
The present study revealed that HCWs working during the COVID-19 pandemic are at risk of moderate stress levels, contributing to the healthcare burden. Occupational stress management strategies need to be implemented to prepare for future outbreaks and reduce stress levels among HCWs.
Declarations
Conflicts of Interest
The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.
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