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Journal of A!ective Disordersjournal homepage: www.elsevier.com/locate/jad

Research paper

Depressed, anxious, and stressed: What have healthcare workers on thefrontlines in Egypt and Saudi Arabia experienced during the COVID-19pandemic?Ahmed Arafaa,b,!, Zeinab Mohammedb, Omaima Mahmoudc, Momen Elshazleyd,e, Ashraf Ewisf,ga Department of Public Health, Graduate School of Medicine, Osaka University, Osaka, Japanb Department of Public Health, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egyptc Department of Psychiatric Nursing, Faculty of Nursing, Beni-Suef University, Beni-Suef, Egyptd Department of Medicine, Taibah College of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabiae Department of Occupational Medicine, Faculty of Medicine, Sohag University, Sohag, Egyptf Department of Public Health, Faculty of Medicine, Minia University, El-Minia, Egyptg Department of Public Health and Occupational Medicine, Faculty of Health Sciences – AlQunfudah, Umm AlQura University, Meccah, Saudi Arabia

A R T I C L E I N F O

Keywords:AnxietyCOVID-19DepressionHealthcare workersSleeping hoursStress

A B S T R A C T

Introduction: As the Novel Corona Virus Disease (COVID-19) was declared by the world health organization apandemic in March 2020, thousands of healthcare workers (HCWs) worldwide were on the frontlines fightingagainst the pandemic. Herein, we selected two Middle East countries; Egypt and Saudi Arabia to investigate thepsychological impacts of the COVID-19 pandemic on their HCWs.Methods: In this cross-sectional study, a Google survey was used to access HCWs in many hospitals in Egypt andSaudi Arabia between the 14th and 24th of April 2020. The survey assessed HCWs regarding their socio-demographic and occupational features, sleeping hours, and psychological impacts of the COVID-19 pandemicusing the Depression Anxiety Stress Scale-21 (DASS-21).Results: This study included 426 HCWs (48.4% physicians, 24.2% nurses, and 27.4% other HCWs). Of them,69% had depression, 58.9% had anxiety, 55.9% had stress, and 37.3% had inadequate sleeping (<6 h/day).Female sex, age "30 years, working in Egypt, attending emergency and night shifts, watching/reading COVID-19 news #2 h/day, and not getting emotional support from family, society, and hospital were associated with ahigh likelihood of depression, anxiety, stress, and inadequate sleeping.Limitations: the cross-sectional design restricted our ability to distinguish between preexisting and emergingpsychological symptoms.Conclusion: HCWs on the frontlines in Egypt and Saudi Arabia experienced depression, anxiety, stress, and in-adequate sleeping during the COVID-19 pandemic.

1. Introduction

With more than 110 countries a!ected, the World HealthOrganization (WHO) declared, on the 11th of March 2020, the NovelCorona Virus Disease (COVID-19) a pandemic (WHO 2020a). As of the1st of May 2020, 3175,207 confirmed COVID-19 cases and 224,172related deaths have been reported worldwide (WHO, 2020b). In re-sponse to the COVID-19 pandemic, a state of lockdown in severalcountries has been set to prevent the spread of infection which resultedin huge economic losses, breaks in the global supply chains, wide mediacoverage, political division, disrupted travel plans, school closures, and

future uncertainty. These consequences led to a global atmosphere ofpsychological distress (Ebrahim et al., 2020; Ho et al., 2020; Peng et al.,2020).

Healthcare workers (HCWs) on the frontlines are, however, morevulnerable to traumatization and psychological deficits during theCOVID-19 pandemic (Roy et al., 2020; Lai et al., 2020; Cai et al., 2020;de Pablo et al., 2020). In addition to the previous factors, the fear ofgetting infected or infecting family and friends, the hefty workload, theintermittent shortage of personal protective equipment (PPE), and theneed to take stressful precautions during the medical examination andin the operative fields can add enormous psychological burdens to

https://doi.org/10.1016/j.jad.2020.09.080Received 3 May 2020; Received in revised form 18 August 2020; Accepted 17 September 2020

! Corresponding author.E-mail address: [email protected] (A. Arafa).

Journal of Affective Disorders 278 (2021) 365–371

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279 2020

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HCWs (Joob and Wiwanitkit, 2020; Montemurro, 2020). These burdensdo not only undermine the health-related quality of life of HCWs butalso diminish their caring behaviors and increase practice errorsleading to worse outcomes and additional costs (Sarafis et al., 2016;Wagner et al., 2018).

Reports emerging from China, where the COVID-19 was first de-tected, showed a high prevalence of depression, anxiety, and insomniaamong HCWs (Du et al., 2020; Lai et al., 2020; Zhang et al., 2020a,2020b; Liu et al., 2020; Xiao et al., 2020). In Arab countries, wheresurveillance and infection control programs, laboratory capacity, andpublic health resources are limited (Jabbour, 2013; Asbu et al., 2017),the response of HCWs to the COVID-19 pandemic would be challengingand, as a result, the psychological impacts of the pandemic on HCWs inArab countries could be augmented. Egypt and Saudi Arabia, in parti-cular, are among the most a$icted Arab countries on the human andfinancial levels (WHO, 2020b; Al-Tawfiq and Memish, 2020). Living inseverely hit areas by the COVID-19 was shown to be associated withpsychological distress (Tang et al., 2020). Hence, we conducted thiscross-sectional study to evaluate psychological disturbances amongHCWs on the frontlines in Egypt and Saudi Arabia during the COVID-19pandemic and to investigate the potential associations with these dis-turbances. We hope that our study can help in detecting HCWs at highrisk of psychological disturbances and determining potential associa-tions for possible interventions during this pandemic or future waves ofinfection in both countries.

2. Methods

2.1. Subjects

HCWs in Egypt and Saudi Arabia were invited to participate in thiscross-sectional survey during the period between the 14th and 24th ofApril 2020. Because of the lockdown in both countries, a non-prob-ability snowball sampling technique was used. A Google survey wascreated and the link to the survey was sent by e-mails to HCWs withrecorded contact details in Beni-Suef University Hospital and Beni-SuefGeneral Hospital in Egypt and Taibah Teaching Hospital in Al-MadinahAl-Munawwarah in Saudi Arabia. The e-mails were sent on the 14th ofApril 2020 and reminders were sent 5 days later. We also shared thesurvey link to the social network groups that include HCWs from bothcountries. HCWs were asked to forward the link to other HCWs fromtheir contact e-mail and social network lists. Social network use iswidespread among HCWs in Egypt (Abdel Wahed et al., 2020) andSaudi Arabia (Almaiman et al., 2015). Our eligibility criteria included:1) HCWs working in Egypt and Saudi Arabia, 2) aged #18 years old,and 3) currently working in a hospital managing patients infected orcould be infected with COVID-19. HCWs included physicians, nurses,pharmacists, technicians, and paramedics. HCWs who reported workingin academic and research but not in hospitals managing COVID-19 wereexcluded.

2.2. Data collection

We designed an Arabic questionnaire composed of 4 sections tocollect the data. Section I included a detailed explanation of the steps,aims, and eligibility criteria of the study. Section II included questionsabout the sociodemographic and occupational features of HCWs in-cluding age (18–30, 31–45, or >45 years), sex (man or woman),country (Egypt or Saudi Arabia) and city where he/she works (type thename), living with children (yes or no), living with older adults (yes orno), profession (physician, nurse, pharmacist, technician, paramedic, orothers and specify), department (internal medicine: general and spe-cialties, surgery: general and specialties, emergency, radiology, orothers and specify), and years of experience (1–5, 6–15, or >15 years).Section III included questions related to occupation during the previousmonth only and included the following: average daily working hours

(1–6, 7–12, or >12 h/day), average daily sleeping hours (<6, 6–9, or>9 h/day), attending emergency shifts (never, 1–2, or >2 shifts/week), attending night shifts (never, 1–2, or >2 shifts/week), watchingor reading news about COVID-19 (<1, 2–4, or >4 h/day), gettingenough emotional support from family (yes or no), getting enoughemotional support from the society (yes or no), and getting enoughemotional support from the hospital where he/she works (yes or no).Section IV included the Arabic version of the Depression Anxiety StressScale-21 (DASS-21). The DASS-21 is a quantitative measure of depres-sion, anxiety, and stress symptomatology (7 statements each) duringthe past week. The depression statements evaluate hopelessness, dys-phoria, self-deprecation, devaluation of life, lack of interest and in-volvement, anhedonia, and inertia. The anxiety statements evaluateskeletal muscle e!ects, autonomic arousal, situational anxiety, andsubjective experience of anxious a!ect. The stress scale evaluates ner-vous arousal, di%culties in relaxation, and being easily upset or over-reactive. Participants should decide how much the statements apply forthem using a scale from 0 to 3 where 0 refers to “did not apply to me atall”, 1 refers to “applied to me to some degree or some of the time”, 2refers to “applied to me to a considerable degree or a good part of thetime”, and 3 refers to “applied to me very much or most of the time”.The score of each axis is multiplied by 2 to lie within a 0 to 42 scalewhere higher scores indicate worse outcomes (Lovibond andLovibond, 1995). The Arabic version of the DASS-21 was validated in aprevious study and the Cronbach's alpha for its subscales was 0.81,0.76, and 0.67, respectively (Ali et al., 2017). In this study, depression,anxiety, stress, and sleeping <6 h/day were considered outcomes.Sleeping <6 h/day was referred to in this article as “inadequatesleeping”. We programed the Google survey to make all questions butone (the name of the city where subject works) mandatory.

2.3. Statistical analyses

The adopted cut-o! values for the DASS-21 scales were the fol-lowing: 1) Depression: normal (0–9), mild to moderate (10–20), andsevere to extremely severe (#21), 2) Anxiety: normal (0–7), mild tomoderate (8–14), and severe to extremely severe (#15), and 3) Stress:normal (0–14), mild to moderate (15–25), and severe to extremely se-vere (#26) (Lovibond and Lovibond, 1995).

The logistic regression analyses were used to calculate the un-adjusted and adjusted odds ratios (ORs) and their 95% confidence in-tervals (CIs) of di!erent sociodemographic factors for HCWs with mildto moderate and severe to very severe depression, anxiety, and stress,and inadequate sleep compared with HCWs without the correspondingpsychological conditions. The following variables were included in theregression models: age, sex, profession, and country. HCWs other thanphysicians and nurses were assigned to one group referred to as “otherHCWs”. Data were analyzed using the Statistical Package for SocialScience (SPSS) released in 2013 (IBM SPSS Statistics for Windows,Version 22.0, IBM Corporation, Armonk, New York).

2.4. Ethical considerations

We conducted the study in full accordance with the guidelines forGood Clinical Practice and the Declaration of Helsinki. The conditionsand eligibility criteria of the study were described in section I and re-spondents had to agree to proceed to the upcoming sections and tosubmit their answers after filling out the survey which was consideredapproval of participation.

3. Results

This study included 426 HCWs (275 from Egypt and 151 from SaudiArabia) distributed as follows: 206 (48.4%) physicians, 103 (24.2%)nurses, and 117 (27.4%) other HCWs. Of them, 47.2% were aged "30years, 50.2% were men, 65% were living with children, and 51.6%

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were living with older adults. More than half of HCWs reported at-tending emergency shifts (55.6%) and night shifts (51.4%) andwatching or reading COVID-19 news #2 h/day (56.1%) during theprevious month. Getting enough emotional support from family duringthe pandemic was higher than that from society and hospital; 78.9%,44.6%, and 35.6%, respectively (Table 1).

Up to 69% of HCWs had depression (39.4% mild to moderate and29.6% severe to very severe), 58.9% had anxiety (31.9% mild tomoderate and 27.0% severe to very severe), and 55.9% had stress(36.6% mild to moderate and 19.3% severe to very severe). More than athird (37.3%) of HCWs reported inadequate sleeping during the pre-vious month (Table 2).

In the multivariable-adjusted regression model, several personaland occupational factors were associated with depression, anxiety,stress, and inadequate sleeping. Of these factors, age "30 years wasassociated with severe to very severe forms of depression (OR 2.88,95% CI: 1.25, 6.62) and stress (OR 2.49, 95% CI: 1.00, 6.18). Comparedwith men, women had more severe to very severe depression (OR 2.57,95% CI: 1.43, 4.61), anxiety (OR 2.68, 95% CI: 1.56, 4.62), and stress(OR 2.39, 95% CI: 1.33, 4.32). HCWs in Egypt were more likely toshow, compared with their counterparts in Saudi Arabia, mild tomoderate depression (OR 2.19, 95% CI: 1.28, 3.74), anxiety (OR 2.27,95% CI: 1.32, 3.88), and stress (OR 3.67, 95%CI: 2.13, 6.31) and severeto very severe depression (OR 4.71, 95% CI: 2.45, 9.04), anxiety (OR3.31, 95% CI: 1.78, 6.15), and stress (OR 2.81, 95% CI: 1.45, 5.45).Also, attending emergency and night shifts was associated with variousforms of depression, anxiety, stress, and inadequate sleeping.Watching/reading COVID-19 news #2 h/day was associated with ahigh risk of depression, anxiety, stress, and inadequate sleeping.Besides, lack of perceived emotional support from family, society, and

hospital was related to depression, anxiety, stress, and inadequatesleeping. However, depression, anxiety, stress, and inadequate sleepingdid not di!er between professions or departments (Table 3).

4. Discussion

This study indicated that, during the COVID-19 pandemic, 69% ofHCWs in Egypt and Saudi Arabia had depression (39.4% mild tomoderate and 29.6% severe to very severe), 58.9% had anxiety (31.9%mild to moderate and 27.0% severe to very severe), 55.9% had stress(36.6% mild to moderate and 19.3% severe to very severe), and 37.3%experienced inadequate sleeping.

In line with our findings, a cross-sectional study reported a highprevalence of depression (50.4%) and anxiety (44.6%) among 1257Chinese HCWs on the frontlines during the COVID-19 pandemic(Lai et al., 2020). Another study conducted on 134 HCWs from Chinaput the prevalence of anxiety at 20.1% (Du et al., 2020). Similar psy-chological disturbances were recognized among HCWs during the se-vere acute respiratory syndrome (SARS) epidemic (Chua et al., 2004;Lee et al., 2005). In contrast, a study on 470 HCWs in Singapore put theprevalence of depression, anxiety, and stress during the COVID-19pandemic at 8.1%, 10.8%, and 6.4%, respectively. These relatively lowrates of psychological distress could be attributed to improved mentalhealth preparedness and rigorous infection control measures in Singa-pore in the wake of the SARS outbreak epidemic (Tan et al., 2020). Still,a meta-analysis of cross-sectional studies including 11 studies fromChina in addition to the Singaporean study estimated the pooled pre-valence of depression and anxiety among HCWs during the COVID-19pandemic with 22.8% and 23.2%, respectively (Pappa et al., 2020).However, we cannot claim that the prevalence of psychological dis-turbances in the current study is higher than the Chinese studies be-cause of the high heterogeneity between studies regarding the socio-demographic characteristics of HCWs and the scales and cut-o!s usedfor psychological assessment.

However, the psychological disturbances among HCWs in Egyptwere significantly worse than those among HCWs in Saudi Arabia. Thisfinding may reflect the robustness of the healthcare system in SaudiArabia compared with the Egyptian one. During the past decade, theSaudi government adopted a long-term plan to improve the healthcaresystem which was translated into allocating about 15% of the govern-ment budgetary expenditures for health services and social develop-ment (Al-Hanawi et al., 2019). This plan resulted in significant signs ofprogress in healthcare human and financial resources and striking im-provements in key health indicators such as life expectancy and theavailability of health resources (Al-Hanawi et al., 2019). Moreover, thecirculation of the Middle East Respiratory Syndrome Coronavirus(MERS-CoV) in Saudi Arabia in 2012 led to significant improvement ininfection control preparedness in healthcare institutions across thecountry (Barry et al., 2020; Temsah et al., 2020). On the other hand, thehealthcare system in Egypt faces several challenges related to defectivespending and limitations in human resources and infrastructure(Fakhouri, 2016).

Further, this study showed a gender gap of psychological dis-turbances with a higher prevalence of depression, anxiety, and stressamong women than men. In agreement, the Pappa et al. (2020) meta-analysis showed that female HCWs were more likely to su!er depres-sion and anxiety during the COVID-19 pandemic compared with maleHCWs.

Moreover, our results showed that watching/reading COVID-19news #2 h/day was associated with depression, anxiety, stress, andinadequate sleeping. The COVID-19 pandemic is characterized by widemedia coverage with plenty of untrustworthy sources of information.For example, 27% of HCWs in Egypt reported retrieving their in-formation on COVID-19 from the social network, newspapers, and tel-evision (Abdel Wahed et al., 2020). Social media can be a source ofmisinformation of COVID-19 that may result in panic (Cuan-

Table 1Sociodemographic and occupational characteristics of HCWs deployed in facingCOVID-19 pandemic in Egypt and Saudi Arabia.Characteristics Study population

n = 426 (%)

Age (years) 18–30 201 (47.2)31–45 172 (40.4)>45 53 (12.4)

Sex Men 214 (50.2)Women 212 (49.8)

Country Egypt 275 (64.6)Saudi Arabia 151 (35.4)

Profession Physician 206 (48.4)Nurse 103 (24.2)Others 117 (27.4)

Department Internal & ICU 84 (19.7)Emergency 84 (19.7)Others 258 (60.6)

Years of experience 1–5 189 (44.4)6–15 153 (35.9)>15 84 (19.7)

Working hours per day 1–6 153 (35.9)7–12 211 (49.5)>12 62 (14.6)

Emergency shifts per week Never 189 (44.4)"2 90 (21.1)>2 147 (34.5)

Night shifts per week Never 207 (48.6)"2 96 (22.5)>2 123 (28.9)

Watching/reading COVID-19 newshours per day

<2 187 (43.9)

2–4 159 (37.3)>4 80 (18.8)

Living with children 277 (65.0)Living with older adults 220 (51.6)Emotional support from family 336 (78.9)Emotional support from society 190 (44.6)Emotional support from hospital 150 (35.6)

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Baltazar et al., 2020). Dong and Zheng (2020) described “headlinestress disorder” among the general public due to COVID&19 news.Therefore, HCWs should be advised to cautiously select their sources ofhealth information during public health crises. The WHO and govern-ments should exert more e!orts to provide reliable sources of in-formation and force the social network platforms, newspapers, andtelevision channels to take down misinformation of the COVID-19.However, it is worth pointing out that the cross-sectional design of thisstudy cannot imply a temporal association between watching/readingCOVID-19 news and psychological disturbances. It could be suggestedthat depressed, anxious, and stressed HCWs have resorted to COVID-19news to look for hopeful news of COVID-19 medications and vaccines toalleviate their psychological distress. One study, for instance, showedthat COVID-19 anxiety could lead to excessive internet use (Elhai et al.,2020).

Furthermore, we could detect that HCWs who lacked emotionalsupport from family, society, and hospital showed worse psychologicaldisturbances compared with their counterparts who were o!eredemotional support. A study on medical students from China showedthat social support correlated negatively with their level of anxiety(Cao et al., 2020). One study discussed the need for providing mentalhealthcare services to HCWs on the frontlines to alleviate their psy-chological distress and improve their physical health (Kang et al.,2020). These findings, therefore, highlight the importance of psycho-logical counseling.

Also, attending night shifts was associated with psychological

distress and inadequate sleeping. Previous research conducted on HCWsunder normal circumstances reached also the same conclusion(Jehan et al., 2017), thus, we cannot assume that working the nightshifts during the COVID-19 pandemic, per se, increased the psycholo-gical distress. However, increased psychological distress and disturbedsleep during the COVID-19 pandemic alongside attending night shiftscould have worsened the situation.

It should be noted that this study had several strengths such as in-cluding HCWs representing di!erent professions of healthcare, limitingthe inclusion criteria to HCWs currently serving on the frontlines duringthe COVID-19 pandemic, using a validated assessment tool to measurethe outcomes, and avoiding the chronic problems of online surveyingsuch as lurking, dropping out, and item non-response by making thequestions mandatory.

However, some limitations should be addressed. First, the cross-sectional design restricted our ability to distinguish between preexistingand new symptoms and to study whether the psychological symptomsof HCWs have been worsening or not, therefore, a longitudinal study iswarranted. Second, because of the lockdown, we had to solely rely onthe online survey to access HCWs. This method of data collection can beaccompanied by non-response bias that could undermine the general-izability of the study because non-respondents might carry di!erentcharacteristics compared with the respondents (Arafa et al., 2019). Toavoid this bias, we did not ask the respondents to unveil their identitiesor include any sensitive questions related to income or availability ofPPE. We also forwarded the link to the Google survey via di!erent

Table 2Prevalence of depression, anxiety, stress, and inadequate sleeping among HCWs deployed in facing COVID-19 pandemic in Egypt and Saudi Arabia.Characteristics Depression Anxiety Stress Sleeping hours/day

Normal Mild tomoderate

Severe tovery severe

Normal Mild tomoderate

Severe tovery severe

Normal Mild tomoderate

Severe tovery severe

#6 <6

Overall 31.0 39.4 29.6 41.1 31.9 27.0 44.1 36.6 19.3 62.7 37.3Age (years) 18–30 29.2 39.9 30.9 39.4 23.7 27.9 42.4 37.5 20.1 63.5 36.5

>30 43.4 35.8 20.8 52.8 26.4 20.8 56.6 30.2 13.2 56.6 43.4Sex Men 40.6 36.0 23.4 51.4 30.4 18.2 54.7 30.8 14.5 65.9 34.1

Women 21.2 42.9 35.9 30.7 33.5 35.8 33.5 42.5 24.0 59.4 40.6Profession Physicians 26.2 35.4 38.4 39.3 31.6 29.1 39.8 37.4 22.8 67.5 32.5

Nurses 35.0 46.6 18.4 40.8 35.0 24.3 46.6 37.9 15.5 57.3 42.7Others 35.9 40.2 23.9 44.4 29.9 25.7 49.6 34.2 16.2 59.0 41.0

Country Egypt 21.5 40.7 37.8 31.6 34.9 33.5 23.7 44.4 22.9 63.3 36.7Saudi Arabia 48.3 37.1 14.6 58.3 26.5 15.2 64.9 22.5 12.6 61.6 38.4

Department Internal, ICU &Emergency

34.5 38.1 27.4 41.1 34.5 24.4 47.0 38.1 14.9 62.5 37.5

Others 28.7 40.3 31.0 41.1 30.2 28.7 42.2 35.7 22.1 62.8 37.2Experience (years) 1–5 33.3 36.0 30.7 45.5 30.2 24.3 49.7 36.5 13.8 61.9 38.1

>5 29.1 42.2 28.7 37.6 33.3 29.1 39.7 36.7 23.6 63.3 36.7Working hours/day 1–6 21.6 44.4 34.0 39.9 32.0 28.1 39.9 42.5 17.6 70.6 29.4

>6 36.3 36.6 27.1 41.8 31.9 26.3 46.5 33.3 20.2 58.2 41.8Emergency shifts Yes 28.3 40.5 31.2 34.6 36.3 29.1 40.9 38.8 20.3 59.9 40.1

No 34.4 38.1 27.5 49.2 26.5 24.3 48.1 33.9 18.0 66.1 33.9Night shifts Yes 32.9 36.5 30.6 37.0 33.8 29.2 42.9 35.6 21.5 58.0 42.0

No 29.0 42.5 28.5 45.4 30.0 24.6 45.4 37.7 16.9 67.6 32.4Watching/reading

COVID-19 news(hours/day)

<2 20.5 43.5 36.0 30.1 35.1 34.8 33.5 41.0 25.5 59.0 41.0

#2 44.4 34.2 21.4 55.1 27.8 17.1 57.8 31.0 11.2 67.4 32.6Living with children Yes 27.8 40.4 31.8 39.4 31.0 29.6 41.2 37.2 21.6 61.4 38.6

No 36.9 37.6 25.5 44.3 33.6 22.1 49.7 35.6 14.7 65.1 34.9Living with older

adultsYes 21.8 39.5 38.7 35.0 33.6 31.4 39.1 39.1 21.8 58.2 41.8

No 40.8 39.3 19.9 47.6 30.1 22.3 49.5 34.0 16.5 67.5 32.5Emotional support

from familyYes 34.8 40.2 25.0 45.2 30.7 24.1 48.2 35.7 16.1 64.9 35.1

No 16.7 36.7 46.6 25.6 36.7 37.7 28.9 40.0 31.1 54.4 45.6Emotional support

from societyYes 51.1 37.9 11.0 59.5 26.3 14.2 61.6 28.9 9.5 67.4 32.6

No 14.8 40.7 44.5 26.3 36.4 37.3 30.1 42.8 27.1 58.9 41.1Emotional support

from hospitalYes 49.3 36.7 14.0 58.7 28.7 12.6 64.7 27.3 8.0 69.3 30.7

No 20.3 41.3 38.4 31.4 33.2 35.4 32.1 42.1 25.8 59.0 41.0

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Table3

Oddsratiosand

confidenceintervalsoftheassociationswithdepression,anxiety,stress,

andinadequatesleepingamongHC

WsdeployedinfacingCOVID-19

pandemicinEgyptand

SaudiArabia.

Characteristics

Regressionmodels

Depression

Anxiety

Stress

Sleepinghours/day

Normal

Mild

tomoderate

Severetovery

severe

Normal

Mild

tomoderate

Severetovery

severe

Normal

Mild

tomoderate

Severetovery

severe

Age:18–30vs.>

30years(ref)

ModelI

11.66

(0.86,3.19)

2.21

(1.03,

4.74)

11.66

(0.84,3.29)

1.80

(0.86,3.78)

11.66

(0.87,3.18)

2.03

(0.86,4.84)

10.75

(0.42,

1.34)

ModelII

11.95

(0.97,3.93)

2.88

(1.25,

6.62)

11.81

(0.88,3.71)

2.03

(0.92,4.48)

11.90

(0.95,3.81)

2.49

(1.00,

6.18)

10.68

(0.37,

1.24)

Sex:Wom

envs.m

en(ref)

ModelI

12.29

(1.43,

3.66)

2.94

(1.77,

4.88)

11.85

(1.17,

2.91)

3.30

(2.01,

5.40)

12.25

(1.46,

3.47)

2.71

(1.59,

4.63)

11.32

(0.89,

1.95)

ModelII

12.05

(1.21,

3.48)

2.57

(1.43,

4.61)

11.54

(0.93,2.54)

2.68

(1.56,

4.62)

11.74

(1.07,

2.83)

2.39

(1.33,

4.32)

11.30

(0.84,

2.01)

Country:Egyptvs.SaudiArabia(ref)

ModelI

12.48

(1.55,

3.96)

5.85

(3.30,

10.38)

12.43

(1.51,

3.90)

4.05

(2.35,

6.98)

13.91

(2.43,

6.29)

3.61

(2.01,

6.50)

10.93

(0.62,

1.40)

ModelII

12.19

(1.28,

3.74)

4.71

(2.45,

9.04)

12.27

(1.32,

3.88)

3.31

(1.78,

6.15)

13.67

(2.13,

6.31)

2.81

(1.45,

5.45)

10.92

(0.57,

1.47)

Profession:Physiciansvs.others(non-physician

s,non-nurses)(ref)

ModelI

11.21

(0.70,2.08)

2.19

(1.22,

3.96)

11.19

(0.70,2.04)

1.28

(0.73,2.25)

11.36

(0.82,2.27)

1.75

(0.93,3.29)

10.69

(0.43,

1.11)

ModelII

11.00

(0.54,1.86)

1.50

(0.75,3.00)

10.93

(0.51,1.70)

0.89

(0.46,1.70)

10.91

(0.50,1.65)

1.32

(0.65,2.69)

10.66

(0.40,

1.11)

Profession:Nursesvs.others(non-physician

s,non-nurses)(ref)

ModelI

11.19

(0.65,2.17)

0.79

(0.38,1.65)

11.27

(0.69,2.36)

1.03

(0.53,2.01)

11.18

(0.66,2.11)

1.02

(0.47,2.19)

11.07

(0.63,

1.83)

ModelII

10.70

(0.35,1.38)

0.36

(0.16,

0.82)

10.83

(0.42,1.63)

0.53

(0.25,1.12)

10.63

(0.32,1.22)

0.57

(0.25,1.31)

10.98

(0.55,

1.73)

Departm

ent:Internalmedicine,ICU,and

emergencyvs.others(ref)

ModelI

10.79

(0.49,1.25)

0.73

(0.45,1.21)

11.14

(0.72,1.80)

0.85

(0.52,1.39)

10.96

(0.62,1.48)

0.61

(0.35,1.05)

11.01

(0.68,

1.51)

ModelII

10.92

(0.56,1.51)

0.94

(0.54,1.64)

11.32

(0.81,2.14)

1.12

(0.66,1.90)

11.15

(0.72,1.84)

0.75

(0.42,1.35)

11.06

(0.70,

1.61)

Experience:1–5vs.>

5years(ref)

ModelI

10.75

(0.47,1.18)

0.93

(0.57,1.52)

10.75

(0.48,1.17)

0.69

(0.43,1.11)

10.79

(0.52,1.21)

0.46

(0.27,

0.80)

11.06

(0.72,

1.58)

ModelII

10.77

(0.45,1.34)

1.18

(0.65,2.14)

10.71

(0.42,1.19)

0.72

(0.42,1.25)

10.81

(0.49,1.34)

0.46

(0.25,

0.85)

11.10

(0.71,

1.71)

Working

hours:>6vs.1–6

h/day(ref)

ModelI

10.49

(0.30,

0.81)

0.48

(0.28,

0.81)

10.95

(0.60,1.52)

0.90

(0.55,1.46)

10.67

(0.43,1.05)

0.98

(0.56,1.70)

11.72

(1.13,

2.63)

ModelII

10.70

(0.40,1.23)

1.10

(0.58,2.06)

11.52

(0.88,2.65)

2.20

(1.21,

4.02)

11.28

(0.75,2.18)

2.27

(1.17,

4.39)

12.03

(1.25,

3.28)

Emergencyshifts:Yesvs.no

(ref)

ModelI

11.35

(0.88,2.07)

1.32

(0.78,2.24)

11.95

(1.23,

3.08)

1.70

(1.06,

2.74)

11.35

(0.88,2.07)

1.32

(0.78,2.23)

11.31

(0.88,

1.95)

ModelII

11.63

(0.98,2.70)

2.04

(1.15,

3.64)

12.46

(1.48,

4.08)

2.68

(1.54,

4.66)

11.71

(1.05,

2.77)

1.78

(0.99,3.20)

11.49

(0.97,

2.27)

Nightshifts:Yesvs.no(ref)

ModelI

10.76

(0.48,1.20)

0.95

(0.58,1.54)

11.39

(0.88,2.17)

1.46

(0.91,2.34)

11.00

(0.65,1.53)

1.34

(0.80,2.27)

11.51

(1.02,

2.25)

ModelII

10.95

(0.57,1.57)

1.57

(0.87,2.81)

11.82

(1.09,

3.02)

2.69

(1.53,

4.75)

11.38

(0.84,2.25)

2.13

(1.16,

3.89)

11.81

(1.17,

2.80)

Watching/readingCOVID-19

news:#

2vs.

<2hour/day

(ref)

ModelI

12.75

(1.72,

4.41)

3.64

(2.18,

6.10)

12.31

(1.46,

3.66)

3.71

(2.24,

6.16)

12.28

(1.48,

3.52)

3.92

(2.21,

6.96)

11.44

(0.96,

2.14)

ModelII

12.62

(1.60,

4.29)

2.95

(1.68,

5.16)

12.24

(1.39,

3.62)

3.32

(1.94,

5.70)

12.07

(1.30,

3.30)

3.41

(1.87,

6.23)

11.52

(1.00,

2.30)

Living

withchildren:Yesvs.no

(ref)

ModelI

11.43

(0.89,2.29)

1.65

(0.99,2.77)

11.04

(0.66,1.66)

1.51

(0.91,2.50)

11.26

(0.81,1.96)

1.77

(1.00,

3.13)

11.17

(0.78,

1.78)

ModelII

11.25

(0.76,2.07)

1.43

(0.80,2.53)

10.91

(0.56,1.48)

1.32

(0.76,2.28)

11.07

(0.66,1.73)

1.55

(0.85,2.84)

11.23

(0.80,

1.89)

Living

witholderadults:Yesvs.no(ref)

ModelI

11.88

(1.18,

3.00)

3.63

(2.17,

6.07)

11.52

(0.97,2.38)

1.91

(1.18,

3.08)

11.46

(0.95,2.23)

1.67

(0.99,2.83)

11.49

(1.00,

2.22)

ModelII

11.38

(0.83,2.29)

2.39

(1.35,

4.24)

11.07

(0.65,1.75)

1.14

(0.67,1.94)

10.85

(0.52,1.38)

1.02

(0.57,1.82)

11.60

(1.04,

2.47)

(continuedon

nextpage)

A. Arafa, et al. Journal of Affective Disorders 278 (2021) 365–371

369

social networks to access HCWs who did not have professional e-mails.Moreover, we extended the survey collection period to 10 days so thatHCWs were able to choose when to respond according to their busyschedule, and reminders were sent after the first 5 days. Third, we hadto merge HCWs other than physicians and nurses in one group to obtainstatistical power, despite some professions such as paramedics andradiology technicians could be more vulnerable than pharmacists.Fourth, some potential confounders that can be associated with themental health of HCWs such as the history of chronic diseases andpracticing leisure activities were not collected. Fifth, we did not collectdata on the availability of PPE and infection control training. Such in-formation could have spotted another risk factor for deteriorated psy-chological conditions. Sixth, the results of our study might not be ex-trapolated to other HCWs in countries that showed adequate pandemicresponse and preparedness.

In conclusion, the psychological impacts of COVID-19 were en-ormous among the HCWs, particularly, in Egypt. Intervention programstargeting HCWs should prioritize young women. Providing psycholo-gical support and counseling for HCWs should be encouraged.

Funding

None.

Declaration of Compeing Interest

Authors declare no conflict of interest.

Acknowledgement

None.

References

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ble3(continued)

Characteristics

Regressionmodels

Depression

Anxiety

Stress

Sleepinghours/day

Normal

Mild

tomoderate

Severetovery

severe

Normal

Mild

tomoderate

Severetovery

severe

Normal

Mild

tomoderate

Severetovery

severe

Emotionalsupportfromfamily:Novs.yes(ref)

ModelI

11.91

(0.99,3.68)

3.90

(2.03,

7.49)

12.12

(1.18,

3.81)

2.77

(1.53,

5.02)

11.87

(1.07,

3.26)

3.23

(1.74,

5.98)

11.55

(0.97,

2.48)

ModelII

11.77

(0.89,3.54)

3.26

(1.60,

6.67)

11.89

(1.02,

3.49)

2.36

(1.25,

4.46)

11.53

(0.85,2.77)

2.70

(1.40,

5.23)

11.70

(1.04,

2.78)

Emotionalsupportfromsociety:Novs.yes(ref)

ModelI

13.70

(2.26,

6.05)

13.86(7.55,

25.44)

13.14

(1.97,

5.00)

5.94

(3.49,

10.10)

13.03

(1.95,

4.71)

5.86

(3.22,

10.68)

11.44

(0.97,

2.15)

ModelII

13.07

(1.76,

5.38)

9.81

(4.96,

19.42)

12.54

(1.49,

4.33)

4.44

(2.42,

8.18)

11.85

(1.11,

3.08)

4.25

(2.14,

8.44)

11.94

(1.20,

3.13)

Emotionalsupportfromhospital:No

vs.yes(ref)

ModelI

12.74

(1.70,

4.41)

6.66

(3.71,

11.95)

12.17

(1.35,

3.47)

5.23

(2.94,

9.30)

13.10

(1.96,

4.91)

6.50

(3.30,

12.80)

11.57

(1.03,

2.40)

ModelII

12.39

(1.45,

3.94)

5.20

(2.78,

9.74)

11.83

(1.12,

2.99)

4.28

(2.34,

7.85)

12.50

(1.54,

4.07)

5.38

(2.66,

10.86)

11.74

(1.11,

2.72)

ModelI:Unadjusted.

ModelII:Adjustedforage,sex,profession,andcountry.

Bold(Statisticallysignificant).

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