|Year : 2021 | Volume
| Issue : 3 | Page : 170-177
A study to assess the level of anxiety and stress among health-care professionals during the early stage of COVID-19 outbreak in Bangladesh: A cross-sectional study
Sohel Ahmed1, Md Matiur Rahman2, Md Nazrul Islam3, Rahemun Akter1, Ahmed Riad Chowdhury4
1 Department of Physiotherapy and Neuro-Rehabilitation, Mount Adora Hospital, Sylhet, Bangladesh
2 Department of Neurology, Mount Adora Hospital, Sylhet, Bangladesh
3 Department of Neurology, Parkview Medical College Hospital, Sylhet, Bangladesh
4 Department of Psychiatry, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
|Date of Submission||31-Mar-2021|
|Date of Acceptance||05-Nov-2021|
|Date of Web Publication||6-Dec-2021|
Department of Physiotherapy and Neuro-Rehabilitation, Mount Adora Hospital, Sylhet
Source of Support: None, Conflict of Interest: None
Background: The health-care professionals are at high risk of getting infection of COVID-19 due to the highly interactivity of the disease. The virulence of the disease causes huge stress among health-care professionals. Aim: Our study aimed to find out the level of stress and fear among health-care professionals due to COVID-19 outbreak in Bangladesh. Materials and Methods: A cross-sectional study was conducted by using a structured questionnaire containing demographic data, Fear of COVID-19 Scale (FCV-19S), Kessler Psychological Distress Scale, and factor causing stress. A total number of 146 participants, both male and female, were participated in this study. We utilized Google Platform to construct the questionnaire and virtual snowball sampling method to collect the data. Results: The mean age, height, and weight of the participants were 27.52 ± 6.10, 162.53 ± 10.67, and 64.75 ± 10.89, respectively. The mean score of Kessler Psychological Distress Scale was 23.57 ± 5.38, ranging from 27 to 38 and the mean score of FCV-19S was 24.27 ± 6.27, ranging from 7 to 35. The participants those who are living with their family are at significant level of stress (P = 0.041) that they can affect their family members. Conclusion: The health-care professionals are in highly stressed due to the COVID-19 outbreak. Stress management strategies should be taken as a preventive measure to overcome the further serious situation.
Keywords: COVID-19, cross-sectional study, health-care professionals, stress
|How to cite this article:|
Ahmed S, Rahman MM, Islam MN, Akter R, Chowdhury AR. A study to assess the level of anxiety and stress among health-care professionals during the early stage of COVID-19 outbreak in Bangladesh: A cross-sectional study. Saudi J Health Sci 2021;10:170-7
|How to cite this URL:|
Ahmed S, Rahman MM, Islam MN, Akter R, Chowdhury AR. A study to assess the level of anxiety and stress among health-care professionals during the early stage of COVID-19 outbreak in Bangladesh: A cross-sectional study. Saudi J Health Sci [serial online] 2021 [cited 2023 Jun 9];10:170-7. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/3/170/331778
| Introduction|| |
The coronavirus disease was first identified at the city of Wuhan, Hubei State, in China on December 31, 2019, it had affected more than 213 countries around the world. The causative agent was identified on January 7, 2020, and named as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by the Chinese Center for Disease Control and Prevention. The World Health Organization named the disease COVID-19 and declared the outbreak a global emergency on January 30 due to the virulence and highly interactivity.
The number of cases increased day by day, more than 77.9 million confirmed cases and 1.71 million deaths have been reported as of December 23, 2020, all over the world. Billions of people are staying at home to reduce transmission; on the opposite, the health-care workers are leaving home, putting themselves at high risk to serve the nation. Health-care workers who are directly involved in sample collection, diagnosis, and treatment of the patients were at high risk of infection during COVID-19 pandemic. The current scenario of COVID 19 in Bangladesh is going to be critical day by day. The total number of infected cases has been touched 503,501 and deaths have been reported 7329 on December 23, 2020.
The widespread outbreak of the virulence disease is associated with mental illness. Evidence suggests that health-care workers are at high risk of developing psychological distress those who are directly involved in the diagnosis, management, and treatment of COVID-19 patients. Anxiety, anger, depression, distress, and fear of infection to the family and friends were some of the immediate psychological impacts among health-care workers.,
Previous studies have reported mental health status among health-care workers due to COVID-19,,,,, SARS, and MARS-CoV outbreak. Studies showed that health-care workers are mentally feared about contagion of their friends and family, and another study reported high level of stress, depression, and anxiety among health-care workers., In similar ways, few studies have been conducted during and after epidemic of Ebola-2014 and SARS-2003 in the general population, and depression, anxiety, and stress disorder were found in health-care workers.,
In this current situation, uncertainty of returning normal life, deaths, and unavoidable ongoing restrictions were also likely to develop long-term mental health issues. Due to the raising number of new cases and highly virulence of the disease, it is natural that the health-care professionals would be in a state of acute stress. Evidence examining the factors associated with stress, anxiety, and fear among health-care professionals due to COVID-19 pandemic in Bangladesh was limited. To address the gap, our study aimed to find out the level of stress, anxiety, and fear among health-care professionals due to COVID-19 outbreak in Bangladesh. This study will help to design proper psychological intervention and will provide a baseline against appropriate interventions.
| Materials and Methods|| |
We adopted this cross-sectional survey study to assess the level of stress, anxiety, and fear among health-care professionals due to the early stage of COVID-19 outbreak in Bangladesh. The study was conducted from April 5, 2020, to April 31, 2020. Ethical approval of this study protocol was obtained from the Ethics Committee of Mount Adora Hospital. The study was conducted in accordance with the ethical guideline of Bangladesh Medical Research Council 2013 and Helsinki Declaration (Revised) 2013. As the World Health Organization recommended the people to maintain social distance, minimize face-to-face interaction, and advised to stay home, we utilized the Google Platform to conduct an online survey. We created a structured survey questionnaire and circulated the survey link via social networking sites (Facebook, WhatsApp, and Messenger) with a proper description of the study protocol. The survey was open for the health-care professionals who were living in Bangladesh.
Sample size estimation
The participants who fulfilled the inclusion and exclusion criteria were invited to participate in this study. The required sample was calculated by using the formula for cross-sectional study for estimating proportion: n = Zα2 P (1 − P)/d2; here Zα = 1.96; P = 90% as the online survey response rate >90% and d = 5%. We estimated the minimum sample required for this study to be 139. We expected 5% incomplete form and targeted the final required sample to be 146. We recruited all participants by virtual snowball sampling method that was focused on recruiting the health-care professionals living in the specific area of Bangladesh. The link of this online survey was first circulated to our hospital staff and they were invigorated to spread out it to their other colleagues. Data collection was continued from April 13, 2020, to April 25, 2020.
We recruited the participants from a specific area of Bangladesh. The selection criteria of this study were health-care professionals (doctor, dentist, physiotherapist, nurse, medical technologist, and hospital staff), minimum educational qualification – higher secondary, and able to fill up the questionnaire in English. We excluded the participants who were not willing to participate, ongoing psychiatric therapy treatment, and taking any psychiatric medication. We also excluded those who have already been affected by COVID-19. We provided information about the study, nature, and purpose of the study in the survey by separating a section named information and consent form at the beginning of the survey. We promised the participants that their identification and all information provided by them would be kept confidential.
A structured online questionnaire was used to collect the data from the participants, which was developed on the basis of a previous published study., The data were collected regarding (1) demographic data, (2) personal coping strategies used to reduce stress, (3) Kessler Psychological Distress Scale, (4) Fear of COVID-19 Scale (FCV-19S), and (5) factor causing stress. The preliminary draft of the survey questionnaire was distributed to an expert panel (two professors of neurology, an epidemiologist, and an assistant professor of psychology) for review, organization, wording, criticism, and suggestion for constructive changes. The revised questionnaire was tested on a small representative sample of the target population, whether the question was misleading or unclear. The response time was monitored while testing the questionnaire. We observed that it takes not more than 20 min to complete the questionnaire. We ensure the completeness of the questionnaire by utilizing the option required in Google Form Platform; the respondent can submit the questionnaire after complication of all the questions.
The first section consists of demographic data that included age, gender, height, weight, marital status, parental status, educational qualification, profession, living with family or not, and current workplace in the hospital. The second section consists of questions regarding personal coping strategies used to reduce stress that include knowledge about COVID-19, its prevention and mechanism of transmission, history of mask use, number of handwash per day, use of PPE during patient handling, history of separate clothes use at the hospital to minimize transmission, avoiding going public place or not, considered every patient as covid-19 positive, and use of full protective gear.
The third section consists of Kessler Psychological Distress Scale (K10). K10 was found to be a valid and reliable tool to measure stress and anxiety in clinical practice. K10 is a 5-point Likert scale (none, a little time, sometimes, most of the time, and all time) ranging the score of 10–50. The total score is categorized into our sections, low score (10–15), moderate score (16–21), high score (22–29), and very high score ranging from 30 to 50.,
The fourth section consists of FCV-19S. The FCV-19S is a valid and reliable tool to measure fear of COVID-19 pandemic, developed most recently due to the ongoing demand., The scale is 7-item, 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree).
The fifth section consists of the questions regarding factors causing stress. We utilized 20-item questions from a previous study by Khalid et al., with some modifications. The severity of the stress factor was measured by a scale ranging from 0 to 3 (0 = not at all, 1 = slight, 2 = moderate, and 3 = very much). The internal consistency of this questionnaire was 0.81 (Kuder–Richardson formula 20) for stressors number and 0.83 (Cronbach's α) for the severity of stress.
Descriptive statistics were calculated for the study variables. Continuous variables were expressed as mean and standard deviation. To conduct analysis, we defined the K10 score into low score (10–15) and moderate to high score (16–50). Chi-square test was used to find the association between the variables. The data analysis was carried out by using the software Statistical Package for Social Sciences, Chicago, USA 20.0 for Windows. We set the level of significance at 5% to minimize type 1 error.
| Results|| |
A total number of 146 participants, both male and female, have participated in this study. Among the study participants, no one reported a history of any psychiatric illness. The mean age, height, and weight of the participants were 27.52 ± 6.10, 162.53 ± 10.67, and 64.75 ± 10.89, respectively. More than three-fourth of the study participants (76%) completed at least bachelor degree. Majority of the participants were doctors (45.9%). The demographic variables of the participants are presented in [Table 1]. More than one-third of the participants experienced high to very high levels of psychological distress (36.3%) [Table 2]. About 71.9% of study participants experienced high levels of fear of COVID-19 [Table 3]. The causative factors that may cause stress among health-care professionals are presented in [Table 4]. The participants those who are living with their families are at significant levels of stress (P = 0.041) that can affect their family members. There was no significant difference in stress level and fear of COVID-19 among the study participants in respect of age group, gender, marital status, educational qualification, workplace, and profession [Table 5].
|Table 5: Factor associated with level of fear of COVID 19 and psychological distress among the study participants based on FCV19S and K10 scale (n=146)|
Click here to view
| Discussion|| |
Health-care professionals are frontline heroes, who risk their lives in the fight against coronavirus disease. In any epidemic or pandemic, health-care workers are at high risk of getting an infection, which causes huge stress among them. The prevalence of each infectious disease varies based on its geographical location, pathogenesis, transmissibility, infectivity, and severity of the disease. Two different diseases are not alike and each has its own impact that affects hospital staff feelings, emotions, and stress levels., The COVID-19 outbreak in China caused panic and mental stress due to the raising number of patients and public worry about becoming infected. Our study aimed to find out the level of stress and fear among health-care professionals who served the nation during COVID-19 outbreak in Bangladesh.
The result of this study demonstrates that health-care professionals are at high level of stress. In our present study, about 78.1% of study participants face moderate to very high level of psychological distress and 71.9% had a high score of FCV-19S score. A similar result was found in recent studies that showed 53.8% of participants scored moderate-to-severe levels of psychological distress in China and 62.6% of participants showed moderate-to-high levels of psychological distress in Australia. We found no significant difference in stress levels among doctors, physiotherapists, dentists, nurses, medical technologists, and hospital administration staff. During the outbreak, health-care professionals are at high risk of getting an infection, who are involved in patient care; however, there is a high chance among those who work at the corona care unit and emergency unit.
Almost 98.6% of the study participants know the transmission mechanism of COVID-19 and they were conscious about personal safety measures such as mask use, handwash, and wearing of PPE. Most of the health-care professionals felt that they were working due to their professional and ethical duty. About 65.1% of health-care professionals were not unhappy with their duty and 76% were not thinking about quitting the job. The health-care professionals who were living with their families during this study were in significantly high level of stress (P = 0.041) of being infected by their family members. The stress level is also due to the virulence of the disease and unavailability of appropriate treatment. Those factors were also seen among the health-care works who faced SARS and MERS-CoV epidemic.,
Similar studies were conducted during SARS, MERS-CoV, and COVID-19 outbreak which showed significant levels of stress, anxiety, and fear among health-care professionals. A recent systematic review study showed two among five health-care professionals reported stress, anxiety, distress, depression, and fear during COVID-19 pandemic. Wong et al. conducted a study during SARS epidemic in Hong Kong among university students. The result of this study found a significant difference in anxiety and stress among medical students those who are attached with the hospital. Another study by Khalid et al. reported that health-care workers face high level of stress during MERS-CoV outbreak in Saudi Arabia. Ji et al. reported that Ebola virus disease survivors had an extreme level of psychological symptoms. Wang et al. reported immediate psychological responses among the general population during COVID-19 outbreak in China. In this study, one-third of the respondent informed moderate-to-severe stress and more than half reported moderate-to-severe psychological distress.
The health-care professionals are experiencing unremitting stress that could trigger serious psychological issues such as fear, panic attack, anxiety, and posttraumatic stress syndrome. The sudden role of a health-care provider treating a COVID-19-positive patient or a suspicious case can cause inconsistencies and challenges that lead to a sense of frustration and helplessness. Health-care professionals who are in high stress should undergo stress management strategies. An awareness program focused on stress management strategies should be developed.
This present study has several limitations. Due to the time sensitivity and lockdown caused by COVID-19 outbreak, we chose snowball sampling method for data collection. The snowball sampling is not based on a random selection of subjects and there is a high chance of selection bias. To minimize the bias, we used respondent-driven sampling called virtual snowball sampling that helps to increase responsiveness and reach to the large sample population. We cannot estimate the response rate of the participants. In our study, we did not include other health-care workers (ward boy, cleaner, and watchman) that might change our results. We have chosen an online survey and virtual snowball sampling because it was time demanding (lockdown due to COVID-19 outbreak), easily accessible, time saving, and cost-effective. In future, studies can be done with a large sample size focusing on anxiety, depression, and stress. We suggest to increase the staff sample size involving other populations such as ward boy, cleaner, and watchman.
| Conclusion|| |
The COVID-19 outbreak in Bangladesh caused severe stress among health-care professionals. Stress management strategies should be planned for the health-care professionals to improve their quality of service during the pandemic.
The author would like to thank Mount Adora Hospital for its valuable support.
Financial support and sponsorship
This study was self-funded by the first author.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology in Wuhan, China: The mystery and the miracle. J Med Virol 2020;92:401-2.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al.
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al.
World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71-6.
Corona Info. Dhaka Tribune. Online Report. Available from: https:// corona.gov.bd/
. [Last accessed on 2021 Jan 20].
Ramanathan K, Antognini D, Combes A, Paden M, Zakhary B, Ogino M, et al
. 2019-nCoV epidemic: Address mental health care to empower society. Lancet 2020;22:e37-8.
Thombs BD, Bonardi O, Rice DB, Boruff JT, Azar M, He C, et al.
Curating evidence on mental health during COVID-19: A living systematic review. J Psychosom Res 2020;133:110113.
Furlong Y, Finnie T. Culture counts: The diverse effects of culture and society on mental health amidst COVID-19 outbreak in Australia. Ir J Psychol Med 2020;37:237-42.
Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al.
Depression, anxiety and stress during COVID-19: Associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020;17:4065.
The Lancet. COVID-19: Protecting health-care workers. Lancet 2020;395:922.
Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al.
Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e15-6.
Mental Health and Psychosocial Considerations During COVID-19 Outbreak [Internet]. World Health Organization. 2020. Available from: WHO/2019-nCoV/MentalHealth/2020.1. [Last accessed on 2020 Apr 18].
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al.
Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729.
Wong TW, Gao Y, Tam WW. Anxiety among university students during the SARS epidemic in Hong Kong. Stress Health 2007;23:31-5.
Khalid I, Khalid TJ, Qabajah MR, Barnard AG, Qushmaq IA. Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Clin Med Res 2016;14:7-14.
Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al.
The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168:1245-51.
Shultz JM, Cooper JL, Baingana F, Oquendo MA, Espinel Z, Althouse BM, et al.
The role of fear-related behaviors in the 2013-2016 West Africa ebola virus disease outbreak. Curr Psychiatry Rep 2016;18:104.
Person B, Sy F, Holton K, Govert B, Liang A; National Center for Inectious Diseases/SARS Community Outreach Team. Fear and stigma: The epidemic within the SARS outbreak. Emerg Infect Dis 2004;10:358-63.
Blakey SM, Kirby AC, McClure KE, Elbogen EB, Beckham JC, Watkins LL, et al
. Posttraumatic safety behaviors: Characteristics and associations with symptom severity in two samples. Traumatology (Tallahass Fla) 2019;26:74-83.
Shuja KH, Aqeel M, Jaffar A, Ahmed A. COVID-19 pandemic and impending global mental health implications. Psychiatr Danub 2020;32:32-5.
Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, et al
. Suicide risk and prevention during the COVID-19 pandemic published. Lancet Psychiatry 2020;7:468-81.
Ahmed S, Pokhrel N, Roy S, Samuel AJ. Impact of nomophobia: A nondrug addiction among students of physiotherapy course using an online cross-sectional survey. Indian J Psychiatry 2019;61:77-80.
] [Full text]
Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al.
Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002;32:959-76.
Enticott JC, Lin E, Shawyer F, Russell G, Inder B, Patten S, et al.
Prevalence of psychological distress: How do Australia and Canada compare? Aust N Z J Psychiatry 2018;52:227-38.
Tzur Bitan D, Grossman-Giron A, Bloch Y, Mayer Y, Shiffman N, Mendlovic S. Fear of COVID-19 scale: Psychometric characteristics, reliability and validity in the Israeli population. Psychiatry Res 2020;289:113100.
Winter T, Riordan BC, Pakpour AH, Griffiths MD, Mason A, Poulgrain JW, et al
. Evaluation of the English Version of the Fear of COVID-19 Scale and Its Relationship with Behavior Change and Political Beliefs. Int J Ment Health Addict [Internet]. 2020. Available from: https://doi.org/10.1007/s11469-020-00342-9
. [Last accessed on 2020 Apr 18].
Simonds AK, Sokol DK. Lives on the line? Ethics and practicalities of duty of care in pandemics and disasters. Eur Respir J 2008;34:303-9.
Lin CY, Peng YC, Wu YH, Chang J, Chan CH, Yang DY. The psychological effect of severe acute respiratory syndrome on emergency department staff. Emerg Med J 2007;24:12-7.
Ji D, Ji YJ, Duan XZ, Li WG, Sun ZQ, Song XA, et al.
Prevalence of psychological symptoms among ebola survivors and healthcare workers during the 2014-2015 ebola outbreak in Sierra Leone: A cross-sectional study. Oncotarget 2017;8:12784-91.
Rahman MA, Hoque N, Alif SM, Salehin M, Islam SM, Banik B, et al.
Factors associated with psychological distress, fear and coping strategies during the COVID-19 pandemic in Australia. Global Health 2020;16:95.
Muller AE, Hafstad EV, Himmels JP, Smedslund G, Flottorp S, Stensland SØ, et al.
The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review. Psychiatry Res 2020;293:113441.
Rana W, Mukhtar S, Mukhtar S. Mental health of medical workers in Pakistan during the pandemic COVID-19 outbreak. Asian J Psychiatr 2020;51:102080.
Fabiola B, Ignasi B. Social research 2.0: Virtual snowball sampling method using facebook. Internet Res 2012;22:57-74.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]