Introduction

On March 12, 2020, the World Health Organization (WHO) declared the Coronavirus Disease (COVID-19) outbreak a pandemic. As of January 2, 2022, WHO reports that there have been approximately 289 million confirmed cases and 5.44 million COVID-19-related deaths globally.¹ WHO guidance’s regarding mental health and COVID-19 state that the main psychological impact to date involved elevated rates of stress or anxiety. As new measures and impacts are introduced to reduce the transmission of COVID-19, especially the effects of quarantine on usual routines (such as social distancing and working remotely), levels of isolation may lead to reduced levels of social support, one of the main coping mechanisms of stress, anxiety, and depression.^2,3 Importantly, the widespread increase in mental health issues has become an alarming concern.^4-6 Substance abuse and self-harm or suicidal behavior have also risen.^6,7 One group that is particularly at high-risk to acquire this infection and thus, more vulnerable to the psychological impact of COVID-19 are healthcare workers (HCWs).^8-10

The psychological impact of COVID-19 has been measured amongst frontline workers, HCWs¹ , and specific medical specialties mainly through selfadministered questionnaires across Asia, Europe, and North America.^6-21 So far, there is limited evidence on this topic in the Middle East with only a few studies conducted.^{12, 22-27}

Globally, prevalence rates of stress (27-71%) and anxiety (23-51%) have been the highest and most reported mental health symptoms among HCWs during the COVID-19 pandemic.^{6, 9, 10, 28} Regional studies have reported similarly high rates of stress, anxiety, and depressive disorder. They also highlighted that female, young, non-married HCWs, particularly nurses, were more likely to report these symptoms during the COVID-19 outbreak. ^{12,22, 29, 30}

Similar studies conducted in the Kingdom of Bahrain during the pandemic also corroborated these findings. Results demonstrated that 20-30% of participants reported symptoms of depression and stress, whereas approximately 18% showed signs of anxiety.^31,32 In both studies, females were shown to have a greater prevalence in symptoms of depression, stress, and anxiety. Another Bahrain-based study found that 60% of HCWs had poor sleep quality, which can contribute to moderate-severe stress.³² These studies used several validated psychological assessments to measure various psychological well-being components in HCWs. In contrast, the current study utilized the Impact of Events ScaleRevised (IES-R), to assess psychological distress by measuring post-traumatic stress disorder (PTSD) prevalence. This has previously not been explored in HCWs in Bahrain in the context of a specific traumatic event (COVID-19 pandemic).

Six months after the first COVID-19 case was found in the Kingdom of Bahrain on February 21^st, 2020, the Kingdom reported 11,804 related cases and 68 related deaths.³³ In the span of four months, the number of positive cases exponentially rose and was reported to be 83,456 on November 9, 2020, representing approximately 6.3% of the population.³⁴ This study aimed to assess the psychological impact of COVID-19 on HCWs at two time periods (T1=2020; T2=2021) during the pandemic. We hypothesized that psychological distress (assessed as the prevalence of PTSD) and anxiety would decrease over time due to increased awareness and psychological support services provided by the hospital.

To the best of our knowledge, this was the first study to evaluate the psychological impact (assessed as the prevalence of PTSD) and anxiety levels of HCWs as a direct result of the COVID-19 pandemic in Bahrain, by utilizing the IES-R and Beck Anxiety Inventory (BAI). The objectives were threefold; to assess the prevalence and severity of psychological distress and anxiety, in relation to the demographic and associated risk factors among HCWs at two time periods (T1 and T2); to assess their knowledge of available psychological support services at the hospital; and to Compare whether psychological distress, anxiety, and knowledge of psychological services changes from T1 to T2.

Methods

Study Design & Setting

In this cross-sectional quantitative study, we developed an online survey using the platform Survey Monkey^TM to collect our data. Data collection was conducted from July 29^th to August 31^st, 2020 (T1) and from January 29^th to February 28^th, 2021 (T2). The study was conducted in King Hamad University Hospital (KHUH), one of the three major governmental hospitals in the Kingdom of Bahrain. Ethical approval from the Institutional Review Board at KHUH was acquired prior to study initiation.

Participant Recruitment and Sample Size

Participants were selected through convenience sampling, where the survey link was sent to all KHUH staff via email providing an opportunity for all who fit the inclusion criteria to participate. The email specified that only physicians, nurses, allied healthcare, and administrative staff could participate. The study categorized participants as HCW if they held a position as medical staff (nurses, doctors, technicians, pharmacists), and non-medical staff (clerks, secretaries).³²

The target sample size was estimated based on the WHO recommendations for a prevalence study.³⁵ The required sample size was 306 participants from the study population (CI: 95%, SD: 0.5, marginal error = 5%). During the initial assessment (T1), a sample of 580 HCWs were recruited (of which 406 completed the survey). Out of the 406, 17 were excluded because they stated that they were previously diagnosed with a mental illness prior to the COVID-19 outbreak, bringing the sample size for data analysis to 366 HCWs. During the followup assessment (T2), a sample of 685 HCWs were recruited (of which 555 completed the survey). Out of the 555, 18 were excluded for the same reason above. The final sample size at T2 was 537 HCWs (Figure 1).

KHUH does not admit or manage COVID-19 positive cases as per the guidelines of the Bahrain National Taskforce for Combating the Coronavirus (COVID-19). However, screening tents are provided outside the hospital, which are covered by Emergency Department physicians and nurses on rotation. Therefore, they would be categorized as frontline workers and were included in this study. The exclusion criteria were non-healthcare workers and HCWs who had been diagnosed with a mental illness prior to the COVID-19 outbreak. This exclusion criterion was included to ensure that any psychological impact incurred was related to COVID-19 only and not due to any previous mental illness.

Measures

Psychological Impact

The psychological impact was measured by the Impact of Event Scale-Revised (IES-R), a highly reliable 22-item self-report scale that assesses subjective distress caused by traumatic events.^36,37 The latest IES-R includes 3 subscales: 1- intrusion (8 items), e.g., repeated thoughts about the trauma; 2- avoidance (8 items), assessing effortful avoidance of situations that serve as reminders of the trauma and 3- psychological hyperarousal (6 items), which indicates symptoms of PTSD e.g. irritability, anger, trouble falling asleep, and others.³⁸

Respondents are asked to identify a specific stressful life event (in this study, the COVID-19 outbreak) and then indicate how much they were distressed or bothered during the past seven days by each “difficulty” listed. Response options are based on a 5-point Likert Scale from ‘Not at all’ (0) to ‘Extremely’ (4). Total scores range from 0 to 88. Subscale scores ranged from 0 to 32 for the intrusion and avoidance subscales and 0 to 24 for the hyperarousal subscale. A cut-off score of 33 and above indicated severe psychological distress and probable preliminary diagnosis of PTSD (mild/ positive).^{16, 39}

According to a recent meta-analysis, the IES-R is the most common standardized instrument to measure symptoms of distress among HCWs during emerging virus outbreaks, including COVID-19.^{6, 10, 13, 16, 40} Recent studies yielded a high Cronbach’s alpha coefficient of 0.96.^{13, 41} In this study, we had a similar high internal consistency for the total scale and three subscales (α=0.85 to α=0.94).

Anxiety

The Beck Anxiety Inventory (BAI) was used to measure clinical anxiety.³⁸ The BAI consists of 21 items, each of which is rated by the participant on a 4-point Likert Scale from ‘Not at all’ (0) to ‘Severely, it bothered me a lot’.³ The possible total score ranges from 0 to 63. Four categories of anxiety (minimal, mild, moderate, and severe) were identified based on the current literature examining anxiety (using the BAI) among HCWs during COVID-19 or a similar trauma for relevant comparison. Cut-off scores were: 0-7 indicate minimal anxiety, 8-15 indicate mild anxiety, 16- 25 indicate moderate anxiety, and 26-63 indicate severe anxiety.⁴² The BAI has been used to look at the psychosocial impact of the SARS epidemic on Chinese health professionals41 and frontline HCWs during the COVID-19 outbreak in Wuhan.¹¹ This tool has shown high internal consistency (α=0.91) and adequate test–retest reliability (0.65).⁴² In this study, the BAI had a high and similar internal consistency (α=0.94).

Demographic, Lifestyle, and COVID-19 related Variables

There were 11 items considered in demographics, lifestyle, and the COVID-19 pandemic. The demographic variables collected in this study included: age, gender, marital status, occupation, and educational level. Variables related to lifestyle habits included: history of chronic illness (Yes/No), smoker (Yes/No), and sleep disturbances (Yes/No). Sleep disturbances were defined as: difficulty falling asleep, early awakening, affected sleep pattern, and/ or tiredness during the daytime. COVID-19 related variables included: stayed in quarantine (Yes/No), how many days (if response to earlier item was yes), and whether they were infected with COVID-19 (Yes/No).

These variables were identified in literature as having a significant effect on mental health during the COVID-19 pandemic and collected to control for potential confounding variables.^{6, 16, 25}

Knowledge of KHUH Psychological Support Services

Current KHUH psychological support services included access to a psychological support hotline available daily via telephone or in-person sessions, follow-up with staff cases who were COVID-19 positive, mental health screening, including screening for suicidality, and subsequent counseling by both the psychiatrist and psychologist.

As a secondary objective, 5 items were included to assess HCWs’ knowledge and utilization of these services. The items were: Have you ever used psychological support services before; are you aware of the KHUH psychological support services available; are you aware that KHUH offers a peer psychological support hotline; do you consider having a support line beneficial; and have you been diagnosed before with a mental illness. The response options were Yes or No.

Study Protocol

In the online survey, participants were first asked to complete an informed consent and were made aware that their responses would be confidential, anonymous, and that they could withdraw at any point if they decided to do so. The purpose, risks, and benefits of the study were listed. The main investigator’s contact details were provided for any questions. No personal identifiers were obtained, and all data was kept confidential through password protection. Participants were notified to check their emails and email reminders were sent once a week to increase the response rate. No incentives or other methods of coercion were used.

The survey was composed of five sections: 1- Informed Consent; 2- Demographics, Lifestyle, and COVID-19 related variables (11 items); 3- Knowledge about KHUH psychological support services (5 items); 4- IES-R (22 items); and 5- BAI (21 items). The IES-R and BAI appeared in random sequence to enhance response rate and eliminate order bias.

Data analysis

Data was analyzed using SPSS software version 23.0 to determine quantitative and descriptive statistics. Descriptive statistics were calculated, and 95% confidence intervals are presented. The IES-R and BAI were analyzed as both continuous and dichotomous variables. Pearson correlation coefficients were estimated. Mann-Whitney tests were performed to assess significant differences in IES-R and BAI scores during T1 and T2. A p-value of < .05 was considered statistically significant and p < .01 was considered highly significant.

Results

Participant characteristics

Demographic characteristics are summarized in Table 1. Most participants were female in both time periods (T1: 68.6%, T2: 65.7%). The majority were between 30-39 years old (T1: 45.1%, T2: 46.7%), followed by the 20-29 age group (T1: 30.9%, T2: 26.3%). Nurses comprised the majority of HCWs (T1: 58.7%, T2: 56.8 %) followed by physicians (T1: 19.9%, T2: 21.2%). Most participants had a bachelor’s degree (T1: 68.9%, T2: 59.4%). There was an increase in quarantine cases and COVID-19 infected cases during T2 (12 months into the pandemic). The majority (T1: 75.7%, T2: 77.5%) stated that the hotline was beneficial.

Prevalence of psychological distress/PTSD and anxiety

At T1, around 18.9 % of HCWs reported PTSD and the prevalence rate was almost the same (19.6%) at T2 (Table 2). Anxiety rates from T1 to T2 were 69.9% vs. 72.6% for minimal anxiety, 14.5% vs. 11.4% for mild anxiety, 10.7 % vs. 9.1% for moderate anxiety and 4.9% vs. 6.9% for severe anxiety (Table 2).

The most severe domain for HCWs was avoidance, followed by intrusion and hyperarousal. A mean reduction of 1.19 ± 1.18 was noted in the IES-R total score with a marginal level of significance (p= 0.06). There was a significant mean reduction in BAI scores of 0.44 ± 0.68 (p = 0.005) (Table 3).

Sleep-related disturbances significantly decreased from T1 to T2 (32.5% vs 24.8%, p= 0.013). This may have been related to lower stress and anxiety levels at T2. Although HCW figures with PTSD and anxiety did not change over time, there was a decrease in IES-R scores (non-significant) and anxiety (p=0.005). Approximately 75% of the HCWs were aware of the psychiatry services at the medical centre and had lower IES-R and BAI scores. Bivariate analysis indicated a strong positive correlation between IES-R and BAI scales at both time periods (Table 4).

Significant predictors of psychological distress/PTSD and anxiety

Logistic regression was conducted to identify the significant predictors of psychological distress/ PTSD and anxiety during the COVID-19 pandemic for HCWs (see Table 5).

At T1, HCWs who had sleep related disturbances (OR = 3.10, 95% CI: 1.79 – 5.36, p < 0.001), and those who got infected with COVID-19 (OR = 4.57, 95% CI: 1.36 – 15.35, p = 0.014) were more likely to report PTSD symptoms. At T2, HCWs who had chronic illness (OR = 0.78, 95% CI: 0.20-0.40, p < 0.001), sleep related disturbances (OR = 0.25, 95% CI: 0.15-0.40, p < 0.001), and those who quarantined (OR = 1.88, 95% CI: 1.17-3.03, p = 0.09) were more likely to suffer from PTSD symptoms.

Multinomial regression was used to identify significant predictors of anxiety. At T1, HCWs who had been infected with COVID-19 had higher odds for mild (OR=5.76, 95%CI: 0.50-12.4, p=0.260) or severe (OR=1.75, 95%CI: 0.89-37.20, p=0.060) anxiety. Subsequently, HCWs who smoked had higher odds for moderate anxiety (OR=6.30, 95%CI: 2.36-16.78, p=0.000). Furthermore, the common predictor for anxiety was sleep related disturbances, statistically significant for moderate (OR=3.70, 95%CI: 1.78-7.70, p=0.000) and severe anxiety (OR=4.76, 95%CI: 1.72-13.12, p=0.003). Furthermore, participants between 20-29 years were 0.48 times more likely to suffer from moderate anxiety (OR=0.48, 95%CI: 0.27-0.85, p=0.012).

At T2, HCWs who had sleep related disturbances had significantly higher odds of suffering from anxiety: ranging from 4.2 to 8.7 times more likely to suffer from mild, moderate, or severe anxiety, respectively (OR=4.20, 95%CI: 2.26-7.80, p=0.000; OR=7.10, 95%CI: 3.58-14.09, p=0.000; OR=8.71, 95%CI: 3.83-19.81, p=0.000). Additionally, HCWs who quarantined experienced mild (OR=2.08, 95%CI: 1.15-3.77, p=0.016) and severe (OR=2.92, 95%CI: 1.34-6.38, p=0.007) anxiety. Severe anxiety was 29.6 times more likely among those aged 20-29 (OR=29.60, 95%CI: 2.71-323.0, p=0.005) and 14.35 times more likely among those 30-39 (OR=14.35, 95%CI: 1.41-145.53, p=0.024).

Discussion

The COVID-19 pandemic has taken a significant toll on the morbidity and mortality rates of populations worldwide, but less focus has been placed on its impact on mental health, especially among vulnerable healthcare workers (HCWs).

The results indicate that non-severe psychological distress (no PTSD) was reported among 81.1% HCWs at T1 and 80.4% HCWs at T1. Mild psychological distress (mild PTSD) was reported by 18.9% and 19.6% at T1 and T2, respectively. These findings align with a meta-analysis on the health impact of coronavirus syndromes (SARS/ MERS/COVID-19) on HCWs, reporting a PTSD rate of 20.7%.⁹ However, the study also anticipated a rise in figures as the pandemic progressed, which was observed in this study, but not significantly. The decline of psychological distress could be attributed to further understanding of the virus and implementing appropriate regulations and measures. Another explanation could be that PTSD features were more frequent in coronaviruses that had higher mortality rates such as in MERS (35%) and SARS (9.6-21%) compared to COVID-19 (2- 5%).^9,43 Additionally, this can be attributed to several initiatives taken on by the Bahraini government and KHUH, recently recognized as important to reduce the mental health burden and trauma associated with COVID-19 for HCWs ^{4, 6, 8, 44, 45}:

1) Ready access to psychological support services for HCWs, ensuring that HCWs were appreciated and acknowledged for their efforts during the pandemic.

2) HCWs were provided the latest updates and facts on COVID-19 regularly through online weekly lectures and email circulars so that they can make informed decisions.

3) Best-practice protocols and guidelines were developed and updated on a regular basis in coordination with the Bahrain National Taskforce for Combating the Coronavirus (COVID-19) to ensure HCWs face the least possible risk of contracting and spreading COVID-19. For example, HCWs were allowed to work remotely where possible and elective surgeries were cancelled and then later, reduced to 30% when the number of COVID-19 cases decreased.

Avoidance (i.e., effortful avoidance of situations that remind them of COVID-19) was the most prevalent PTSD criteria in our study population. This is contrary to a study (2020) where the most significant domain among medical care workers in China was intrusion (i.e., having repeated thoughts of the trauma).¹⁶ On the other hand, a study among HCWs in Saudi Arabia found that hyperarousal was the most common.⁴⁶ While variance can be attributed to regional perceptions of the pandemic, our results were aligned with the mental health advice provided by the medical centre. Multiple hospital wide lectures during the COVID-19 pandemic were held at our study setting to emphasize methods of infection prevention and how to reduce levels of anxiety.

Studies conducted in Jordan and Saudi Arabia documented notably higher levels of anxiety (ranging from 38.0 - 68.2% mild anxiety, 20.8 - 21.5% moderate anxiety, and 11% severe anxiety) among HCWs compared to our study.^23,25,47 At T1, 30.1% reported mild to severe anxiety, and at T2, 27.4% reported mild to severe anxiety, and these rates were similar to other studies.⁴³ However, these studies underwent data collection during the acute outbreak of COVID-19, whereas our study was conducted at six and 12 months post the start of the pandemic in Bahrain. As less information was available and no vaccine drives were considered when the outbreak started, this would have led to higher anxiety rates.

Sleep related disturbances were considered the greatest risk factor for manifesting psychological distress/PTSD and anxiety.⁴⁸ The prevalence of sleep problems during the COVID-19 pandemic is high and affects approximately 40% of people from general and health care populations.⁴⁸ Other predictors included having quarantined or being infected with COVID-19. Some studies suggest that those who were infected with COVID-19 and underwent isolation had higher levels of sleep disturbances and mental health issues due to loneliness.^48-51 In addition, those who fell within the 20-29 age group exhibited moderate anxiety levels at T1 and severe anxiety levels at T2, highlighting the emotional burden carried by younger HCWs.

Our secondary objective was to assess the knowledge of HCWs towards the centre’s psychological support services. Approximately 75% of HCWs were aware of the available services and had lower IES-R and BAI scores. HCWs who used these services also suffered from higher levels of psychological distress and anxiety than those who were unaware. Assessing knowledge and utilization of these services may be useful to explore whether they act as potential coping mechanisms for psychological distress and anxiety.⁴⁸

Limitations

Due to the study’s time period, the most significant limitation is the time-sensitivity of the pandemic that affected each HCW differently. As such, it was difficult to measure the pandemic’s influence on external factors that influenced psychological well-being. Secondly, the survey design did not allow for appropriate screening for mental illnesses and/or medications. As such, there is the potential for participants to underreport their negative mental health outcomes due to stigma.^{49, 50} Another limitation is that the majority of the participants did not work directly with COVID-19 patients, which could result in assessing psychological impact in the context of a lower perceived risk of COVID-19 compared to frontliners.

Conclusion

The COVID-19 pandemic has caused notable psychological distress and anxiety to HCWs within a teaching hospital in Bahrain and through this study, important risk factors were identified. However, our relatively lower psychological impact and anxiety rates compared to other studies may be due to initiatives taken by the Bahraini government and medical centre to reduce the mental health burden associated with COVID-19 for HCWs. It is recommended that in addition to strict measures of infection prevention and acute care provided to infected HCWs during a pandemic, a responsive and proactive strategy by the leadership should be taken. These strategies should aim to implement interventions focused on psychological support to improve mental wellbeing and reduce levels of distress and anxiety.