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Journal of Infection and Public Health 13 (2020) 1645–1651

Contents lists available at ScienceDirect

Journal of Infection and Public Health

j o u r n a l h o m e p a g e : h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / j i p h

Original Article

Prevalence and predictors of anxiety among healthcare workers inSaudi Arabia during the COVID-19 pandemic

Thamer H. Alenazi a,b,!, Nasser F. BinDhim c,d,e, Meteb H. Alenazi f,g, Hani Tamim h,Reem S. Almagrabi i, Sameera M. Aljohani a,b, Mada H Basyouni j, Rasha A. Almubark c,Nora A. Althumiri c, Saleh A. Alqahtani k,la Ministry of National Guard Health-Affairs, Riyadh, Saudi Arabiab King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabiac Sharik Association for Health Research, Riyadh, Saudi Arabiad College of Medicine, Al-Faisal University, Riyadh, Saudi Arabiae Saudi Food and Drug Authority, Riyadh, Saudi Arabiaf Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabiag King Saud University Medical City, King Saud University, Riyadh, Saudi Arabiah Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanoni Department of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabiaj Ministry of Health, Saudi Arabiak Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabial Division of Gastroenterology and Hepatology, John Hopkins University, Baltimore, USA

a r t i c l e i n f o

Article history:Received 5 July 2020Received in revised form 31 August 2020Accepted 6 September 2020

Keywords:Healthcare workersHCWsAnxietyCOVID-19Silent epidemic

a b s t r a c t

Background: During pandemics, healthcare workers (HCWs) may be prone to higher levels of anxiety thanthose of the general population. This study aimed to explore the anxiety levels among HCWs in SaudiArabia during the COVID-19 pandemic and the predictors of increased anxiety levels.Method: HCW participants in this cross-section study were solicited by email from the database of reg-istered practitioners of the Saudi Commission for Health Specialties between 15 May and 18 May 2020.Sociodemographic characteristics, work-related factors, and organization-related factors were collected.Results: Four thousand nine hundred and twenty HCWs (3.4%) responded. Reported levels of anxietywere low anxiety (31.5%; n = 1552), medium (36.1%; n = 1778), and high (32.3%; n = 1590). Participantsreporting high anxiety levels were more likely to be unmarried (OR = 1.32, 95% CI: 1.14–1.52); nurses (OR= 1.54, 95% 1.24–1.91); workers in radiology (OR = 1.52, 95% CI: 1.01–2.28); or respiratory therapists (OR= 2.28, 95% CI: 1.14–4.54). Social factors associated with high anxiety levels were: living with a personwho is elderly (p = 0.01), has a chronic disease (p < 0.0001), has immune deficiency (p < 0.0001), or has arespiratory disease (p-value <0.0001). Organization-related factors associated with a high level of anxietywere: working in an organization that hosts COVID-19 patients and working with such patients (p-value<0.0001).Conclusion: Self-reported medium and high levels of anxiety were present in 68.5% of HCWs in the COVID-19 pandemic. This highlights the urgent need to identify high-risk individuals to offer psychologicalsupport and provide up to date information on the pandemic. These data should help policymakers driveinitiatives forward to protect and prepare HCWs psychological wellbeing.

© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University forHealth Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.

org/licenses/by-nc-nd/4.0/).

! Corresponding author at: P.O. box 59690, Riyadh 11535, Saudi Arabia.E-mail addresses: [email protected], [email protected]

(T.H. Alenazi).

Introduction

The epidemic of a novel coronavirus disease 2019 (COVID-19)began in mainland China in late 2019 and spread throughout theworld to cause a global pandemic [1]. As of August 23, 2020, therewere over 23 million confirmed cases and 800,000 deaths world-wide, and the pandemic had reached 220 countries and territories

https://doi.org/10.1016/j.jiph.2020.09.0011876-0341/© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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T.H. Alenazi et al. Journal of Infection and Public Health 13 (2020) 1645–1651

[2]. In Saudi Arabia, as of August 27, 2020, there were 311,855confirmed COVID-19 case, with 3785 deaths [3].

Emerging infectious disease pandemics usually are accom-panied by a hidden silent pandemic, namely, the psychologicalimpact [4–7]. The general population, including healthcare workers(HCWs), are prone to this silent pandemic. HCWs, as the front-line force to control pandemics, are expected to have differentlevels of anxiety than those of the general population. Various fac-tors may contribute to the perceived altered anxiety levels amongHCWs, such as the fear of contracting the infection during work;fear of transmitting the infection to loved ones; scarcity of avail-able knowledge; quality of the knowledge presented in the officialportals or the social media; and shortage of personal protectiveequipment.

The psychological effect of epidemics on HCWs was studiedduring and after the severe acute respiratory syndrome (SARS)epidemic in 2002. The short-term impact of the epidemic wasdescribed among Chinese HCWs, where 68% of those surveyedexperienced high levels of stress, and 57% suffered from psychologi-cal distress [5]. Moreover, HCWs who had dealt with SARS patientsin their institutions surveyed 13–26 months after the epidemic,had higher rates of psychological distress and post-traumatic stressdisorders than did HCWs who were not exposed to SARS patients[8].

It is not surprising that anxiety has been found associated withthe current COVID-19 pandemic. In a nationwide survey conductedearly in the pandemic in China, almost 35% of general-populationrespondents reported psychological distress [9]. A month later,when the epidemic had spread to many countries outside China, asurvey of 1210 respondents from the general public in 194 citiesin China found that 53.8% of respondents rated the psychologi-cal impact of the outbreak as moderate to severe; 16.5% reportedmoderate to severe depressive symptoms; 28.8% reported moder-ate to severe anxiety symptoms; 8.1% reported moderate to severestress levels [10]. In a review of 14 studies of the psychologicalburden of COVID-19 pandemic on medical and non-medical hospi-tal staff, significant stress and anxiety symptoms were reported bythe surveyed staff [11]. In one of those studies, where 2299 hospi-tal staff were surveyed, 22.6% reported mild to moderate anxietysymptoms, and 2.9% reported severe symptoms [12]

The COVID-19 pandemic is so far the largest in the current cen-tury, and none of the practicing HCWs in the world had faced apandemic of such magnitude; thus, exploration of the psychologicaleffect of COVIC-19 among the HCWs would be especially interest-ing.

Our study aimed to explore the prevalence of anxiety and themain predictors for high anxiety levels among HCWs in Saudi Ara-bia during the current COVID-19 pandemic.

Method

Design

This was a nation-level cross-sectional study of participantsfrom all the 13 administrative regions in Saudi Arabia.

Participants

Participants eligible to participate in this study were healthcareprofessionals performing their medical duties during the peak timeof COVID-19 in Saudi Arabia.

Recruitment

Registered HCWs of the Saudi Commission for Health Special-ties were invited to participate via email, and the responses were

collected anonymously. The study was approved by SharikHealthInstitutional Review Board (IRB) number 01"2020.

Sampling and sample size

The study used a convenience sampling technique and a self-reported online questionnaire. Assuming that there would bemoderate differences between regions in terms of anxiety andsources of information, a sample of at least 80 participants perregion, was required to provide a medium-effect size of 0.35 and80% power at 95% confidence. Which gives a total sample size of atleast 1040 participants [13]. Participants from the database of reg-istered practitioners at the Saudi Commission for Health Specialtieswere invited to participate between 15 May and 18 May 2020.

Survey design and validation

Characteristics of HCWsIn the first section, after providing online consent, participants

were asked about their sociodemographic characteristics, age, gen-der, region, and healthcare profession. Questions also consisted ofthe type of facility, if the facility was in terms of receiving COVID-19infected patients cases or not, and if the HCW was performing alltheir usual. In addition to the eligibility question of being currentlypreforming their healthcare duties in a healthcare facility.

Information distributionIn the second section, the participants were asked about their

level of satisfaction about sufficiency and the quality of informationthey received about COVID-19 from the healthcare institute.

Worry and anxietyIn the third section, participants were asked whether they wor-

ried about contracting COVID-19 and spreading it to others, thefrequency and severity of worrying, and general anxiety. The worryquestions were adapted from the dispositional cancer worry scale,which has a total score range between 1 to 28 [14]; using the scale,we classified the participant into three groups: low anxiety (score <10), medium anxiety (score 10"15), and high anxiety (score > 15).The one-item question Likert scale for anxiety was used to measuregeneral anxiety [15].

Facility preparednessIn the last section, the participants were asked about the pre-

paredness of their work facility in preventive and precautionarymeasures.

The survey was developed by the initial group of authors usingQ-Platform which was developed by SharikHealth, and linguisticvalidation was conducted by a focus group with 8 participants.The survey tool then was modified and piloted with 150 health-care practitioners. The authors discussed the results of the pilotstudy, and minor modifications were made to improve the surveyquestions.

Statistical analysis

Data were transferred to the Statistical Package for Social Sci-ences (SPSS), version 25, which was used for data management andanalyses. Categorical variables were presented as number and per-cent, whereas continuous variables were presented as mean andstandard deviation. A chi-square test was used to assess the associ-ation between anxiety level and various categorical variables, andthe ANOVA test was used for the continuous variables. To iden-tify significant predictors of anxiety, we carried out multivariate(mainly multinomial regression) analyses. Results were presented

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as odds ratio (OR) and 95% confidence interval (CI). p < 0.05 wasused to indicate statistical significance.

Results

The survey was delivered to 143,187 registered HCWs via emailthrough the Saudi Commission for Health Specialties. Our sam-ple of 4920 HCWs was collected in four days (response rate of3.4%.) When divided into three groups according to anxiety levelon the worry scale, 1552 (31.5%), 1778 (36.1%), and 1590 (32.3%)participants were in the low, medium, and high anxiety groups,respectively.

Personal and sociodemographic information gathered in thefirst part of the survey and its relation to anxiety levels describedin section three is presented in Table 1. Participants reportinghigh anxiety levels were more likely to be unmarried (OR = 1.32,95% CI: 1.14–1.52). Additionally, a high anxiety level was associ-ated with smoking, having chronic diseases, and having <5 yearsof experience, compared to those who reported “Medicine” astheir professional field, high anxiety level was associated with“Nursing” (OR = 1.54, 95% 1.24–1.91), “Radiology” (OR = 1.52,95% CI: 1.01–2.28), and “Respiratory therapy” (OR = 2.28, 95% CI:1.14–4.54), whereas anxiety level was not significantly associatedwith any of the other professional specializations. No significantdifference in anxiety level was reported among participants fromthe 13 administrative regions of Saudi Arabia. Furthermore, HCWswho reported being anxious before the current pandemic, or whohad been prescribed medications to relieve anxiety before thepandemic, were more likely to be more worried during the cur-rent COVID-19 pandemic than were HCWs who had not reporteda history of anxiety. Similarly, participants who reported a highlevel of anxiety were more likely to have sought help froma mental health professional or were considering seeking suchhelp.

HCWs who reported high anxiety level were associated with liv-ing with one of the following persons living in the same residenceas the HCW: an elderly person (p = 0.01), a person with chronic dis-ease (p < 0.0001), a person with immune deficiency (p < 0.0001),or a person with respiratory disease (p < 0.0001). Moreover, higheranxiety levels were if the HCW had a friend, coworker, or familymember who had been diagnosed with COVID-19, or they them-selves had been isolated due to a suspected COVID-19 infection. Asexpected, high anxiety levels were also associated with HCWs whoperceived themselves at a high risk of contracting COVID-19 (p <0.0001).

Table 2 presents the associations of organization factors, job-related factors, and preparedness of the workplace, with anxietylevel. Participants reporting a high level of anxiety were more likelyto be working in an organization that hosts COVID-19 patients andto have a job that requires dealing with such patients (p-value<0.0001). Furthermore, HCWs who reported that their organizationprovided frequent communication and updates about COVID-19and provided COVID-19 tests for all HCWs were less likely to havea high level of anxiety. Adding to that, HCWs who worked in anorganization that had a documented outbreak-management planwere likely to be less anxious.

Using social media as a source of information for COVID-19 wasassociated with a higher level of anxiety among the surveyed HCWs.HCWs who reported that the information they received from sci-entific and official portals or social media as n̈ot sufficient,r̈eportedlow-level anxiety (35.8%), medium-level anxiety (40.4%), and high-level anxiety (40.9%) (p-value <0.0001). HCWs also rated the qualityof the information they received about COVID-19 on a scale of 1–5;the HCWs with low, medium, and high anxiety levels reported

average scores of 3.86 (sd 1.14), 3.58, (sd 1.08), and 3.34 (sd1.19),respectively.

Table 3 reports the results of the multivariate regression analy-ses for the predictors of anxiety. After adjustment for most of thedemographic and background variables, high anxiety was associ-ated with being a smoker and having a chronic disease. Amongprofessions, nursing, radiology, and respiratory therapy were sig-nificantly associated with high anxiety.

Discussion

This study surveyed a large sample of HCWs working in SaudiArabia during the COVID-19 pandemic and evaluated their level ofanxiety during this time. Data showed that 32.3% of HCWs surveyedhave a high anxiety level, and 68.5% have medium- or high-levelanxiety. Many factors were associated with high anxiety levels;the factors can be categorized into three themes: individual, social,and organizational. Individual factors associated with high anxietylevels were being a smoker, living with a chronic disease, beinga nurse, having a high self-perceived risk of getting COVID-19,and previous history of anxiety. Social factors that were associ-ated with a high anxiety level were living with an elderly person,a person with chronic disease, a person with immune deficiency,or a person with respiratory disease. In addition, HCWs who had acoworker, friend, or family member tested positive for COVID-19were more likely to report a high level of anxiety. Organizationalfactors that were related to increased anxiety levels were lack ofregular communication and updates from the organization, insuf-ficient and unsatisfactory quality of information about COVID-19,lack of access to COVID-19 testing for the staff, and lack of a crisismanagement plan; These findings are consistent with other studieslooking at the impact of COVID-19 on the mental health of HCWs[16,17].

Policymakers having to make national decisions on health-care organizations and provisions will benefit from data generatedin this and other studies looking at the impact of COVID-19 onfrontline workers. This study offers potential predictors of anxietyfor HCWs and considering these and applying strategies in crisismanagement plans to identify high-risk HCWs will allow for bet-ter management of stress, anxiety, and mental health issues onworkers. This survey offers a voice of the HCWs for policy decision-makers. Ensuring regular and reliable communication of COVID-19,providing PPEs, and offering professional support for those alreadyfeeling anxious will reduce the burden on these HCWs.

Several studies among HCWs in other countries have found sim-ilar findings: A systematic review and meta-analysis found thatnurses and female health providers had higher rates of affectivesymptoms than did male and medical staff; also the prevalence ofinsomnia was 38.9% in five studies [16]. Another study from NewYork city, USA had surveyed 657 HCWs, 33% of them had a positivescreen for anxiety symptoms. Nurses were also more likely thanattending physicians to screen positive for anxiety (40% vs. 15% [p= 0.001]) [18]. Obviously, nursing staff has longer and more closecontact with patients compared to other professionals, providingthe round-the-clock care that COVID-19 patients need. Thus, theseresults highlight the importance of focusing on nursing staff viamonitoring and screening to detect, treat and hopefully preventanxiety.

A similar study conducted in Saudi Arabia in February 2020,looking at HCWs anxiety levels during the COVID-19 pandemic [19].Using the GAD-7 Anxiety scale, it found that about one-third of thestudied HCWs reported moderate to high anxiety; 20.8% had mod-erate anxiety; 8.1% had high-moderate anxiety, and 2.9% had veryhigh anxiety. However, this study was conducted when not onecase had been recorded in Saudi Arabia. By applying this data with

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Table 1Healthcare worker demographic and background information in relation to anxiety level reported.

Total n = 4920 Anxiety level (Tertile) p-Value 10–15 (Reference <10) >15 (Reference<10)

Low Medium High OR (95%CI) OR (95%CI)<10 10"15 >15n = 1552 n = 1778 n = 1590

Age 34.11 ± 8.13 34.96 ± 8.76 34.20 ± 8.17 33.18 ± 7.32 <0.001 0.99 (0.98"1.0) 0.97 (0.96"0.98)Gender

<0.0001Male 2307 (46.9) 801 (51.6) 898 (50.5) 608 (38.2) Reference ReferenceFemale 2613 (53.1) 751 (48.4) 880 (49.5) 982 (61.8) 1.05 (0.91"1.19) 1.72 (1.50"1.99)

Marital status<0.0001Married 2983 (60.6) 977 (63.0) 1111 (62.5) 895 (56.3) Reference Reference

Unmarried 1937 (39.4) 575 (37.0) 667 (37.5) 695 (43.7) 1.02 (0.89"1.17) 1.32 (1.14"1.52)Region

0.02

Riyadh 1627 (33.1) 455 (29.3) 602 (33.9) 570 (35.8)Makkah 1042 (21.2) 323 (20.8) 392 (22.0) 327 (20.6)Eastern Region 853 (17.3) 264 (17.0) 308 (17.3) 281 (17.7)Madinah 255 (5.2) 84 (5.4) 90 (5.1) 81 (5.1)Asir 247 (5.0) 90 (5.8) 93 (5.2) 64 (4.0)Qassem 209 (4.2) 80 (5.2) 63 (3.5) 66 (4.2)Jazan 202 (4.1) 76 (4.9) 58 (3.3) 68 (4.3)Tabuk 116 (2.4) 41 (2.6) 43 (2.4) 32 (2.0)Hail 98 (2.0) 40 (2.6) 34 (1.9) 24 (1.5)Najran 85 (1.7) 34 (2.2) 31 (1.7) 20 (1.3)Jouf 71 (1.4) 29 (1.9) 23 (1.3) 19 (1.2)Baha 61 (1.2) 20 (1.3) 21 (1.2) 20 (1.3)Northern borders 54 (1.1) 16 (1.0) 20 (1.1) 18 (1.1)

Profession

<0.0001

Medicine 734 (14.9) 246 (15.9) 272 (15.3) 216 (13.6) Reference ReferenceNursing 1913 (38.9) 540 (34.8) 643 (36.2) 730 (45.9) 1.08 (0.88"1.33) 1.54 (1.24"1.91)Pharmacy 580 (11.8) 210 (13.5) 238 (13.4) 132 (8.3) 1.03 (0.80"1.32) 0.72 (0.54"0.95)Medical laboratories 365 (7.4) 132 (8.5) 145 (8.2) 88 (5.5) 0.99 (0.74"1.33) 0.76 (0.55"1.05)Dentistry 299 (6.1) 99 (6.4) 111 (6.2) 89 (5.6) 1.01 (0.74"1.40) 1.02 (0.73"1.44)Radiology 193 (3.9) 51 (3.3) 74 (4.2) 68 (4.3) 1.31 (0.88"1.95) 1.52 (1.01"2.28)Physical Therapy 107 (2.2) 39 (2.5) 37 (2.1) 31 (1.9) 0.86 (0.53"1.39) 0.91 (0.55"1.50)Respiratory therapy 52 (1.1) 13 (0.8) 13 (0.7) 26 (1.6) 0.90 (0.41"1.99) 2.28 (1.14"4.54)Other 677 (13.8) 222 (14.3) 245 (13.8) 210 (13.2) 1.00 (0.78"1.28) 1.08 (0.83"1.40)

Specialization

0.58

Internal medicine 167 (15.6) 42 (12.1) 61 (16.3) 64 (18.2) Reference ReferencePediatrics 141 (13.2) 44 (12.7) 53 (14.2) 44 (12.5) 0.83 (0.47"1.45) 0.66 (0.37"1.16)Emergency Medicine 130 (12.1) 41 (11.8) 44 (11.8) 45 (12.8) 0.74 (0.41"1.32) 0.72 (0.41"1.28)Surgery 123 (11.5) 38 (11.0) 44 (11.8) 41 (11.7) 0.80 (0.44"1.43) 0.71 (0.39"1.28)Family medicine 117 (10.9) 34 (9.8) 40 (10.7) 43 (12.3) 10.81 (0.44"1.48) 0.83 (0.46"1.50)OB-GYN 69 (6.4) 22 (6.4) 24 (6.4) 23 (6.6) 0.75 (0.37"1.51) 0.69 (0.34"1.39)Psychiatry 18 (1.7) 9 (2.6) 5 (1.3) 4 (1.1) 0.38 (0.12"1.22) 0.29 (0.08"1.01)Dermatology 11 (1.0) 6 (1.7) 2 (0.5) 3 (0.9) 0.23 (0.04"1.19) 0.33 (0.08"1.38)Neurology 6 (0.6) 3 (0.9) 1 (0.3) 2 (0.6) 0.23 (0.02"2.28) 0.43 (0.07"2.73)Other 289 (27.0) 107 (30.9) 100 (26.7) 82 (23.4) 0.64 (0.40"1.04) 0.50 (0.31"0.82)

Children 2647 (53.8) 868 (55.9) 976 (54.9) 803 (50.5) 0.005 0.96 (0.83"1.10) 0.80 (0.70"0.93)Cigarette smoker

0.02No, never 4042 (82.2) 1285 (82.8) 1486 (83.6) 1271 (79.9) Reference ReferenceYes 878 (17.8) 267 (17.2) 292 (16.4) 319 (20.1) 0.95 (0.79"1.13) 1.21 (1.01"1.45)

Any chronic disease 547 (11.1) 147 (9.5) 185 (10.4) 215 (13.5) 0.001 1.11 (0.88"1.39) 1.49 (1.20"1.87)Health care worker 3762 (76.5) 1121 (72.2) 1351 (76.0) 1290 (81.1) <0.0001 1.22 (1.04"1.42) 1.65 (1.40"1.96)Experience, years

0.003<5 years 1588 (32.3) 472 (30.4) 550 (30.9) 566 (35.6) Reference Reference#5 years 3332 (67.7) 1080 (69.6) 1228 (69.1) 1024 (64.4) 0.98 (0.84"1.13) 0.79 (0.68"0.92)

our own, which recorded anxiety during the pandemic, it offersan interesting view of how anxiety levels have evolved in HCWsbefore and during the crisis. What would be interesting is to eval-uate anxiety as the numbers start to fall and lockdown restrictionsstart to loosen. One would predict that anxiety levels would dropin number but on the other hand, perhaps there will be an increasein HCWs reporting post-traumatic stress symptoms.

What is clear is that we need to support and protect our HCWsat all stages of the pandemic.

Given the nature of a self-report survey, we wonder whetherunconscious processes might have affected individuals’ responsesto high-stress situations. For example, that HCWs who indicatedthat they “don’t think they will get COVID-19” (despite the avail-ability of the choice “very low risk”) suggests that the unconsciousdefense mechanism of denial played a role in their responses.Not surprisingly, this group (5.3% of respondents) reported a low-

level of anxiety. It is inconceivable, though, at an intellectual,logical level, that a health care practitioner would deny the pos-sibility of getting infected. Defense mechanisms are well-studiedunconscious processes that protect the conscious mind from whatmight be overwhelming anxiety [20]. Discussion of defense mech-anisms that may be at work when self-reporting anxiety in suchan unsettling situation is beyond the scope of this presentation,but clinicians and decision-makers should be aware of such mech-anisms.

Another response that stood out in our survey was that marriedindividuals and those with children below 15 years of age claimedlower levels of anxiety, which is counterintuitive to what one wouldthink: we thought that the fear of transmitting illness to one’s fam-ily might result in more distress amidst the pandemic. To expand onthis, the concept of “death anxiety” is relevant. There are psycho-logical models and psychotherapies that primarily deal with death

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Table 2Healthcare worker response to information, job-related factors, and preparedness of the workplace according to anxiety level reported.

Total n = 4920 Anxiety level (tertile) p-Value

Low Medium High<10 10"15 >15n = 1552 n = 1778 n = 1590

Working in an organization that host COVID-19 patients 2738 (55.7) 816 (52.6) 957 (53.8) 965 (60.7) <0.0001Previous experience in dealing with pandemic/epidemic 1874 (38.1) 595 (38.3) 646 (36.3) 633 (39.8) 0.11Nature of job requires dealing with COVID-19 patients 2570 (52.2) 734 (47.3) 898 (50.5) 938 (59.0) <0.0001Residence during COVID-19 pandemic

0.43Moved to a different residence 422 (8.6) 125 (8.1) 149 (8.4) 148 (9.3)Still living in the same residence 4498 (91.4) 1427 (91.9) 1629 (91.6) 1442 (90.7)

Household contacts include:An elderly person 1093 (22.2) 310 (20.0) 396 (22.2) 387 (24.3) 0.01A person with chronic disease 1014 (20.6) 274 (17.7) 349 (19.6) 391 (24.6) <0.0001A person with immune deficiency 272 (5.5) 57 (3.7) 106 (6.0) 109 (6.9) <0.0001A person with respiratory disease 453 (9.2) 95 (6.1) 170 (9.6) 188 (11.8) <0.0001Children below 15 years old 1948 (39.6) 589 (38.0) 742 (41.7) 617 (38.8) 0.06

A coworker, friend, or family member has beendiagnosed with COVID-19

1025 (20.8) 225 (14.5) 353 (19.9) 447 (28.1) <0.0001

HCWs who were isolated due to suspected COVID-19 606 (12.3) 144 (9.3) 204 (11.5) 258 (16.2) <0.0001HCWs who reported anxiety before 2020 2.33 ± 1.27 1.73 ± 0.93 2.31 ± 1.12 2.92 ± 1.42 <0.001HCWs who were prescribed any treatment for anxiety

relief before 2020299 (6.1) 72 (4.6) 99 (5.6) 128 (8.1) <0.0001

Perception of the risk getting COVID-19

<0.0001High 1887 (38.4) 294 (18.9) 641 (36.1) 952 (59.9)Low 2774 (56.4) 1101 (70.9) 1092 (61.4) 581 (36.5)I don’t think I will get COVID-19 259 (5.3) 157 (10.1) 45 (2.5) 57 (3.6)

HCWs who attended online seminars to deal with stress 1928 (39.2) 598 (38.5) 736 (41.4) 594 (37.4) 0.046HCWs who are interested in attending online seminars

to deal with stress3516 (71.5) 982 (63.3) 1298 (73.0) 1236 (77.7) <0.0001

Using social media to get information about COVID-19 4167 (84.7) 1239 (79.8) 1528 (85.9) 1400 (88.1) <0.0001Perception on the sufficiency of information received

from scientific portals and social media <0.001Not sufficient 1925 (39.1) 556 (35.8) 719 (40.4) 650 (40.9)Sufficient 2995 (60.9) 996 (64.2) 1059 (59.6) 940 (59.1)

HCWs who rated the quality of information receivedabout COVID-19 as high quality, (1 = poor quality, 5 =excellent quality) mean (SD)

3.59 ± 1.15 3.86 ± 1.14 3.58 ± 1.08 3.34 ± 1.19

<0.0011 252 (5.1) 73 (4.7) 62 (3.5) 117 (7.4)2 571 (11.6) 121 (7.8) 209 (11.8) 241 (15.2)3 1471 (29.9) 340 (21.9) 574 (32.3) 557 (35.0)4 1270 (25.8) 437 (28.2) 505 (28.4) 328 (20.6)5 1356 (27.6) 581 (37.4) 428 (24.1) 347 (21.8)

HCWs who were anxious because of lack of knowledgeabout infection control, (1 = total agree, 7 = not at all),mean (SD)

5.87 ± 1.56 6.56 ± 0.99 5.92 ± 1.42 5.14 ± 1.83

<0.0011 144 (2.9) 12 (0.8) 34 (1.9) 98 (6.2)2 128 (2.6) 14 (0.9) 34 (1.9) 80 (5.0)3 210 (4.3) 16 (1.0) 63 (3.5) 131 (8.2)4 387 (7.9) 30 (1.9) 132 (7.4) 225 (14.2)5 513 (10.4) 68 (4.4) 236 (13.3) 209 (13.1)6 1029 (20.9) 253 (16.3) 427 (24.0) 349 (21.9)7 2509 (51.0) 1159 (74.7) 852 (47.9) 498 (31.3)

HCWs who sought help from a mental healthprofessional during the current pandemic

392 (8.0) 59 (3.8) 108 (6.1) 225 (14.2) <0.0001

HCWs who are considering seeking help from a mentalhealth professional after COVID-19

715 (14.5) 106 (6.8) 222 (12.5) 387 (24.3) <0.0001

Organization provided continuous information aboutCOVID-19

3783 (76.9) 1228 (79.1) 1376 (77.4) 1179 (74.2) 0.003

Organization provided regular COVID-19 checks onHCWs

<0.0001Yes, on all healthcare workers 1862 (37.8) 646 (41.6) 687 (38.6) 529 (33.3)Yes, only on those who deal with COVID-19 patientsdirectly

1092 (22.2) 328 (21.1) 404 (22.7) 360 (22.6)

No regular COVID-19 checks for healthcare workers 1158 (23.5) 278 (17.9) 409 (23.0) 471 (29.6)I don’t know 808 (16.4) 300 (19.3) 278 (15.6) 230 (14.5)

Availability of :PPEs (gloves/facemasks/gowns) 4679 (95.1) 1470 (94.7) 1698 (95.5) 1511 (95.0) 0.57Hand sanitizer 4587 (93.2) 1442 (92.9) 1673 (94.1) 1472 (92.6) 0.18Ventilators 2367 (48.1) 721 (46.5) 859 (48.3) 787 (49.5) 0.23Prevention or crises management plan 2728 (55.4) 892 (57.5) 1006 (56.6) 830 (52.2) 0.006Infection control unit or team 3053 (62.1) 959 (61.8) 1091 (61.4) 1003 (63.1) 0.57

anxiety and view it as an influential force, albeit hidden, in our psy-chological world [21]. Undoubtedly, a pandemic of this magnitudeis expected to stir this hidden anxiety. The reproductive drive that

propels humankind to mating has been hypothesized to be an anti-dote to death anxiety [22]. In this context, we wonder if the lowerlevels of anxiety among married individuals and individuals with

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Table 3Multivariate multinomial regression for predictors of anxiety predictors of anxiety.

10–15 (reference: <10) >15 (reference: <10)

OR 95%CI p-Value OR 95%CI p-Value

Age 0.98 0.97 0.99 <0.0001 0.97 0.96 0.98 <0.0001Gender (reference: female) 0.99 0.84 1.18 0.95 0.64 0.54 0.77 <0.0001Marital status (reference: married) 0.96 0.78 1.19 0.73 1.09 0.88 1.35 0.45Children (reference: no) 1.03 0.84 1.28 0.75 1.18 0.95 1.47 0.14Cigarette smoke (reference: no) 0.95 0.78 1.15 0.59 1.49 1.22 1.81 <0.0001Chronic disease any (reference: no) 1.22 0.96 1.55 0.10 1.83 1.44 2.32 <0.0001Experience, years (reference: <5 years) 1.11 0.91 1.35 0.29 1.05 0.86 1.29 0.62Profession (reference: medicine)

Nursing 1.02 0.76 1.36 0.90 1.44 1.06 1.95 0.02Pharmacy 0.95 0.69 1.31 0.76 0.79 0.56 1.12 0.19Medical laboratories 0.92 0.64 1.31 0.63 0.66 0.44 0.97 0.03Dentistry 0.99 0.69 1.42 0.96 1.07 0.72 1.58 0.74Radiology 1.22 0.79 1.90 0.36 1.49 0.94 2.35 0.09Physical therapy 0.80 0.47 1.34 0.39 0.80 0.46 1.38 0.42Respiratory therapy 0.84 0.37 1.90 0.68 1.96 0.94 4.06 0.07Other 0.94 0.69 1.29 0.71 1.00 0.72 1.41 0.98

Specialization (reference: internalmedicine)Pediatrics 0.86 0.49 1.50 0.59 0.70 0.39 1.26 0.23Emergency medicine 0.73 0.41 1.31 0.29 0.77 0.43 1.39 0.39Surgery 0.83 0.46 1.50 0.5 0.81 0.44 1.48 0.50Family medicine 0.79 0.43 1.44 0.44 0.77 0.42 1.42 0.41OB-GYN 0.74 0.37 1.50 0.41 0.64 0.31 1.31 0.22Psychiatry 0.40 0.12 1.28 0.12 0.30 0.08 1.06 0.06Dermatology 0.24 0.05 1.25 0.09 0.31 0.07 1.33 0.11Neurology 0.21 0.02 2.14 0.19 0.36 0.05 2.46 0.30Other 0.76 0.49 1.18 0.22 0.54 0.35 0.83 0.01

children during this unprecedented pandemic are a unique wayto point to this characteristically hidden, ubiquitous worry — theworry of dying. It might be as if these persons have won roundsagainst death anxiety, so to speak. The higher anxiety levels amongthose who smoke, compared with non-smokers, also point towardthoughts about one’s own mortality, should they get the infection.Those who were isolated due to COVID19 had a higher anxiety level,which could be related to breaking the barrier of denial, with deathanxiety lurking beneath it.

We believe that our research has highlighted some of the factorsassociated with higher levels of anxiety that could help decision-makers and clinicians identify and offer help to practitioners whohave high anxiety levels. Practitioner’s stress has been found associ-ated with an increased rate of patient-safety incidents, poor qualityof care due to low professionalism, and reduced patient satisfac-tion [23]. In our study, practitioners with high anxiety indicatedthey would be interested in attending online webinars on how todeal with stress, and were more likely to seek help; 24.3% of thosewith high anxiety level said they plan to seek help from a mentalhealth professional after the current pandemic, while only 14.2% ofHCWs with high anxiety said they are currently seeking help. Mak-ing mental health resources accessible and effective likely will bebeneficial.

This study has limitations. First, the response rate was low, andthat might be attributed to the short time given to respond (only4 days) where a busy HCW did not have time to respond, how-ever, we think that the large sample size compensated for the lowresponse rate and achieved the desired power. Since we recruitedHCWs via email, those who responded may have been those inter-ested in exploring how they feel; thus, we might have heard fromthe more self-aware individuals and consequently overestimatedanxiety. Conversely, individuals who were too overwhelmed toparticipate in a voluntary questionnaire might have opted out,resulting in an underestimation of anxiety. Thus, given the effectof opposite forces on our results, we believe it likely that oursample is balanced. Second, we grouped questions about anxietyinto three categories; given the large sample size, we thought this

would be the most meaningful way to interpret the data. Third, thelimitations of self-reporting cannot be overlooked when trying toevaluate the level of anxiety. We hope that our discussion of theunconscious considerations was an attempt to be mindful of thislimitation. On the other hand, the strength of the study is that wehad surveyed a large number of HCWs from all the 13 regions inSaudi Arabia, from all different fields to be representative. Also, thetiming of the study was appropriate to assess the anxiety associ-ated with COVID-19, where the number of cases in the country washigh.

We suggest that further research on anxiety among HCWs in theCOVID-19 pandemic include variables that were not included in oursurvey: level of tolerance of uncertainty; income level; beliefs aboutthe mortality rate of COVID19 and factors related to mortality rate,such as trust of the medical services in one’s community to treatCOVID19 (intensive care unit-bed capacity, physician competency,advanced medical resources, and other variables).

Since we have identified the high risk groups that are more likelyto develop anxiety during the COVID-19 pandemic, we recom-mend that decision maker in healthcare institutes to be proactiveand target those groups with preventative measures to avoid highlevel anxiety in their very precious assets in fighting the pandemic.Emphasis on having a well-written outbreak management plan,effective psychological support, adequate and timely communica-tion may help in reducing the likelihood of a stress

Conclusion

This study is the latest and largest study conducted in SaudiArabia to evaluate the anxiety levels of HCWs during the COVID-19pandemic. What we can conclude is that two-thirds of the HCWswho responded indicated moderate or high anxiety. Considerationshould be given to providing high-risk groups more psychologi-cal support and communication. A written outbreak managementplan may reduce the anxiety level among HCWs and their overallpsychological wellbeing. The association of anxiety with other fac-

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tors such as income level, tolerance of uncertainty, and trust in thehealthcare system should be explored in future research.

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