TX_1~ABS:AT/ADD:TX_2~ABS:AT 67 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2023, 7 (1): 67-73 ReseaRch aRticle Psychological Stress of the COVID-19 Pandemic on the Mental Health of Healthcare Workers in the Kurdistan Region Delan J. Qadir1, Jamal K. Shakor2, Trifa M. Mohammed3, Raza M. Abdulla4 1Department of Adult, College of Nursing, University of Sulamani, Sulaimani, Iraq, 2Department of Nursing, Sulaimani Polytechnic University, Darbandikhan Technical Institute Sulaimani, Iraq, 3Department of Psychiatric Nursing and Mental Health, College of Nursing, University of Sulamani, Sulaimani, Iraq, 4Department of Statistic and Computer, College of Commerce, University of Sulamani, Sulaimani, Iraq ABSTRACT Coronavirus disease-19 (COVID-19) pandemic can lead to terrific condition among healthcare workers (HCWs) and severe stress reactions can raise the risk of secondary trauma. The aim of this study was determine the psychological burden of the COVID-19 outbreak on HCWs. The cross-sectional quantitative survey was conducted online from September 1 to September 18, 2020. Online questionnaires employing scales including the generalized anxiety disorder (GAD-7), patient health questionnaire (PHQ-9), and perceived stress scale (PSS-10) were used to investigate anxiety, depression, and stress. This study has shown that percentage of severe anxiety, stress, and depression were (22%), (3.9%), and (11%) respectively among HCWs. There was a significant association of PHQ score with age, gender, marital status, number of children, kind of employment, and work experiences. GAD score was found to have a significant relationship (P = 0.05) with gender, job title, and healthcare experiences in this study. The PSS score of women who worked in hospitals was found to be considerably higher. Health-care professionals in Kurdistan experienced high anxiety and stress during the COVID-19 epidemic. Keywords: Anxiety, coronavirus disease-19, depression, health care workers, Kurdistan INTRODUCTION The coronavirus disease infection (COVID-19) first appeared in China in December 2019 and quickly spread to nearly every country on the planet. The World Health Organization declared the virus a global pandemic in March 2020.[1] The Kurdistan Region of Iraq (KRI) alone saw 10,595 illnesses and 402 fatalities on March 30, 2020, according to statements made by the Kurdistan Regional Government (KRG).[2] To address this urgent matter, the government mandated a public holiday from February 26 to March 10, 2020, for all public and private institutions, including kindergartens. Public and private universities were likewise closed from February 29 to March 10. They will remain closed for spring break from March 10 through March 23 and reopen on March 24 if conditions improve. The KRG has also made the decision to declare a halt to all religious rituals, activities, and events until further notice. This includes Friday sermons in mosques, churches, and temples throughout the KRI. Even though the lockdown’s time limit was ultimately extended, the health-care professionals continued to work to address the situation. Due to their direct and indirect interactions with COVID-19 patients as well as their susceptibility to infection,[3] they are at risk of developing mental health difficulties.[4] In facilities that have been trained and specialized for COVID-19. Iraq had reported approximately 319,035 cases of infection and 8555 deaths as of September 30, 2020, with the majority of sickness and deaths coming from Western Europe and North America.[5] COVID-19,[6] the immediate response from departments of respiratory medicine and intensive care units (ICUs),[7] or the stress on mental health faced by critical care practitioners were all factors that contributed to the onset of COVID-19,[6] the immediate response from departments of respiratory medicine and intensive care units (ICUs),[7] or the place stress on mental health faced by practitioners in critical care.[8] Health-care professionals (HCPs) who care for COVID- 19 patients were said to have a negative impact on them. Corresponding Author: Jamal K. Shakor, Department of Nursing, Sulaimani Polytechnic University, Darbandikhan Technical Institute Sulaimani, Iraq. E-mail: jamal.shakor@spu.edu.iq Received: August 22, 2022 Accepted: May 03, 2023 Published: June 20, 2023 DOI: 10.24086/cuesj.v7n1y2023.pp67-73 Copyright © 2023 Jamal K. Shakor, Delan J. Qadir, Trifa M. Mohammed, Raza M. Abdulla. This is an open-access article distributed under the Creative Commons Attribution License (CC BY-NC-ND 4.0) Cihan University-Erbil Scientific Journal (CUESJ) Cihan University-Erbil Scientific Journal (CUESJ) Qadir, et al.: COVID-19 Mental Health Related Among Healthcare Workers 68 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2023, 7 (1): 67-73 Physical exhaustion and sleep troubles have been recorded in HCPs, as well as worry and fear of infection.[9] As well as, the spread of the virus among relatives, as a family was hampered by severe preventative measures.[10] Evaluation support and mental healthcare are important aspects of the response to the COVID-19 outbreak,[11] and these mental health issues have been addressed in both international and local legislation. HCPs dealing with the COVID-19 epidemic have noticed several unusual symptoms.[12] MERS CoV has a low overall human-to-human transmission capability; nonetheless, 38% of all confirmed illnesses are occasionally aggravated in the healthcare setting.[13] MERS CoV infections caused by healthcare workers occur for 1–27% of all MERS CoV cases.[14] Healthcare worker (HCWs) are said to be more insecure, and the severity of the psychological effect was found to be connected to the length of the quarantine period.[15] It is feared that such a negative impact would persist and have long-term consequences. HCWs are the backbone of any country’s health-care system, and they may suffer from a variety of mental health issues as a result of their work during the COVID-19 epidemic. As a result, the goal of this study was to determine the levels of depression, anxiety, and stress among a group of health-care employees who answered our online survey. REVIEW OF LITERATURE The research studies from China, India, Italy, Spain, Iran, and Kurdistan/Iraq were among those in the review. All the others have a cross-sectional layout. The increase in mental health issues has been noted in editorials, scientific words, viewpoints, and commentary in scientific literature as well as reporting in print and visual media. Experts asked for mental health support as they were concerned over the rising number of mental health issues.[11] Another A significant global public health concern during this epidemic is the rise in mental health issues in every community and age group across all countries.[16-23] To relieve psychological anguish and its impacts, experts have recommended appropriate and affordable solutions.[24] This new predicament with mental health issues has received a lot of attention. However, there is still a lack of quantifiable data regarding the rise in mental health issues brought on by the pandemic. Before making the proper arrangements for tackling this issue of growing mental health difficulties, authorities need to be aware of the scope of the issue. This scoping review was carried out to estimate the number of different mental health issues brought through COVID-19. METHODOLOGY Design of the Study This cross-sectional quantitative survey was done online from September 1–18, 2020, following an 8-month lockdown in the Kurdistan Region due to a coronavirus pandemic. Administrative Arrangement The proposal for the study was accepted by the Council of Nursing College and approved by the scientific committee of Nursing College/University of Sulaimani. Participant This cross-sectional design quantitative survey was done online from September 1–18, 2020, following an 8-month lockdown in the Kurdistan Region due to a coronavirus pandemic. The online poll drew the participation of 334 HCWs. After reading the study purpose, the survey was generated in Google Survey (www.google.com) and the link was provided through email with invitations to possible participants who were eligible for the written consent section in the first section of the online survey. If they agreed, they could then proceed to fill out the questionnaire. Tools and Measurement Age, sex, marital status, degree of education, work, year of experience, economic situation, possible direct interaction with COVID-19 patients, and disease severity were some of the sociodemographic issues mentioned. Simply checking the answer checkbox takes an average of 5 min to complete the inquiry. The Kurdish translation of the perceived stress scale (PSS-10),[25] patient health questionnaire (PHQ-9),[26] and generalized anxiety disorder (GAD-7) was a significant aspect of the questionnaire for recording the degree of stress, grief, and anxiety.[27] PSS10 scores vary from 0 to 13 (low), 14 to 26 (moderate), and 27 to 40 (high) (extreme stress perceived). The PHQ-9 scale has scores of 5–9, 10–14, 15–19, and 20–27 for mild, moderate, moderate, intense, and severe depression, respectively. The 7-item GAD scale was used to assess anxiety. The GAD-7 scale is a self-reporting scale with great reliability and validity. If the score is <5, there is no anxiety, whereas the cutoffs for moderate, mild, and severe anxiety are 5, 10, and 15 respectively. In this study, a cutoff of five on the PHQ-9 and GAD-7 was used to identify persons who had or did not have any symptoms of depression or anxiety. Statistical Analysis After data were automatically registered in the survey’s Excel file and imported into SPSS, statistical analysis was performed using SPSS version 22. For descriptive analysis, the frequency with percentage and mean with standard deviation was used. As inferential analysis, the T-test and ANOVA were utilized to evaluate for significance. Informed Consent The study protocol was accepted by Sulaimani University. RESULTS Table 1 shows that the participants were largely from Sulaimani (79.9%), that they were mostly men (52.1%), that they were mostly married (71.3%), and that they had 1–3 children (56.6%). A responder was mostly a nurse (74.9%), worked in a critical department of a hospital (46.4%), had 1–9 years of experience (44.0%), and was employed permanently (79.9%) with monthly 100–120 h of work in hospitals (45.2%). Table 2 illustrated that most responders had direct contact with COVID-19 infected patient, and (31.7%) was infected Qadir, et al.: COVID-19 Mental Health Related Among Healthcare Workers 69 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2023, 7 (1): 67-73 Table 2: COVID-19 suffers and contacts among participants Place of resident Frequency Percentage From the beginning of the COVID-19 outbreak, did you have contact with infected peoples Yes 243 72.8 No 91 27.2 Total 334 100.0 Due to contact, did you have infected by COVED-19 Yes 106 31.7 No 162 48.5 I don’t know 66 19.8 Total 334 100.0 If you are infected, how do you rate your symptoms? Severe 27 8.1 Mild 99 29.6 No Symptoms 35 10.5 No infected 173 51.8 Total 334 100.0 From the beginning of the COVID-19 outbreak, Did you have used personal protective measures? Yes 279 83.5 No 55 16.5 Total 334 100.0 by COVID-19 due to their work with mostly mild symptoms (29.6%). Meanwhile, nearly (84%) have used personal protective measures since the COVID-19 outbreak. Table 1: Sociodemographic and work status of the participants Variables Frequency Percentage Place of resident Sulaimani 267 79.9 Hawler 37 11.1 Kirkuk 13 3.9 Halabja 17 5.1 Total 334 100.0 Age groups 20–29 118 35.3 30–39 119 35.6 40–49 67 20.1 50–59 30 9.0 Total 334 100.0 Gender Male 174 52.1 Female 160 47.9 Total 334 100.0 Marital status Single 97 28.7 Married 238 71.3 Total 334 100.0 Number of children No child 116 34.7 1–3 children 189 56.6 4 children and more 29 8.7 Total 334 100.0 Job title Nurse 250 74.9 Physician 49 14.7 Lab technicians 7 2.1 Others 25 7.5 Total 331 99.1 The hospital departments where the staff work at them Word 87 26.0 Critical department (ICU, emergency) 155 46.4 Lab 13 3.9 Administration 32 9.6 Health centre 47 14.1 Total 334 100.0 Health service experience <1 year 24 7.2 1–9 years 147 44.0 10-19 years 93 27.8 20 and more years 70 21.0 Total 334 100.0 (Contd...) Variables Frequency Percentage Type of employments Public employee 267 79.9 Bond (temporary employment) 34 10.2 Volunteer 33 9.9 Total 334 100.0 How long do you work in the month in hospitals 100–120 151 45.2 121–144 80 24.0 145–168 51 15.3 169–192 52 15.6 Total 334 100.0 Economic status Sufficient 69 20.7 Barley sufficient 239 71.6 Insufficient 26 7.8 Total 334 100.0 Table 1: (Continued) Qadir, et al.: COVID-19 Mental Health Related Among Healthcare Workers 70 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2023, 7 (1): 67-73 Table 3 demonstrates the psychiatric condition of health staff. This study has shown that percentages of severe anxiety, stress, and depression were (22%), (3.9%), and (11%), respectively. Table 4 has shown the significant association of PHQ score (P < 0.05) with age, gender, marital status, number of children, kind of employment, and work experiences. Mean of PHQ score was significantly higher in the age group 20–29 years (10.36 ± 4.22), female (9.71 ± 4.20), single marital status (10.23 ± 4.28), not have children (9.92 ± 4.21), volunteered employed (11.91 ± 4.16), and <1 years have experienced (10.58 ± 4.31). This study showed the significant association of GAD score (P < 0.05) with gender, job title, and health service experiences. The mean GAD score was significantly higher in females (7.41 ± 3.65), administrative staff (7.72 ± 4.17), and <1 year have experienced (8.08 ± 3.53). Similarly, the significant association of PSS score (P < 0.05) was observed with gender, kind of employment, and work hours in hospitals. The mean PSS score was significantly higher in females (18.07 ± 5.91), voluntary employment (18.76 ± 6.35), and have 121–144 h of work in the hospitals (18.44 ± 5.74). Table 5 explained the relationship between the psychiatric health condition and experience with COVID-19 among health staff. There was a significantly high PHQ score among those who had COVID-19 contact (9.43 ± 4.16), those who were infected by COVID-19 (10.18 ± 4.18), and had severe symptoms (10.30 ± 4.54). Similarly, there was a significant high GAD score among those who were infected by COVID-19 (7.69 ± 3.70) and had severe symptoms (7.85 ± 3.91). DISCUSSION COVID-19 has caused some psychiatric problems in HCWs because of their sensitivity to infection or other diseases.[19] Table 3: The level of the psychiatric condition among health staff Psychiatric conditions Frequency Percentage Anxiety levels Minimal (normal) 90 26.9 Mild anxiety 170 50.9 Moderate anxiety 65 19.5 Severe anxiety 9 2.7 Total 334 100.0 Stress levels Low perceived stress 84 25.1 Moderate perceived stress 237 71.0 Severe perceived stress 13 3.9 Total 334 100.0 Depression levels Mild perceived depression 194 58.1 Moderate perceived depression 101 30.2 Moderate severe depression 34 10.2 Severe perceived depression 5 1.5 Total 334 100.0 COVID-19 anxiety and stress were found to be higher in HCWs than MERS-Cov and seasonal influenza.[20] HCWs are concerned about infecting their family members and coworkers, therefore Table 4: The association of sociodemographic and work experience with psychiatric health conditions Variables Mean±SD GAD score PHQ score PSS score Place of resident Sulaimani 6.87±3.56 9.24±4.08 17.09±5.77 Hawler 6.84±4.27 8.97±3.73 17.49±6.32 Kirkuk 5.69±2.50 6.77±4.32 14.23±6.93 Halabja 6.71±4.54 9.88±5.45 17.06±7.28 Total 6.81±3.65 9.15±4.14 17.02±5.96 P value 0.730 0.170 0.376 Age groups 20–29 7.21±3.73 10.36±4.22 17.63±6.26 30–39 7.00±3.55 8.56±3.92 16.86± 40–49 5.79±3.61 8.75±4.21 16.24±5.82 50–59 6.77±3.61 7.57±3.46 17.07±5.72 P value 0.072 0.000 0.483 Gender Male 6.26±3.58 8.63±4.03 16.06±5.87 Female 7.41±3.65 9.71±4.20 18.07±5.91 P value 0.004 0.016 0.002 Marital status Single 7.08±3.61 10.23±4.28 17.34±6.36 Married 6.70±3.68 8.71±4.02 16.90±5.82 Other 8.00± 11.00± 17.00± P value 0.649 0.009 0.834 Economic status Sufficient 6.10±2.82 8.19±3.63 15.71±5.67 Barley sufficient 6.88±3.79 9.38±4.28 17.35±5.97 Insufficient 8.08±4.04 9.58±3.84 17.54±6.35 P value 0.054 0.095 0.119 Number of children No child 7.04±3.71 9.92±4.21 17.22±6.46 1–3 children 6.85±3.57 8.83±3.98 17.13±5.73 four children and more 5.66±3.88 8.14±4.56 15.59±5.33 P value 0.184 0.031 0.395 Type of employments Public employee 6.64±3.63 8.70±3.95 17.13±5.70 Bond (temporary employment) 7.12±4.22 10.00±4.51 14.50±6.89 Volunteer 7.85±3.12 11.91±4.16 18.76±6.35 P value 0.178 0.000 0.011 Job title Nurse 6.80±3.55 9.27±4.23 16.91±5.99 (Contd...) Qadir, et al.: COVID-19 Mental Health Related Among Healthcare Workers 71 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2023, 7 (1): 67-73 Table 5: The association of psychiatric health conditions with COVID-19 Variables Mean±SD GAD score PHQ score PSS score From the beginning of the COVID-19 outbreak, did you have contact with infected peoples Yes 6.99±3.66 9.43±4.16 17.01±5.88 No 6.33±3.60 8.40±4.03 17.05±6.22 P value 0.140 0.042 0.954 Due to contact, did you have infected by COVED-19 Yes 7.69±3.70 10.18±4.18 17.42±5.71 No 6.22±3.70 8.30±0.00 16.78±5.75 I don’t know 6.86±3.19 9.56±4.39 16.97±6.87 P value 0.005 0.001 0.690 If you are infected, how your symptoms are? Severe 7.85±3.91 10.30±4.54 17.30±5.82 Mild 7.48±4.05 10.13±4.39 17.32±6.09 No symptoms 6.49±3.15 8.86±3.40 17.51±5.57 No infected 6.33±3.40 8.46±3.95 16.71±6.02 P value 0.031 0.005 0.798 From the beginning of the COVID-19 outbreak, Did you have used personal protective measures? Yes 6.73±3.61 8.97±4.15 16.77±6.02 No 7.24±3.89 10.05±4.03 18.29±5.54 P value 0.346 0.075 0.085 GAD: Generalized anxiety disorder, PHQ: Patient health questionnaire, PSS: Perceived stress scale, SD: Standard deviation Variables Mean±SD GAD score PHQ score PSS score Physician 7.04±3.74 8.86±3.62 18.00±4.69 lab technicians 2.86±3.24 6.00±3.74 12.71±9.32 Others 7.72±4.17 9.40±4.28 17.40±6.89 P value 0.019 0.207 0.163 Hospital department of work of the participant Word 6.99±3.42 9.70±4.10 17.05±5.85 Critical department (ICU, emergency) 7.19±3.66 9.42±4.18 17.70±5.51 Lab 4.85±4.10 8.38±4.25 16.00±7.74 Administration 5.87±3.43 7.72±3.72 15.25±5.83 Health center 6.40±3.88 8.40±4.14 16.23±6.97 P value 0.079 0.091 0.195 How long do you work in the month in hospitals 100–120 h 6.46±3.74 8.92±4.27 17.03±5.91 121–144 h 7.58±3.34 9.44±3.79 18.44±5.74 169–192 h 7.17±4.00 9.77±4.50 15.42±6.86 P value 0.091 0.469 0.032 Health service experience <1 year 8.08±3.53 10.58±4.31 15.13±8.20 1–9 years 7.23±3.89 9.82±4.23 17.96±5.65 10–19 years 6.29±3.16 8.59±4.07 16.52±5.86 20 and more years 6.19±3.63 7.99±3.64 16.39±5.66 P value 0.031 0.003 0.056 GAD: Generalized anxiety disorder, PHQ: Patient health questionnaire, PSS: Perceived stress scale, ICU: Intension care unit Table 4: (Continued) they wear protective clothing.[21] Psychiatric conditions of HCWs were altered during the COVID-19 epidemic in the present study, with the percentages of severe anxiety, stress, and depression being (22%), (3.9%), and (11%) accordingly. The anxiety rate in this study was higher than that of HWs in Suadi, at 11%,[20] and depression was also higher than that of HCWs in China, at 6.2% (mean PHQ-9: 15.1).[22] These findings are in line with a significant amount of research that has been published[28,29] and show that HCWs experience anxiety at this time. In the present study, there were considerably more people who reported having moderate or severe anxiety (22.5%) than there were in the general population (5%), as had been observed prior to the pandemic.[30] Meanwhile, anxiety and depression prevalence rates among HCWs during COVID-19 were found to be lower in the present study than in the systematic review (232 and 228%, respectively).[29] The difference in psychiatric levels is primarily due to the use of various techniques and metrics. The prevalence of moderate-to-severe psychiatric illnesses was rated in the current investigation. The majority of study participants had direct contact with COVID-19-infected patients and worked more than 120 h each month, and one-third of them was infected with COVID-19. Since the COVID-19 outbreak, roughly four-fifths had adopted personal preventive measures. According to a study, the high workload causes a shortage of medical protective supplies as well as staff behavioral issues.[31] In the present study, demographic status and job conditions were the most important factors of HWs’ psychological problems. PHQ score was significantly higher (P = 0.05) in the age group 20–29 years, female, single marital status, no children, volunteers employed, and had <1 year of experience. PHQ score was shown to be considerably higher among females, most outbreaks placed, nurses, frontline job, non-volunteer employed, self-infected, or colleague infected in several Wuhan research.[2,4] In an Indian study, however, gender had no bearing on the severity of psychiatric problems.[32] GAD score, P = 0.05 was found to have a significant relationship with female gender, administrative staff, and experience of <1 year in this study. This finding was in line with a Wuhan study that found that the critical department Qadir, et al.: COVID-19 Mental Health Related Among Healthcare Workers 72 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2023, 7 (1): 67-73 of the hospital, gender, and marital status were all linked to high GAD and PHQ[33] levels.[4] Nurses were shown to be more anxious than other medical care professionals in earlier studies in China.[32] The majority of the study’s participants were nurses who worked in the hospital’s critical care units, although a high psychiatric disorder score had no bearing on nursing professionalism. Other Italian research has found no link between PHQ and GAD scores and nursing professionalism, ICU work, or frontline work; nonetheless, nursing and frontline work had high PHQ and GAD scores.[34] PHQ and GAD scores were shown to be considerably higher in those who had COVID-19 contact, were infected with COVID-19, and had severe symptoms in the current investigation. The leading determinants of stress among HCWs were found to be demographics and working conditions. According to an Italian study, stress is caused by youthful age, female gender, front-line employment, and nursing professionalism.[35] Meanwhile, there was a significant relationship between PSS score (P = 0.05) and female gender, voluntary employment, and having 121–144 h of work in hospitals in the present study. A Chinese study also discovered a link between PSS score and age, working years, and current job title.[33] Younger employees are almost inexperienced, and they would be unable to handle stressful circumstances such as working on the front lines for more than 120 h. The female gender is likewise more susceptible to psychological problems. The association of COVID-19-related stress with female gender was confirmed among physicians in another study in Kurdistan, moderate/ high stress was high among female physicians.[36] CONCLUSION During the COVID-19 outbreak, healthcare workers in Kurdistan experienced severe anxiety and stress due to unpleasant psychiatric effects. Screening for negative psychological outcomes and establishing efficient prevention strategies might be advantageous in minimizing the negative psychological impacts of the COVID-19 pandemic among medical care professionals. REFERENCES 1. N. Othman and N. M. Kamal. 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