Sudan Journal of Medical Sciences SJMS Special Issue 2020, DOI 10.18502/sjms.v15i5.7136 Production and Hosting by Knowledge E Research Article The Psychological Impact of the COVID-19 Pandemic on Health Professionals in Sudan 2020 Muna Mohamed Elamin1, Salih Boushra Hamza2, Yassin Abdelrahim Abdalla2, Ahmed Alsayed Mohammed Mustafa2, Mosab Abbas Altayeb2, Maria Adam Mohammed2, Radi Tofaha Alhusseini3, and Mohamed Fathelrahman Mohammed Abass4 1Community Department, Faculty of Medicine, Omdurman Islamic University, Khartoum, Sudan 2Medical Student, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan 3Medical Student, Faculty of Medicine and Health Sciences, Alzaiem Alazhari university, Khartoum, Sudan 4Department of Pediatrics, Omdurman Islamic University, Khartoum, Sudan Abstract Background: The 2019 novel coronavirus (COVID-19) is highly contagious with pandemic transmission, and is therefore associated with severe health problems and high public anxiety, with healthcare community speculation to be the most distressed because they are at the highest risk of infection. This study aimed to investigate the psychological impact on frontline medical staff in Khartoum state, Sudan, during the COVID-19 pandemic between January and March 2020. Materials and Methods: Patient Health Questionnaire-9 (PHQ-9) scale, Generalized Anxiety Disorders (GAD-7) scale, and the Revised Impact of Event Scale (IES-R) were used to assess depression, anxiety, and Post-traumatic Stress Disorders (PTSD) on the participants, respectively, through an online questionnaire. The data were analyzed using the Statistical Package for Social Science (SPSS) version 24. Results: PHQ-9 depression scale showed that 285 (82%) staff members had some degree of depression, with mild depression being the most frequent, seen in 96 (24.2%), whereas, severe depression was found to be more common among the age group between 45 and 65 years and was associated with working in the emergency room (ER) (P = 0.03). The PTSD among our participants was assessed by the IES-R that showed that 116 (29.3%) had subclinical PTSD, 124 (31.3%) had mild PTSD symptoms, 98 (24.7%) had moderate PTSD symptoms, and 58 (14.6%) had severe PTSD symptoms. Also, a statistical association was seen between the IES-R mean score and the age group between 25 and 34 years (P < 0.0001), having a friend or family member infected with the disease (P < 0.0001), and having a history of contact with a positive case of COVID-19 (P < 0.0001). We used GAD-7 anxiety score that showed mild anxiety in 32 (23.2%) participants, moderate anxiety in 53 (13.4%), and severe anxiety 66 (16.7%). Conclusion: This study aimed to explore the psychological impact of COVID-19 pandemic on medical staff’s perception and its determinants. Most of our participants were found to be suffering from anxiety and depression with combining personal variables and working conditions as predictors. How to cite this article: Muna Mohamed Elamin, Salih Boushra Hamza, Yassin Abdelrahim Abdalla, Ahmed Alsayed Mohammed Mustafa, Mosab Abbas Altayeb, Maria Adam Mohammed, Radi Tofaha Alhusseini, and Mohamed Fathelrahman Mohammed Abass (2020) “The Psychological Impact of the COVID-19 Pandemic on Health Professionals in Sudan 2020,” Sudan Journal of Medical Sciences, vol. 15, Special Issue 2020, pages 54–70. DOI 10.18502/sjms.v15i5.7136 Page 54 Corresponding Author: Muna Mohamed Elamin Ahmed, MD community Medicine, MD Dermatology, MSC medical education, Assistant professor and head department of community medicine, Acting faculty dean; Tel: 0924555942 email: monalameen2@gmail.com Received 12 May 2020 Accepted 19 June 2020 Published 9 July 2020 Production and Hosting by Knowledge E Muna Mohamed Elamin et al. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Editor-in-Chief: Prof. Mohammad A. M. Ibnouf http://www.knowledgee.com mailto:monalameen2@gmail.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Sudan Journal of Medical Sciences Muna Mohamed Elamin et al Keywords: COVID-19, psychological impact, health workers, Sudan, GAD-7, PHQ-9, IES-R 1. Introduction Overthe last century, the world has witnessed great pandemics with potentially destruc- tive effects. Starting from the “Spanish” influenza that swept through the world between 1918 and 1919 and to the severe acute respiratory syndrome (SARS) crisis in November 2003, caused by a novel corona virus that resulted in the death of 349 out of 5327 patients [1]. Since December 2019, an outbreak of severe acute respiratory infection of unknown etiology had emerged in Wuhan City, the capital of Hubei Province, China. Later, a third generation of Corona virus was suspected and the name COVID-19 was given to this novel disease; it gained extreme awareness nationwide and internationally, and was declared as a public health emergency of international concern by the World Health Organization (WHO) on January 30, 2020. A strict range of preventive measures were urgently adopted, including complete social distancing, contact tracing, early identifica- tion using regional and national diagnostic criteria besides isolation of suspected and diagnosed cases. All these scientific and valid measures have resulted in a remarkable and striking decline in the virus transmission rate [2, 3]. Pandemic infectious diseases not only are life-threatening to human beings, but greatly impose psychosocial trauma to people because most people usually lack suffi- cient knowledge about newly emerging diseases, which brings about massive panic in people and leads to an illogical response to the disease [4]. Medical personnel, including paramedics, ambulance personnel, and healthcare workers (HCWs) have been found to be more psychologically traumatized and experi- ence higher levels of stress, depression, and anxiety [5]. This can be explained by the expected anxiety and fear of getting infected due to their risk of exposure and worse is their worry of infection transmission to their families, friends, or colleagues. This puts them at a great challenge of how to balance between professional duty, humanity, and personal fear for oneself and others, a situation that can often cause conflict and dissonance in many HCWs [6]. The SARS epidemic, with high transmission and mortality rates, caused significant terror and apprehension around the world [7–10]. The literature has revealed that HCWs are not at equal risk for developing an adverse psychological sequence; healthcare providers who are in proximal contact with patients and are directly exposed to infection are found to be more vulnerable to developing adverse psychiatric problems. These include healthcare providers in emergency depart- ments, intensive care units, and isolation wards [11]. Apart from the exposure, health workers may suffer from panic and worry of getting sick or dying, feel helpless, or face blame from others who are ill, all precipitating a state of mental collapse [12]. DOI 10.18502/sjms.v15i5.7136 Page 55 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al Different presentations of psychiatric illnesses have been found, ranging from depres- sion, anxiety, panic attacks, somatic symptoms, and post-traumatic stress disorder symptoms to delirium, psychosis, and even suicide [13]. These symptoms have been associated with a younger age and increased feelings of self-guilt [13–15]; stigmatization, and social avoidance had also been reported by Bai et al. and Robertson et al. 2004. In a survey conducted during the initial outbreak of COVID-19 in China to assess the psychological effect, the result showed that 53.8% of respondents rated the psycho- logical impact of the outbreak as moderate or severe [16]. The effect of infectious pandemics extends beyond the healthcare providers to reach the whole healthcare system [12]. As during the outbreak, some hospitals were closed with cancellation of all hospital-based outpatient clinics, severe staff shortages resulted from quarantined health workers [17–22]. During the SARS outbreak, marital status was also found to be associated with stress level, where an elevated fear was reported to be more in married hospital employees compared to those who were divorced or unmarried [23]. Quarantine is an essential and effective preventive measure during an epidemic, although it is often an unpleasant experience for those who go through it [24]. To minimize the adverse effects of quarantine, officials need to ensure that quarantined households have enough supplies for their basic needs [25]. This study was designed to examine the long-term psychological impact of COVID-19 outbreak on healthcare workers in Khartoum state, and aimed to identify personal and environmental variables that increase vulnerability to distress during an epidemic. 2. Materials and Methods 2.1. Participants This is a cross-sectional study that targeted medical staffs in Khartoum state, Sudan, during the COVID-9 pandemic. The sample consisted of 396 healthcare providers; the questionnaire was restricted to respondents who had to authenticate their membership to their specialty through their social media groups. The sample was stratified by profession, including different groups of healthcare workers, doctors, nurses, dentists, pharmacists, and laboratory workers. Disproportion- ate stratified random sample was used for recruitment into the study because our sample size is not proportional to the relative size of the strata and to compensate for the small number of certain groups. Sample size was calculated using the sample size of the unknown population (Cochran’s formula): n0 = 𝑧2𝑝(1−𝑝) 𝑒2 . z = z value (1.96 for 95% confidence interval) p = degree of variability (0.5) e = 95 % confidence interval DOI 10.18502/sjms.v15i5.7136 Page 56 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al n = (1.96)2 x 0.5(1–0.5) ÷ (0.05)2 = 384 2.2. Measures A validated questionnaire containing sociodemographic characteristics, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorders-7 (GAD-7) scale, and the Revised Impact of Event Scale (IES-R) were used to assess depression, anxiety, and post-traumatic stress disorder on the participants, respectively. The IES-R is a short, easy, and self-report measure designed to assess current subjective distress resulting from a traumatic life event for both healthy as well as frail individuals and is composed of 22 items, each one of which is rated using a Likert scale from 0 to 4. The maximum score is 88. The results consist of a total raw score and raw score for three subscales: the avoidance scale, intrusion scale, and the hyperarousal scale [26]. The event used for this questionnaire was the exposure to or infection by COVID-19. The total scores were categorized as follows: subclinical (0–8), mild distress (9–25), moderate distress (26–43), and severe distress (44–88) [27]. PHQ-9 scale contains nine questions to measure depressive symptoms, each ques- tion contains four options ranging from (not at all) given zero points to (nearly every day) given three points and the result is interpreted as (0–4) having minimal or no depression, (5–9) having mild depression, (10–14) having moderate, (15–19) having moderately severe, and (20–27) having severe depression [28]. The GAD scale contains seven questions and is used to measure the anxiety symp- toms in the participants, each question contains four options ranging from (not at all) to (nearly every day) given a three point result and interpreted as (5–9) for mild anxiety, (10–14) moderate anxiety, and (> 15) for severe anxiety [29]. As Arabic or Sudanese versions are not available, the English version of IES-R and GAD scales was translated into Arabic language by two bilingual persons whose native language is Arabic and English. The Arabic version was translated back into English by two independent bilingual persons and both the new and original English versions were compared. The Arabic version of PHQ-9 is available [30] and was used after the consent was taken from the developer. A pilot study was conducted in 10% of the sample (∼ 38 participants) with a Cronbach’s alpha of (0.925), (0.944), and (0.946) for PHQ-9, IES-R, and GAD-7 respectively. 2.3. Procedure As our study was conducted in unusual circumstances, in which there were restrictions on most activities and movements, and person-to-person contacts were maximally reduced due to the fear of the spread of COVID-19 infection, the data were collected using an Internet-mediated questionnaire. DOI 10.18502/sjms.v15i5.7136 Page 57 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al 2.4. Data analysis The data were analyzed using the Statistical Package for Social Science (SPSS) version 24, after being primarily analyzed by Google form. Descriptive analysis was used to describe the demographic data and the COVID-19 exposure and perception and included the mean and standard deviation (SD). As the Wilk–Shapiro test showed a significant deviation from the normal distribution (P-value < 0.0001), the demographic data and the COVID-19 exposure and perception were compared to IES-R scores using the independent samples Kruskal–Wallis and the Mann–Whitney tests. The demo- graphic data and COVID-19 exposure and perception were also compared to GAD-7 and PHQ-9 scores using Chi-square (χ2) test. A P-value < 0.05 was considered statistically significant. 3. Results 3.1. Demographic characteristics In our study, we enrolled 396 healthcare providers, the majority, that is, 203 (51.3%) of them were between 25 and 34 years of age, and among them 262 (66.2%) were females and 124 (33.8%) were males. The majority, that is, 258 (65.2%) were single, while 110 (27.8%) were married. Bachelor holders were 243 (61.4%) and 202 (51.01) of our participants worked in governmental hospitals. About 171 (43.2%) stated that they worked in the Emergency Room (ER) (Table1). 3.2. COVID 19 exposure and perception Regarding the COVID 19 exposure and perception, we found that 76 (19.2%) of our participants responded that they handled COVID 19 cases, while 65 (16.4%) had a friend or family member diagnosed with COVID 19. The majority, that is, 317 (80.1%) of our participants stated that their families are worried and afraid that they will transmit the disease to them. About 140 (35.4%) of our participants thought that people started to avoid them because of the nature of their job, and 249 (62.9%) of them stated that their income got lowered during the COVID 19 pandemic, while 256 (65.6%) thought that their working hours were increased during this time. When asked about the availability of enough Personal Protective Equipment in their workplace, 289 (73%) responded with the answer ”no,” and only 57 (14.4%) pointed to the availability of mechanical ventilators in their workplace (Table 2). About 108 (27.3%) of our participants went through home isolation during the COVID 19 pandemic. On asking them about the reason for their home isolation, 33 (8.3%) reported a confirmed case after contact with another confirmed case, and 20 (5.1%) were positive cases. Also, 25 (6.3%) of them reported contact with a suspected case, 9 (2.3%) reported contact with confirmed case, 1 participant (0.3%) reported developing symptoms as a cause of isolation, and 4 (1%) reported other causes (Table 3). About 187 (47.2%) of them stated that they get information from TV, radio, and DOI 10.18502/sjms.v15i5.7136 Page 58 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al social media, while 114 (25.8%) reported getting their information from social media and official websites (Table 4). 3.3. Depression among participants Upon evaluating depression among our participants using the PHQ9 Scale, we found that 285 (82%) of them perceived some degree of depression, with mild depression being the most common in 96 participants (24.2%), followed by moderate depression in 80 (20.2%), while moderately severe and severe depression were among 47 (11.9%) and 62 (15.7%) participants, respectively (Figure 1). Figure 1: PHQ-9 depression score among participants. We explored the association between depressive level and participant’s demographic characteristics and found that those of the age group 45–54 years were having severe depression, but this association was statistically insignificant (p = 0.2). On the other hand, we found that working in an ER is associated with both a high prevalence of depression and a higher percentage of severe depression (p = 0.03). There are no significant associations with COVID-19 exposure and perception of depression. DOI 10.18502/sjms.v15i5.7136 Page 59 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al Figure 2: GAD-7 Score among participants. 3.4. Post-traumatic stress disorder among participants The IES-R scale and its subscales were used to evaluate the post-traumatic stress disorder among our participants, and the result showed that 116 (29.3%) had subclinical PTSD, 124 (31.3%) had mild PTSD symptoms, 98 (24.7%) had moderate PTSD symptoms, and 58 (14.6%) had severe PTSD symptoms. On the other hand, on reviewing the subscales, we found that the participants in our study had a mean of 0.99 in the avoidance scale, 1.05 for the intrusion scale, and 1.026 for the hyperarousal scale (Table 5). We further evaluated the association between the age groups and the educational level of the participants. A higher mean IES-R score was found in the age group between 25 and 34 years and in master degree holders (P-value < 0.0001) (Table 6). Health workers who had no history of contact with an infected patient or no friend or family member infected with the disease had a significantly higher mean IES-R score compared to those who did (P-value < 0.0001). When we explored the effect of working conditions, result showed that participants who did not had enough PPE in their workplace had significantly lower mean IES-R compared to those who did (P-value < 0.0001). No significant difference was found between the person who had been quarantined and the person who had not (Table 6). DOI 10.18502/sjms.v15i5.7136 Page 60 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al TABLE 1: Demographic characteristics Variables Number Percentage (%) Age 18–24 years 104 26.3 25–34 years 203 51.3 35–44 years 40 10.1 45–54 years 10 2.5 55–64 years 16 4 Above 65 years 23 5.8 Gender Male 124 33.8 Female 262 66.2 Marital status Single 258 65.2 Married 110 27.8 Widows 13 3.3 Divorced 15 3.8 Current occupational position House officers 122 30.8 Medical officers 93 23.5 Registrars 53 13.4 Specialists 21 5.3 Consultants 19 4.8 Consultants 19 4.8 Nurses 21 5.3 Lab technicians 35 8.8 Pharmacists 17 4.3 Dentists 12 3.0 Physiotherapist 1 0.3 Radiology technician 1 0.3 Health officer 1 0.3 Educational qualification Bachelor 255 64.4 Master 58 14.6 MD\PHD 80 20.2 Diploma 3 0.8 Current workplace Governmental hospital 202 51.01 Private hospital 48 12.12 Both private and governmental hospitals 79 19.94 Private clinics 39 9.84 Primary health care center 19 3.03 Pharmacies 9 2.3 Private labs 6 1.51 Blood bank 1 0.25 Direct contact with the Emergencies Emergency Room 171 43.2 Respiratory area 59 12.9 Isolation room 9 2.3 X-ray room 6 1.5 Not working in any of them 151 38.1 DOI 10.18502/sjms.v15i5.7136 Page 61 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al TABLE 2: COVID 19 exposure and perception Yes No N % N % Handling a positive patient 76 19.2 320 80.8 Any friend or family member positive for COVID 19 65 16.4 331 83.6 Fear of friends/family members of transmitting the disease 317 80.1 79 19.9 Avoidance of community member from participants 195 49.2 201 50.8 Income reduction during COVID 19 pandemic among participants 249 62.9 147 37.1 Increase in working hours during COVID 19 pandemic among participants 140 35.4 256 65.6 PPE availability in enough amounts in workplace 107 27 289 73 Ventilator availability in workplace 57 14.4 339 85.6 Home isolation among participants 108 27.3 288 72.7 TABLE 3: Cause of home isolation of the participants Cause of home isolation Frequency Percentage Didn’t have home isolation 288 72.7 Diagnosed with the disease 20 5.1 Exciting in place with confirmed case 1 .3 Direct contact with confirmed case 9 2.3 Direct contact with suspected case 25 6.3 Been suspected case 11 2.8 Direct contact with person who had direct contact with confirmed 3 .8 Diagnosed with the disease; direct contact with confirmed case 33 8.3 Come from infected country 1 .3 Other 4 1.0 Feeling symptoms 1 .3 Total 396 100.0 TABLE 4: Source of participants’ information about COVID 19 Source of information Frequency Percentage TV and radio 8 2.0 Social media 25 6.3 Official health website 114 28.8 TV and radio; social media 187 47.2 Social media and official health website 37 9.3 TV and radio and official health website 21 5.3 TV and radio; social media and official health website 4 1.0 Total 396 100.0 DOI 10.18502/sjms.v15i5.7136 Page 62 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al TABLE 5: IES-R subscales among participants IES-R Subscales N Range Minimum Maximum Mean Std. Deviation Avoidance Score 396 3.13 0.00 3.13 0.9953 0.85860 Intrusion Score 396 3.13 0.00 3.13 1.0581 0.91304 Hyperarousal Score 396 3.17 0.00 3.17 1.0261 0.94058 Valid N (listwise) 396 TABLE 6: Comparison of demographic characteristics and COVID-19 exposure and perception with IES-R scale Variable Frequency IES-R Mean SD P-value Age 18–24 104 22.1 19.3 < 0.0001 25–34 203 24.6 16.9 35–44 40 22.4 16.8 45–54 10 21.0 23.4 55–64 16 18.9 26.7 +65 23 9.9 23.2 Educational level Master 58 25.4 18.3 < 0.0001 PHD/MD 80 15.6 22.3 Bachelor 255 24.1 17.2 Diploma 3 18.3 18.9 Dealing with infected person Yes 76 11.8 16.9 < 0.0001 No 320 25.1 18.3 Infected friend or family member Yes 65 8.0 14.9 < 0.0001 No 331 25.4 18.1 Availability of PPE in enough amounts in workplace Yes 107 29.7 21.5 < 0.0001 No 289 19.9 17.0 3.5. Anxiety among participants We used GAD-7 score to evaluate anxiety among our participants, we found that most of our participants had scored different levels of anxiety ranging from mild anxiety in 32 (23.2%), moderate anxiety in 53 (13.4%), and severe anxiety in 66 (16.7%) (Figure 2). When we evaluated the association of the GAD-7 score with our participant’s personal characteristics, we found that those aged 24–35 years had the lowest GAD-7 score compared to other age groups (P = 0.001); those who worked in the ER had a significantly higher GAD-7 scores than those who were working in other departments (P = 0.034); and those who hold bachelor degree had lower GAD-7 score (P < 0.0001) (Table 7). We also explored that those who did not contact a positive case of COVID-19 had lower GAD-7 scores than those who did (P < 0.0001), also those who did not have a DOI 10.18502/sjms.v15i5.7136 Page 63 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al TABLE 7: Comparison of demographic characteristics, COVID-19 exposure, and perception with GAD-7 scale Variable None Mild Moderate Severe Total P-value Age 18–24 53(28.3) 23(25.0) 9(17.0) 19(28.8) 103(26.1) 0.001 25–34 73(39.7) 58(63.0) 37(69.8) 34(51.5) 202(51.1) 35–44 20(10.9) 10(10.9) 6(11.3) 4(6.1) 40(10.1) 45–54 6(3.3) 1(1.1) 1(1.9) 2(3.0) 10(2.5) 55–64 12(6.5) 0(0.0) 0(0.0) 4(6.1) 16(4.1) 65+ 20(10.9) 0(0.0) 0(0.0) 3(4.5) 23(5.8) Occupation Health officer 0(0.0) 0(0.0) 1(1.9) 0(0.0) 0(0.3) 0.034 House officer 59(32.1) 25(27.2) 12(22.6) 26(39.1) 122(30.9) Radiology technician 0(0.0) 0(0.0) 1(1.9) 0(0.0) 1(0.3) General practitioner 43(23.4) 18(19.6) 15(28.3) 17(25.8) 93(23.5) Registrar 13(7.1) 18(19.6) 11(20.8) 10(15.2) 52(13.2) Specialist 14(7.6) 3(3.3) 2(3.8) 2(3.0) 21(5.3) Consultant 10(5.4) 5(5.4) 0(.0) 4(6.1) 19(4.8) Nurse 12(6.5) 6(6.5) 2(3.8) 1(1.5) 21(5.3) Lab worker 19(10.3) 10(10.9) 3(5.7) 3(4.5) 35(8.9) Pharmacist 8(4.3) 4(4.3) 4(7.5) 1(1.5) 17(4.3) Dentist 6(3.3) 3(3.3) 1(1.9) 2(3.0) 12(3.0) Physiotherapy 0(0.0) 0(0.0) 1(1.9) 0(0.0) 1(0.3) education Diploma 2(0.5) 0(0.0) 0(0.0) 1(1.5) 3(0.5) < 0.0001 MBBS 4(2.2) 5(5.4) 3(5.7) 0(.0) 12(3.0) Master 23(15.5) 13(14.1) 13(24.5) 9(13.6) 58(14.7) PHD/MD 57(31.0) 8(8.7) 2(3.8) 13(19.7) 80(20.3) Bachelor 98(53.3) 66(71.7) 35(66.0) 43(65.2) 242(61.3) Handling a positive patient Yes 53(28.8) 11(12.0) 7(13.2) 5(7.6) 76(19.2) < 0.0001 No 131(71.2) 81(88.0) 46(86.8) 61(92.4) 319(80.8) Any friend or family member positive for COVID 19 Yes 52(28.3) 3(3.3) 5(9.4) 5(7.6) 65(16.5) < 0.0001 No 132(71.7) 89(96.7) 48(90.6) 61(92.4) 330(83.5) Fear of friends or family members of transmitting the disease Yes 146(79.3) 81(88.0) 46(86.8) 44(66.7) 317(80.3) 0.005 No 38(20.7) 11(12.0) 7(13.2) 22(33.3) 78(19.7) Increase working hours during COVID19 pandemic among participants Yes 84(45.7) 24(26.1) 14(26.4) 17(25.8) 139(35.2) 0.001 No 100(54.3) 68(73.9) 39(73.6) 49(74.2) 256(64.8) Availability of enough PPE in work place Yes 43(23.4) 29(31.5) 9(17.0) 25(37.9) 106(26.8) 0.031 No 141(46.6) 63(68.5) 44(83.0) 41(62.1) 289(73.2) DOI 10.18502/sjms.v15i5.7136 Page 64 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al friend or a family member diagnosed with COVID 19 had a lower score of GAD-7 and thus less anxiety than those who did (P < 0.0001). While the fear of friends and family members of transmitting the disease was found to be statistically associated with low scores (P = 0.005), no increase in working hours during the COVID-19 pandemic among participants (P = 0.001) and unavailability of enough personal protective equipment in the workplace (P = 0.031) were associated with low GAD-7 score (Table 7). 4. Discussion COVID-19 pandemic crisis is probably one of the most challenging threats to national and international public health in the last few decades. The epidemic had a significant impact on healthcare communities. Initially, the HCWs were placed in a stressful condi- tion due to the uncertainty about the mode of transmission of the disease, tremendous fear, and implementation of rigorous infection control protocols. Therefore, the purpose of this investigation was to examine the psychological impact of COVID-19 pandemic crisis on hospital health workers in Khartoum state, Sudan and to explore the relationship between personal variables and working conditions on stress responses using three validated standard scales that measure depression, anxiety, and post-traumatic stress disorder. To the best of our knowledge, this was the first research on the mental health of Sudanese medical staffs conducted during pandemic times, where there were restric- tions on most activities and significantly reduced person-to-person contact. We chose to rely on the network platform for the questionnaire survey, considering that it is difficult to directly investigate the respondents. Regarding depression, among the participants, 82% perceived some degree of depression, with mild depression being the most common in 24.2% participants, and severe depression seen only in 15.7% of the participants; this result is consistence with another study conducted in China during the SARS outbreak, where 63.33% of the participants showed symptoms of depression with 89% of them having mild depression [31]. This finding is also similar to the result of another study conducted to measure the psychological impact and mental disturbance among medical staff in Wuhan during the COVID-19 epidemic, where most participants experienced mild disturbance, and severe disturbance was found in only about 16% [32]. Severe depression was found to be associated with those working in ER and in isola- tion wards; this correlates with a result obtained from a comparable study conducted in China, which showed that the healthcare providers who were caring for COVID-19 cases showed severe depression [33], this can be explained by the higher risk of infection due to the close proximity with patients. Our study showed that 29.3% of the participants had subclinical PTSD. These results are in contrast with those of Tan et al.’s, which was done in Singapore on 500 health workers and which reported that only 7.7% of clinical concern of PTSD [34], whereas another study done by Lee et al. for health workers who worked during MERS outbreak found higher IES-R scores [35]. DOI 10.18502/sjms.v15i5.7136 Page 65 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al One interesting finding is that there is a significant association between the age and educational level of participants with IES-R score (P < 0.0001). A higher IES-R score was found in people who had not dealt with infected people compared to the ones who had. Moreover, the person who did not have an infected friend or family member had a higher IES-R score. Perhaps, the most interesting finding was that participants who did not have enough PPE in their workplace had a lower IES-R score compared to who did; this finding is at par with the findings of Wang et al. that reported a lower IES-R score for participants using PPE [36]. No significant difference was found between a person who had been quarantined and those who had not, which is consistent with the finding of Lee et al. who found no difference in IES-R scores between people who were quarantined and those who were not [35]. A possible explanation to this is that COVID-19 is a novel virus and that we have little information about it and how to handle it, and it is possible that there are immeasurable variables that could account for some aspects of the results. GAD-7 was applied to evaluate the participant’s anxiety symptoms in the last two weeks. We found that most of our participants had scored different levels of anxiety ranging from mild anxiety in 32 (23.2%), moderate anxiety in 53 (13.4%), and severe anxiety in 66 (16.7%). When the demographic data and COVID-19 exposure and perception were compared with GAD-7 score using Chi-square (χ2) test, the data showed that those who did not have a friend or family member diagnosed with COVID-19 had a lower score of GAD-7 and thus less anxiety than those who did (P = 0.0001); this finding is similar to a study done in Wuhan city, China, during this COVID-19 pandemic that found increase in anxiety among those with infected family member (P = 0.006) [37]. We also found that medical staff who did not deal with a positive case on COVID-19 had a lower GAD-7 score than those who did (P = 0.0001). During the SARS outbreak, all hospital workers are exposed to some risk of infection; however, the extent of this risk is not distributed equally. Some specialties, like ERs and critical care staff, are likely to be at higher risk than those in unrelated or non-acute specialties [38]. Our study showed that health workers who work in ER had higher GAD-7 scores than those who are working in other departments (P = 0.034). Previous studies had shown that nursing staff felt more nervous and anxious when compared with other groups (P=0.02) (34), this is conflicting to our situation where nurses were found to be less anxious. No increase in working hours during the COVID-19 pandemic was associated with low GAD-7 score (P = 0.001. While other study reports that doctors were more unhappy about working overtime during the COVID-19 outbreak than other HCWs (P =0.02) [9], the unavailability of enough personal protective equipment in working places was associated with a low GAD-7 score (P = 0.031); this contradicts another study which found that the availability of strict infection control guidelines, specialized equipment, recognition of their efforts by hospital management and the government, and reduction in reported cases of COVID-19 provided psychological benefit [39]. DOI 10.18502/sjms.v15i5.7136 Page 66 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al 5. Conclusion This study is the first to explore the impact of COVID-19 pandemic on medical staff’s perception and determinants of their psychological distress during this outbreak. Most of our participants were found to be suffering from anxiety and depression with mul- tiple independent factors. This highlights that more attention should be paid to the mental health of frontline medical personnel at the outbreak of COVID-19 in Sudan for healthcare administrators; this means that a likely strategy for appeasing the negative outcomes of stress should be addressed besides the working conditions that they face during novel times of crisis. Future Research Directions Researchers should conduct further studies on the long-term psychological impact of COVID-19 pandemic on healthcare providers, as also a similar study can address samples from the general population and from recovered patients who experienced the unpleasant and traumatizing experience of quarantine. Limitations An online questionnaire was used to collect data in this study. The Internet is a flexible and cost-effective medium for collecting data from large and specialized samples, with research-approved reliability and internal validity characteristics that are in pro- portion to traditional paper-and-pencil questionnaire formats [40–41]. However, it has low acceptance as a data collection tool and due to a lack of interactivity between the respondent and researcher affects the researcher’s ability to authenticate an individual’s responses [40]. In this study, we addressed these issues in the following ways. First, the questionnaire was posted on the personal website or social media groups of the participants, this encouraged their participation. Second, access to the questionnaire was restricted to particular professionals. Lastly, the confidentiality of the participant’s responses was guaranteed on the pre-questionnaire informed consent web page. This was done to motivate the participants to respond more frankly to the questionnaire, which in turn would have increased the validity of our findings. The online questionnaire also affects the interpretation of our results because of the disproportional selection of the strata. Another limitation of this study was our use of cross-sectional self-report data which prohibited attribution of causality. However, the inferences we have made regarding the impact of COVID-19 on healthcare providers are consistent with longitudinal data in the area. It reflects that the important associations among the variables we studied are the strong corroboration between these findings and similar relationships found in the burnout and existing SARS and COVID-19 literature. It can also affect the interpretation of our results because it cannot be used to analyze the psychological impact of the participants overtime, so that the online survey was distributed on 11th of April when there were only 19 reported cases and two deaths according to the report of the official DOI 10.18502/sjms.v15i5.7136 Page 67 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al website of federal ministry of health on the same day [42]. The number of total cases was increased to 5499 cases on the 2nd of June, so that the results of the survey reflect the early stage of local pandemic and there might be an increase in the psychiatric burden of the pandemic. Also, it cannot be used to determine the onset of the psychological impact, whether before or after the onset of the pandemic. Ethical Consideration Ethical clearance was obtained from the research ethical committee (REC), Faculty of Medicine, Omdurman Islamic university. Written consent was taken from all participants through the questionnaire. Acknowledgment The authors express their sincere thanks to all medical staff who participated in this study and to the Faculty of Medicine, Omdurman Islamic University, for their valuable support. Completing Interests None declared. Authors’ Contribution All authors participated in the literature search, manuscript editing, and preparation. MME and SBH were responsible for draft writing, conceiving the idea for the article, and wrote the final manuscript. AM analyzed the data of this study and participated in draft writing. All authors contributed to and approved the final report. References [1] WHO. (2003). Global Alert and Response: Summary of Probable SARS Cases with Onset of Illness From 1 November 2002 to 31 July 2003. Retrieved from: http://www.who.int/csr/sars/country/ table2004_04_21/en/ [2] Phelan, A. L., Katz, R., and Gostin, L. O. (2020). The novel coronavirus originating in Wuhan, China: challenges for global health governance. JAMA, vol. 323, no. 8, pp. 709–710. [3] WHO. (2020). Novel Coronavirus - China Disease Outbreak News. Retrieved from: https://www.who. int/csr/don/12-january-2020-novel-coronavirus-china/en/ [4] Kalichman, S. C. and Simbayi, L. (2004). Traditional beliefs about the cause of AIDS and AIDS-related stigma in South Africa. AIDS Care, vol. 16, no. 4, pp. 572–558. [5] McAlonan, G. M., Lee, A. M., Lee, A. M., et al. (2007). Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. The Canadian Journal of Psychiatry, vol. 52, no. 5, pp. 241–247. [6] Tiong, W. W. and Koh, G. C. H. (2013). Ethical considerations in the review of Singapore’s H1N1 pandemic response framework in 2009. Annals of the Academy of Medicine of Singapore, vol. 42, no. 5, pp. 246–250. DOI 10.18502/sjms.v15i5.7136 Page 68 http://www.who.int/csr/sars/country/table2004_04_21/en/ http://www.who.int/csr/sars/country/table2004_04_21/en/ https://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/ https://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/ Sudan Journal of Medical Sciences Muna Mohamed Elamin et al [7] Chong, M. Y., Wang, W. C., Hsieh, W. C., et al. (2004). Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. British Journal of Psychiatry, vol. 185, no. 2, pp. 127–133. [8] Sim, K. and Chua, H. C. (2004). The psychological impact of SARS: a matter of heart and mind. Canadian Medical Association Journal, vol. 170, no. 5, pp. 811–812. [9] WHO. (2003). Summary Table of SARS Cases By Country, 1 November 2002–7 August 2003. Geneva, CH: WHO. [10] SARS Commission. (2006). Spring of Fear, Volumes 1, 2 and 3. Toronto, ON: SARS Commission (Canada). [11] Naushad, V. A., Bierens, J. J., Nishan, K. P., et al. (2019). A systematic review of the impact of disaster on the mental health of medical responders. Prehospital and Disaster Medicine, vol. 34, no. 6, pp. 632–643. [12] Hall, R. C. W., Hall, R. C. W., and Chapman, M. J. (2008). The 1995 Kikwit Ebola outbreak: lessons hospitals and physicians can apply to future viral epidemics. General Hospital Psychiatry, vol. 30, no. 5, pp. 446–452. [13] Tucci, V., Moukaddam, N., Meadows, J., et al. (2017). The forgotten plague: psychiatric manifestations of Ebola, Zika, and emerging infectious diseases. Journal of Global Infectious Diseases, vol. 9, no. 4, pp. 151–156. [14] Müller, N. (2014). Infectious diseases and mental health. In N. Sartorius, R. I. G. Holt, M. Maj M, (Ed.), Key Issues in Mental Health. Basel: S. KARGER AG, pp. 99–113. Retrieved from: https://www.karger.com/ Article/FullText/365542 [15] Sim, K., Huak, C. Y., Chong, P. N., et al. (2010). Psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease. Journal of Psychosomatic Research, vol. 68, no. 2, pp. 195–202. [16] Wang, C., Pan, R., Wan, X., et al. (2020). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of Environmental Research and Public Health, vol. 17, no. 5, p. 1729. [17] Maunder, R., Hunter, J., Vincent, L., et al. (2003). The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ, vol. 168, no. 10, pp. 1245–1251. [18] Dwosh, H. A., Hong, H. H., Austgarden, D., et al. (2003). Identification and containment of an outbreak of SARS in a community hospital. CMAJ, vol. 168, no. 11, pp. 1415–1420. [19] Mackay, B. (2003). SARS: “a domino effect through entire system.” CMAJ, vol. 16, no. 10, p. 1308. [20] CDC. (2003). Cluster of severe acute respiratory syndrome cases among protected healthcare workers — Toronto, Canada, April 2003. MMWR, vol. 52, no. 19, pp. 433–436. Retrieved from: www.cdc.gov/ mmwr/preview/mmwrhtml/mm5219a1.htm [21] Government of Canada. (2003). Epi-update: Interim Report on the SARS Outbreak in the Greater Toronto Area, Ontario, Canada. Ottawa: Health Canada. Retrieved from: www.hc-sc.gc.ca/pphb- dgspsp/sars-sras/pef-dep/gta-20030424_e.html [22] Patrick, D. M. (2003). The race to outpace severe acute respiratory syndrome (SARS). CMAJ, vol. 168, no. 10, pp. 1265–1266. [23] Wu, P., Fang, Y., Quan, Z., et al. (2009). The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. The Canadian Journal of Psychiatry, vol. 54, no. 5, pp. 303–311. [24] Barbisch, D., Koenig, K. L., and Shih, F. Y. (2015). Is there a case for quarantine? Perspectives from SARS to Ebola. Disaster Med Public Health Prep, vol. 9, no. 5, pp. 547–553. [25] Manuell, M.-E. and Cukor, J. (2011). Mother nature versus human nature: public compliance with evacuation and quarantine. Disasters, vol. 35, no. 2, pp. 417–442. [26] Weiss, D. S. (2004). The Impact of Event Scale-revised. In: J. P. Wilson, T. M. Keane, (Eds.), Assessing Psychological Trauma and PTSD (2nd ed.). Guilford press, New York. [27] Löwe, B., Decker, O., Müller, S., et al. (2008). Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Medical Care, vol. 46, no. 3, pp. 266–274. [28] Kroenke, K., Spitzer, R. L., and Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, vol. 16, no. 9, pp. 606–613. [29] Weiss, D. S. (2007). The Impact of Event Scale: Revised. New York: Guilford Press, pp. 399–411. [30] Alhadi, A. N., Alateeq, D. A., Sharif, E. A., et al. (2017) An arabic translation, reliability, and validation of Patient Health Questionnaire in a Saudi sample. Annals of General Psychiatry, vol. 16, p. 32. [31] Bai, T., Hospital, W. U., Chen, J., et al. (2020). Multiple risk factors of depression and anxiety in medical staffs: a cross-sectional study at the outbreak of SARS-CoV-2 in China. The Lancet Psychiatry, [preprint]. Retrieved from: https://www.ssrn.com/abstract=3551414. DOI 10.18502/sjms.v15i5.7136 Page 69 https://www.karger.com/Article/FullText/365542 https://www.karger.com/Article/FullText/365542 www.cdc.gov/mmwr/preview/mmwrhtml/mm5219a1.htm www.cdc.gov/mmwr/preview/mmwrhtml/mm5219a1.htm www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/pef-dep/gta-20030424_e.html www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/pef-dep/gta-20030424_e.html https://www.ssrn.com/abstract=3551414 Sudan Journal of Medical Sciences Muna Mohamed Elamin et al [32] Kang, L., Ma, S., Chen, M., et al. (2020). Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study. Brain, Behavior, and Immunity, vol. 87, pp. 11–17. Retrieved from: http://www. sciencedirect.com/science/article/pii/S0889159120303482 [33] Lai, J., Ma, S., Wang, Y., et al. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease. JAMA Network Open, vol. 3, no. 3, e203976. [34] Tan, B. Y. Q., Chew, N. W. S., Lee, G. K. H. (2020). Psychological impact of the COVID-19 pandemic on health care workers in Singapore Annals of Internal Medicine. Retrieved from: https://doi.org/10.7326/ M20-1083 [35] Min, S., Sub, W., Cho, A., et al. (2018). Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Comprehensive Psychiatry, vol. 87, no. 8, pp. 123–127. Retrieved from: https://doi.org/10.1016/j.comppsych.2018.10.003 [36] Wang, C., Pan, R., Wan, X., et al. (2020). A Longitudinal Study on the Mental Health of General Population during the COVID-19 Epidemic in China. Brain, Behavior, and Immunity. Retrieved from: doi: https: //doi.org/10.1016/j.bbi.2020.04.028 [37] Zhu, Z., Ph, D., Xu, S., et al. (2020). COVID-19 in Wuhan: Immediate Psychological Impact on 5062 Health Workers. MedRxiv. Retrieved from: https://www.medrxiv.org/content/10.1101/2020.02.20.20025338v2 [38] Simonds, A. K. and Sokol, D. K. (2009). Lives on the line? Ethics and practicalities of duty of care in pandemics and disasters. European Respiratory Society Journal, vol. 34, no. 2, pp. 303–309. [39] Cai, H., Tu, B., Ma, J., et al. (2020). Psychological impact and coping strategies of frontline medical staff in hunan between January and March 2020 during the outbreak of Coronavirus disease 2019 (COVID-19) in Hubei, China. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, vol. 26, e924171. [40] Kraut, R., Olson, J., Banaji, M., et al. (2004). Psychological research online: report of Board of Scientific Affairs’ Advisory Group on the Conduct of Research on the Internet. American Psychologist, vol. 59, no. 2, pp. 105–117. [41] Buchanan, T. and Smith, J. L. (1999). Using the Internet for psychological research: personality testing on the World Wide Web. British Journal of Psychology, vol. 90, no. 1, pp. 125–144. [42] Federal Ministry of Health, Sudan. Committee for Health Emergency Response April 11 2020. Retrieved from: http://fmoh.gov.sd/index.php/files/index/116 DOI 10.18502/sjms.v15i5.7136 Page 70 http://www.sciencedirect.com/science/article/pii/S0889159120303482 http://www.sciencedirect.com/science/article/pii/S0889159120303482 https://doi.org/10.7326/M20-1083 https://doi.org/10.7326/M20-1083 https://doi.org/10.1016/j.comppsych.2018.10.003 https://doi.org/10.1016/j.bbi.2020.04.028 https://doi.org/10.1016/j.bbi.2020.04.028 https://www.medrxiv.org/content/10.1101/2020.02.20.20025338v2 http://fmoh.gov.sd/index.php/files/index/116 Introduction Materials and Methods Participants Measures Procedure Data analysis Results Demographic characteristics COVID 19 exposure and perception Depression among participants Post-traumatic stress disorder among participants Anxiety among participants Discussion Conclusion Future Research Directions Limitations Ethical Consideration Acknowledgment Completing Interests Authors' Contribution References