Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana

Kissinger Marfoh; Ali Samba; Eunice Okyere; Priscilla Kushigbor; Franklin Acheampong

doi:10.12688/f1000research.130447.1

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Research Article

Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana

[version 1; peer review: 1 approved with reservations]

Kissinger Marfoh ^1,2, Ali Samba³, Eunice Okyere², Priscilla Kushigbor⁴, Franklin Acheampong⁵

Kissinger Marfoh ^1,2, Ali Samba³, [...] Eunice Okyere², Priscilla Kushigbor⁴, Franklin Acheampong⁵

PUBLISHED 01 Mar 2023

Author details Author details

¹ CMNHS, Fiji National University, Suva, 000, Fiji
² Public Health Department, Korlebu Teaching Hospital, Accra, 0233, Ghana
³ Medical Directory, Korle-bu Teaching Hospital, Accra, 0233, Ghana
⁴ Clinical Psychology Department, Korl-bu Teaching Hospital, Accra, 0233, Ghana
⁵ Research Unit, Korele-bu Teaching Hospital, Accra, 0233, Ghana

Kissinger Marfoh
Roles: Conceptualization, Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Ali Samba
Roles: Conceptualization, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Eunice Okyere
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Priscilla Kushigbor
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Franklin Acheampong
Roles: Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

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Abstract

Background: Today COVID-19 is having a dire effect on the mental and physical health of the general population. Although the long-term psychological effects of COVID-19 remain unknown, studies have shown increasing depression, anxiety and stress among healthcare workers. The aim of the study was to examine the psychometric properties and validation of the Depression, Anxiety, and Stress Scale (DASS-21) and evaluate the level of depression, anxiety, and stress among healthcare workers in a tertiary hospital during the SARS-CoV-2 delta variant outbreak.
Methods: Using an online questionnaire, we conducted a cross-sectional study on 1201 healthcare workers in a tertiary hospital. The validation of DASS-21 was performed by examining the factorial structure (construct validity) using confirmatory factor analysis (CFA), internal consistency (reliability), convergent validity, discriminate validity and measurement invariance.
Results: Cronbach's Alpha was acceptable for depression (0.88), anxiety (0.81), and stress (0.86). CFA provides support for the three-factor oblique model with the following fit indexes: (Chi-Square χ2/ (degrees of freedom) = 1628.5/(186), p < 0.001), comparative fit index (CFI = 0.923), Tucker-Lewis index (TLI = 0.901), standardized root mean square residual (SRMR = 0.0452) and root mean square error of approximation (RMSEA = 0.07). DASS-21 achieved both configural and metric invariance.
Conclusions: Our results indicate that DASS-21 is a reliable and valid self-reporting screening tool for depression, anxiety and stress among healthcare workers. This tool is also invariant across sex, doctors, nurses, and non-clinical healthcare workers. Thus DASS-21 is an essential screening tool to identify healthcare workers at a higher risk of developing work-related mental health disorders.

Keywords

:COVID-19; Healthcare workers; depression; Anxiety; Stress; reliability; validity

Corresponding author: Kissinger Marfoh

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Marfoh K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Marfoh K, Samba A, Okyere E et al. Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:229 (https://doi.org/10.12688/f1000research.130447.1) First published: 01 Mar 2023, 12:229 (https://doi.org/10.12688/f1000research.130447.1) Latest published: 01 Mar 2023, 12:229 (https://doi.org/10.12688/f1000research.130447.1)

Introduction

COVID-19 is an infectious disease caused by SARS-CoV-2. Since it was identified and isolated in Wuhan, China, COVID-19 has quickly spread to the rest of the world, leading the World Health Organization to declare the situation a pandemic. The disease has affected 500 million people, with less than 1% mortality.

Today, COVID-19 is direly affecting people’s mental and physical health through psychological stress imposed by the disease. Studies have shown an increase in COVID-19-related psychological stress in the general population,¹^–³ which include depression, anxiety, stress, and post-traumatic stress.⁴^,⁵ These unprecedented psychological stresses and physical risks have been more noticed among healthcare workers and their families due to COVID-19 infection. In many countries, there are considerably more COVID-19 infections among healthcare workers than among the general population.⁶ With healthcare workers representing less than 3% of the population, the World Health Organization reports that 14% of COVID-19 cases have been healthcare workers.

Healthcare workers are routinely exposed to stress from their occupation, which is associated with more mental health complaints than others.⁷^,⁸ Besides experiencing these stresses, healthcare workers are exposed to additional stress from taking care of COVID-19-infected patients, fear of being infected and infecting family members, stigmatization, and isolation. In addition, increased COVID-19 cases and deaths, increased workload, lack of socialization and recreation, and a dearth of personal protective equipment have a tremendous psychological impact on healthcare workers.⁹

Healthcare workers have reported psychological stress during previous infectious diseases outbreaks such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), H1N1 influenza, and Ebola.¹⁰^–¹² For example, during the 2003 SARS outbreak, studies reported a 5–10% prevalence of moderate-to-severe post-traumatic stress and an increased high risk of depression and anxiety among healthcare workers who were quarantined or frontline.³^,¹³ In the 2015 outbreak of Ebola in Sierra Leone, there was 48.0% anxiety or depression and 76.0% post-traumatic stress among healthcare workers.¹⁴

Although the long-term psychological effects of COVID-19 remain unknown, studies on healthcare workers have shown 50.4% depression, 44.6% anxiety, and 71.5% stress in China¹⁵; 24.7% depression, 44.6% anxiety and 19.8% stress in Italy¹⁶; and 11.4% depression, 23.4% anxiety and 5.7% stress in India.¹⁷ A systematic review and meta-analysis showed a high prevalence of moderate-to-severe depression, anxiety and stress among healthcare workers during the COVID-19 pandemic.¹⁸ In Ghana, healthcare workers reported an increased prevalence of depression, anxiety, and stress during the early phase of the COVID-19 pandemic.¹⁹ Furthermore, studies comparing emergency and non-emergency healthcare workers found that emergency healthcare workers had a high prevalence of depression, anxiety and stress.²⁰^,²¹

With the poor quality of patient care,²² the rising number of medical errors and medical litigation,²³ and increased disability and absenteeism due to increased levels of poor mental health among healthcare workers, it has become important to screen for mental health issues among healthcare workers. One of the most commonly used scales for screening mental health is the Depression, Anxiety and Stress Scale (DASS).²⁴ Since it was developed in 1995, the psychometric properties of DASS and its short version, DASS-21 (21 items), have been evaluated in both clinical²⁵ and non-clinical²⁶ samples for validity and reliability. The self-reporting scale has 42 items (DASS-42), which was reduced to 21 to form the short version (DASS-21). Seven items with the highest factor loadings from each subscale of the original DASS were selected to form the DASS-21. DASS-21 has three main subscales: depression, anxiety and stress. The depression scale evaluates hopelessness, self-deprecation, dysphoria, devaluation of life, lack of interest/involvement, anhedonia and inertia. The anxiety scale evaluates autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale evaluates nervous arousal, difficulty relaxing and being easily upset and impatient.

Many previous studies have reported excellent reliability and internal consistency of the DASS-21 in healthcare workers.⁴ However, there has been some inconsistency in the factorial structure of DASS-21. This has led to the development of other structural models apart from the original three-factor model. The one-factor model developed by Lovibond and Lovibond²⁴ has shown a good fit in many studies. A two-factor structure of DASS-21 was the best fit in the Brazilian adolescent study.²⁷ However, in the general population, a tripartite structural model consisting of anhedonia, physiology, hyperarousal, and general negativity affect fit better than other proposed DASS-21 structures. The bifactor model (quadripartite) has also been a good fit in several studies.

DASS-21 has been used extensively in various clinical settings and research because of its ability to differentiate between depression distinctly, anxiety and stress clusters of symptoms.²⁴^,²⁶^,²⁸ DASS-21 is designed to detect the symptoms of depression, anxiety and stress. In the clinical setting, DASS-21 cannot be used to diagnose people with depression or anxiety. DASS-21 alerts the doctor to identify people who are highly susceptible to clinical depression or anxiety, indicating the need for further investigations.²⁴

DASS-21 has been validated for different populations, but, to date, no research paper has previously validated the psychometric properties of DASS-21 in a Ghanaian population. This has led to its limited use as a screening tool for mental health; therefore, it is critical to evaluate the psychometric properties of DASS-21 among healthcare workers. This study aimed to examine the psychometric properties of the DASS-21 scale and evaluate the level of depression, anxiety, and stress among healthcare workers in a tertiary hospital during the SARS-CoV-2 delta variant outbreak in Ghana.

Method

Participants

We conducted a cross-sectional study to determine the psychometric property of DASS-21 among healthcare workers in Korle-Bu Teaching Hospital. This study used an online survey method and recruited participants using a convenience sampling technique. Healthcare workers were invited to complete an online survey (https://kbth.gov.gh/kbredcap/) which was distributed through the hospital’s social media platforms. The online survey, created by the research electronic data capture (REDCap) system (RRID:SCR_003445),²⁹^,³⁰ was open for two months (June 3–Aug 3 2021). The survey was aimed at all healthcare workers in Korle-Bu Teaching Hospital working in various departments. These included doctors, nurses, administrators, record officers, pharmacists, laboratory scientists, etc.

Eligibility criteria

The inclusion criteria for the study were all healthcare workers who were at the post during the outbreak of the delta variant. Healthcare workers on leave, travelling, ill, and those with known mental health disorders were excluded from the study. A healthcare worker was defined as anyone employed by the Ministry of Health to work at Korle-Bu Teaching Hospital.

Ethical approval

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The Korle-bu Teaching Hospital institutional review boards (IRD: KBTH-ADM/00014/2021) in Ghana approved all study procedures on 2^nd February 2021. Electronic informed consent was obtained from all participants.

Study sample size

We estimated the minimum sample size based on one item to 10 participants.³¹ Therefore, the minimum acceptable sample size based on 21 items of DASS-21 was 210 respondents. However, the total number of healthcare workers participating in the study was 1201.

Procedure

This study was conducted during the hospital’s SARS-CoV-2 delta variant outbreak. The online survey sent to the participants consists of an introductory statement and an electronic informed consent that briefly explained the study’s aims, purpose, and benefit. It also informed participants that their information would be used for research purposes, kept confidential, and would not be shared with the hospital’s management. After reading the introductory statement, participants who selected “yes” meant that they had consented to participate in the study and were allowed to answer questions in the demographic and eligibility section. Only those who met the inclusion criteria answered the rest of the questionnaire. All answers to the questions were required; thus, there were no missing observations. In total, 1201 healthcare workers were enrolled in the study. All data collected were anonymous and kept confidential.

Incidence of COVID-19 during the study period

During the study period, the global incidence of confirmed COVID-19 cases had increased by 25%. In Ghana, the average weekly cases increased from 45 to 2000. Similarly, the total number of confirmed cases in the hospital increased from 5 to 80 per week.

Measures

Demographic variables

Demographic variables were obtained from a self-reported online questionnaire that included age, sex duration of work, occupation or profession and working in an emergency unit.

Depression, Anxiety and Stress Scale

DASS-21 assesses the state of depression, anxiety, and stress in the last week. DASS-21 consists of three subscales with seven items, each assessing depression, anxiety, and stress. It uses a 4-point Likert response for each item from 0 to 3 (0 = “did not apply to me at all” to 3 = “applies to me most of the time”). A subscale score is generated by summing relevant responses. The composite score of each subscale was multiplied by two (therefore making DASS-21 (short version) comparable to the DASS-42 scale (original version). A high composite score indicates a higher psychological stress.²⁴^,²⁸

Statistical analysis

All statistical analyses were performed using SPSS (version 26) (RRID:SCR_002865), but the confirmatory factor analysis (CFA) was performed using AMOS (version 26) (RRID:SCR_022686. Descriptive statistics used in this paper included mean and standard deviation, and proportion and percentage.

We first validated the DASS-21 by examining the factorial structure (construct validity), internal consistency, convergent validity, and discriminate validity. Validation assesses the ability of the DASS-21 questionnaire to measure the latent construct (depression, anxiety, and stress) intended to be measured. After validation, we examined measurement invariance across the sex and professional groups. Before validation analysis, Kaiser–Meyer–Olkin (KMO) and Bartlett’s tests were performed to check the suitability of the dataset. The results indicated that our sample was adequate for the CFA (Chi-square χ² (210) = 13064.5, p < 0.01) and the overall measurement of sampling adequacy was 0.95.

CFA with maximum likelihood estimation was performed to determine the structure and item loading in DASS-21. We tested five models of DASS-21, which included a one-factor model in which all the 21 items load on a general distress factor,²⁴ a two-factor model in which stress and anxiety were combined as one factor and depression as another factor,³² the original three-factor model,²⁴ a bifactor model with general distress (negatively affectivity) as a factor, with depression, anxiety and stress as specific factors²⁶ and a tripartite model in which all items load on a negative affectivity factor, and a specific factor that is made up of anxiety and depression.³³

The results from CFA were analyzed based on the following fit indexes and goodness-of-fit criteria: 1) adequate fit: root-mean-square error (RMSE) (<0.08),³⁴^,³⁵ comparative fit index (CFI) (>0.9)³⁶; and 2) good fit: RMSE (<0.05)³⁵ and CFI (>0.95).³⁶ The χ² test result is strongly dependent on the sample size but it is estimated for all models.

The internal consistency of the DASS-21 and its subscales (Depression, Anxiety and Stress) were assessed using Cronbach’s alpha. A cut-off Cronbach alpha value of > 0.7 indicates high internal consistency.³⁷^,³⁸ Pearson’s correlation coefficient was used to evaluate the item-total correlation. Items with a very low correlation coefficient of < 0.3 were deleted.³⁷

We assessed both the convergent and discriminant validity of the best-fit model. Convergent validity is the ability of the items to successfully estimate the latent variable(s) of the best-fit model. The average variance extracted (AVE) and composite reliability (CR) were used to assess the convergent validity of the best-fit model. For convergent validity to be significant, a CR value of 7 or greater (CR > 7) and AVE values of 0.5 or greater are required.³⁹

Discriminant validity determines how a model can distinctly identify depression, anxiety and stress from other factors. We assessed discriminant validity by comparing the amount of variance explained by the construct and the share variance with other constructs. Thus, for a model to have discriminate validity, the square root of the AVE of the measured construct should be larger than the correlation coefficients of the other constructs.⁴⁰

A multi-group CFA with sex and professional group was performed to evaluate measurement invariance. The first was the configural model, in which all parameters were unrestricted across the group, and then the metric model, where there was factor loading to equality between groups. Metric invariance was evaluated as a function of a difference between the unconstrained and constrained models. The lack of invariance was indicated when the χ² test of goodness of fit was significant (p < 0.05). Since χ² is sample-size dependent, we also considered a model to be invariant across a group with a slight change (∆) in CFI and root mean square error of approximation (RMSEA)—CFI and RMSEA should not exceed 0.02 and 0.015, respectively.⁴¹

Results

Population characteristics and descriptive statistics on depression, anxiety and stress

A total of 1201 healthcare workers participated in the study. The mean age of the participants was 34 years (SD = 7.1 years), ranging from 20 to 58 years. The participants were predominantly females, nurses, and had worked for less than three years (53.9%). One-fifth of the participants worked in emergency-related units. DASS-21 provided an independent assessment of depression (mean = 13.6, SD = 2.7), anxiety (mean = 15.8, SD = 3.1) and stress score (mean = 12.8, SD = 3.3) with mean scores indicating mild depression, severe anxiety and normal stress levels (Table 1).

Table 1. Summary of the study population characteristics.

Characteristics	Percentage (n) or Mean (standard deviation)
Sex
Male	331 (27.6%)
Female	870 (72.4%)
Group age
<30 years	350 (29.1%)
30–39 years	622 (51.8%)
40–49 years	159 (13.2%)
>50 years	70 (5.8%)
Profession
Doctor	202 (16.8%)
Nurse	765 (63.7%)
Non-clinical staff	234 (19.5%)
Duration of work
≤1 year	294 (24.5%)
1–3 years	341 (28.4%)
3–5 years	169 (14.1%)
5–10 years	185 (15.4%)
>10 years	212 (17.7%)
Emergency unit
Yes	255 (21.2%)
No	946 (78.8%)
DASS21 Depression	13.6 (2.7)
DASS21 Anxiety	15.8 (3.1)
DASS21 Stress	12.8 (3.3)

Confirmatory factor analysis

The summary of the fit statistics is shown in Table 2, indicating that the one-factor and two-factor models had unacceptable fit values. The fit values for the bifactor and tripartite models provided an improved and acceptable fit. However, the three-factor model (Figure 1) provided the best fit for the data.

Table 2. Summary of fit index for DASS-21 CFA models.

Model	χ²	df	CFI	TLI	SRMR	RMSEA
Single-factor model	1923.1	189	0.866	0.851	0.0481	0.084
Two-factor model	1701.1	188	0.883	0.869	0.0457	0.082
Three-factor oblique model	1628.5	186	0.923	0.901	0.0333	0.070
Bifactor model	1120.5	165	0.901	0.874	0.0452	0.074
Tripartite model	1293.8	174	0.913	0.896	0.0388	0.073
Modified three-factor (DASS-21) model	1053.8	151	0.961	0.929	0.0321	0.069

Figure 1. Three-Factor oblique DASS-21, with standardized parameter estimates from the sample.

The standardized factor loadings indicated higher and excellent factor loadings for depression, anxiety and stress, except item 2 (“Dryness of the month”) with a factor loading of 0.38. Therefore, item 2 was considered for removal. The final three-factor model (Figure 2) was further enhanced by allowing correlation between items from the same subscale using a high modification index of > 10. The modified DASS-21 provided the final best-fit model to data (CFI: 0.961, Tucker-Lewis index (TLI): 0.929, standardized root mean square residual (SRMR): 0.032, RMSEA: 0.071).

Figure 2. Modified Three-factor oblique DASS-21 model, with standardized parameter estimates from the sample.

Internal consistency and item-total correlation

From Table 3, the Cronbach alpha for the total DASS-21 scale was adequate. Internal consistency for the three subdomain scales was very good: DASS-21 depression (DASS21-D) was 0.88, DASS-21 anxiety (DASS21-A) was 0.86, and DASS-21 stress (DASS21-S) was 0.81. The item scale and total item scale correlations were satisfactory and ranged from 0.3 to 0.7 and 0.4 to 0.8, respectively.

Table 3. Internal consistency for the subdomain of DASS-21.

	N	Number of items	Cronbach's alpha
Depression	1201	7	0.88
Stress	1201	7	0.86
Anxiety	1201	7	0.81
Total	1201	21	0.93

Convergent and discriminant validity

We estimated the convergent validity based on the value of CR and average variance extracted. From Table 4, all the constructs (depression, anxiety and stress) met the predefined criteria for convergent validity—CR > 0.7, CR > AVE and AVE > 0.5. For discriminant validity, the square of the average variance extracted for depression (0.726), anxiety (0.713) and stress (0.707) constructs were all higher than their correlation with other constructs (off-diagonal) (Table 4). This indicates that depression, anxiety, and stress are distinct elements (discriminant validity), as proposed by Lovibond and Lovibond.²⁵ All constructs passed the convergent and discriminant validity tests.

Table 4. Discriminant validity comparing AVE and square AVE with the latent construct correlation (the off-diagonal values are the correlations between latent variables, and the diagonal is the square root of AVE).

	CR	AVE	MSV	MaxR(H)	Stress	Depression	Anxiety
Stress	0.874	0.500	0.490	0.881	0.707
Depression	0.886	0.527	0.462	0.888	0.680	0.726
Anxiety	0.861	0.508	0.490	0.865	0.700	0.650	0.713

Factorial invariance

The multi-group CFA was used to evaluate the degree of measurement invariance of DASS-21 across sex and professional group. Table 5 shows that the configural and metric models for both sex and professional group provided an excellent fit for the data. The invariance test indicates equivalence across males and females. The increase in model constraint reveals no significant difference between the configural and metric (χ² (17) = 21.1, p > 0.05). For the professional group, configural invariance shows that the data fit adequately to the model without any constraint. The difference between the metric and configural invariance was not statistically significant, which indicates that metric invariance was achieved.

Table 5. Factorial invariance across sex and profession for the DASS-21 model.

	χ²	df	Diff (χ²)	Diff (df)	p value	CFI	RMSEA
Sex
Configural invariance	1303.7	302				0.962	0.053
Metric invariance	1324.8	319	21.1	17	0.226	0.961	0.051
Professional group
Configural invariance	1748.3	453				0.942	0.052
Metric invariance	1787.3	487	39	34	0.255	0.944	0.051

Prevalence of depression, anxiety and stress

The prevalence of moderate-to- severe symptoms of depression, anxiety and stress among healthcare workers was 14.2% (170), 4.5% (54) and 30.8% (370), respectively (Table 6). Doctors had high psychological stress compared with other healthcare workers. Healthcare workers who worked in the emergency setting or for more than 10 years had a higher prevalence of depression, anxiety, and stress than others. Moderate-to-severe depression, anxiety, and stress symptoms were equivalent across males and females. However, healthcare workers older than 50 years had lower psychological stress incidence (Table 6).

Table 6. Prevalence of depression, anxiety and stress using DASS-21.

	Moderate to severe
	DASS-21 D	DASS-21 S	DASS-21 A
Sex
Male	14.5% (48)	4.5% (15)	31.1% (103)
Female	14.0% (122)	4.5% (39)	30.7% (267)
Group age
<30 years	11.4% (40)	4.9% (17)	30.6% (107)
30–39 years	15.1% (94)	4.5% (28)	31.5% (196)
40–49 years	17.6% (28)	4.4% (7)	33.3% (53)
>50 years	11.4% (8)	2.9% (2)	20.0% (14)
Profession
Doctor	18.8% (38)	7.4% (15)	31.2% (63)
Nurse	14.6% (112)	4.2% (32)	30.5% (233)
Non-clinical staff	8.5% (20)	3.0% (7)	31.6% (74)
Duration of work
≤1 year	10.9% (32)	4.1% (12)	31.0% (91)
1–3 years	7.3% (25)	1.7% (6)	17.0% (58)
3–5 years	11.8% (20)	4.7% (8)	27.8% (47)
5–10 years	14.6% (27)	3.2% (6)	27.6% (51)
>10 years	35.8% (66)	10.4% (22)	48.1% (102)
Emergency unit
Yes	15.7% (40)	5.5% (40)	31.8% (81)
No	13.7% (130)	4.2% (14)	30.5% (289)
Total	14.2% (170)	4.5% (54)	30.8% (370)

Discussion

To our knowledge, this study is the first to examine the psychometric properties of DASS-21 and provide evidence for its use as a measure of mental health issues among Ghanaian healthcare workers. Overall, our results support the three-dimension structures of DASS-21 as reported in previous studies.²⁴^,²⁸^,⁴² This indicates that DASS-21 can be used as a self-reported tool to assess mental health issues of depression, anxiety, and stress among healthcare workers.

Psychometric properties of DASS-21

The construct validity of DASS-21 was satisfactory based on the CFA, and all model fit indexes were acceptable. Our CFA showed that the best-fit model for our data was the three-factor oblique model for depression, anxiety, and stress, which has been previously validated in clinical and non-clinical samples.²⁵^,²⁶^,²⁸^,⁴³ The three-factor oblique model was better than the one-factor and two-factor models, indicating that depression, anxiety and stress are distinct constructs, as previously reported.²⁴^,⁴⁴

A modification improved model fitness to items with poor factor loadings (factor loading < 0.4). However, item 2 (“dryness of the mouth”) from the anxiety subscale shows weaker factor loadings than other items in our study sample. Previous studies have questioned the utility of item 2 (“dryness of the mouth”) as a measure of the anxiety construct.²⁵^,⁴⁵^–⁴⁸ On the contrary, some studies have suggested that item 2 (“dryness of the mouth”) performed excellently in the psychological stress construct (one-factor model).⁴⁵^,⁴⁷ Moreover, Parkitny et al.⁴⁶ described the “dryness of the mouth” item as a vague response to DASS-21. Besides the initial improvement, the three-factor model was further enhanced using a modification index that allows correlation error between items from the same scale.

Our reliability results for DASS-21 showed an excellent internal consistency for all the subscales, with the Cronbach alpha ranging from 0.81 to 0.93. These results confirmed previous reports about the reliability of DASS-21 in different studies and populations.²⁶^,²⁸^,⁴⁹^,⁵⁰ We confirm from previous studies that DASS-21 has a high convergent and discriminant validity of the three constructs.²⁶^,⁴²^,⁴⁹^,⁵¹

Measurement invariance

In this study, we also examined invariant measurement across sex and professional groups. Our results showed that DASS-21 has a full configural and metric invariance across sex and professional groups. This indicates that the meaning of DASS -21 to measure depression, anxiety, and stress was the same for females and males or doctors, nurses, and non-clinical healthcare workers—there were no differences across sex and professional groups in the DASS-21 structure.

Depression, anxiety and stress during SARS-CoV-2 delta variant outbreak

In our study, the prevalence of depression, anxiety, and stress among healthcare workers was 14.4% (DASS-21 depression score > 13), 30.8% (DASS-21 anxiety score > 9) and 4.5% (DASS-21 stress score > 18), respectively. These prevalences of depression, anxiety and stress were lower than those reported in previous studies of Ghanaian healthcare workers during the early phase of the pandemic¹⁹ and other studies from China,¹⁵ Italy,¹⁶ and India.¹⁷ The differences in the prevalence of depression, anxiety, and stress may be due to sociocultural differences affecting the individual’s experience and expression of mental health symptoms. This shows that DASS-21 can be used as a screening tool to identify healthcare workers with depression, anxiety and stress. The tool is relevant for the hospital employee assistance program, which aims to identify healthcare workers with mental health issues in order to provide support for them.

The high prevalence of depression and anxiety reported among healthcare workers may be due to the possible impact of the delta variant of SARS-CoV-2 in the hospital. During the COVID-19 outbreak, especially in the vaccine-availability era, when there was widespread disease and an increased number of deaths, it was very common to observe high psychological stress among healthcare workers who may have directly or indirectly managed COVID-19-infected patients. Similar events of the high prevalence of mental health issues among healthcare workers have been observed in the SARS, MERS, H1N1 influenza, and Ebola outbreaks.

With the advent of the COVID-19 vaccine, healthcare workers’ mental status depends on the vaccine’s ability to prevent them from being infected and infecting others. The decrease in vaccine efficacy resulting in increased breakthrough infections severely impacts their mental and physical health. Moreover, the virulent nature of the delta variant, the high influx of infected patients with severe clinical manifestations or hospitalization, high mortality, increased workload, fear of getting infected and the dearth of personal protective equipment all negatively affect the mental health status of healthcare workers.

Strength and limitations

The strength of this study is that it is the first time a DASS-21 validation has been performed among Ghanaian healthcare workers. In addition, this present study provides novel information about the prevalence of mental health issues among healthcare workers during the delta variant outbreak. One limitation of this study was the self-reported response of DASS-21, which may have led to potential biases or measurement errors. For example, some healthcare workers may have provided a socially acceptable response about their mental health issues because of stigmatization. Additionally, using a convenient sampling method could result in selection bias because only healthcare workers with internet access completed the online questionnaire. Finally, all the respondents were healthcare workers from the same hospital, which may affect the generalization of the findings.

Conclusions

In summary, our results indicate that DASS-21 has good psychometric properties among Ghanaian healthcare workers. We found DASS-21 to be valid and reliable, with the ability to distinctly identify depression, anxiety, and stress from other factors. Our data suggest that this tool is invariant across sex and across doctors, nurses, and non-clinical healthcare workers. Thus, DASS-21 can be used as a self-reporting tool to screen for depression, anxiety, and stress in health workers. This will allow authorities, such as employee assistance programs, to identify healthcare workers at higher risk of developing work-related mental health disorders.

Data availability

Underlying data

Figshare: Dataset for psychometric evaluation of depression, anxiety, and stress scale among healthcare worker in Ghana during COVID-19 outbreak. Dataset. https://doi.org/10.6084/m9.figshare.21929697.⁵²

This project contains the following underlying data:

- dass4_3.csv

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

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51. Tonsing KN: Psychometric properties and validation of Nepali version of the Depression Anxiety Stress Scales (DASS-21). Asian J. Psychiatr. 2014; 8: 63–66. PubMed Abstract | Publisher Full Text
52. Marfoh M, Samba A, Eunice Okyere E, et al.:Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana. Dataset. Figshare. 2023. Publisher Full Text

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VERSION 1 PUBLISHED 01 Mar 2023

Author details Author details

¹ CMNHS, Fiji National University, Suva, 000, Fiji
² Public Health Department, Korlebu Teaching Hospital, Accra, 0233, Ghana
³ Medical Directory, Korle-bu Teaching Hospital, Accra, 0233, Ghana
⁴ Clinical Psychology Department, Korl-bu Teaching Hospital, Accra, 0233, Ghana
⁵ Research Unit, Korele-bu Teaching Hospital, Accra, 0233, Ghana

Kissinger Marfoh
Roles: Conceptualization, Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Ali Samba
Roles: Conceptualization, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Eunice Okyere
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Priscilla Kushigbor
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Franklin Acheampong
Roles: Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

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Published: 01 Mar 2023, 12:229

https://doi.org/10.12688/f1000research.130447.1

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Marfoh K, Samba A, Okyere E et al. Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana [version 1; peer review: 1 approved with reservations] F1000Research 2023, 12:229 (https://doi.org/10.12688/f1000research.130447.1)

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PUBLISHED 01 Mar 2023

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9

Reviewer Report 27 Jun 2023

Roy Rillera Marzo, Management and Science University, Shah Alam, Selangor, Malaysia

Approved with Reservations

https://doi.org/10.5256/f1000research.143208.r180287

The introduction of your manuscript titled "Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana" is detailed and provides an in-depth background of the study. However, here are ... Continue reading

The introduction of your manuscript titled "Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana" is detailed and provides an in-depth background of the study. However, here are a few suggestions for improvement:

Clarity and specificity: The current manuscript lacks a clear and concise explanation of the specific context of the study (i.e., the Delta variant). I would suggest emphasizing how the Delta variant has specifically impacted healthcare workers' mental health in Ghana, perhaps necessitating a re-evaluation or adjustment of the DASS-21 for this unique context.
Length: The introduction is quite lengthy. While it is rich in information, the reader could potentially get lost in the details. Consider pruning less critical information or consolidating points to make it more reader-friendly.
Consistency: Some figures provided appear inconsistent, especially in the part where the number of COVID-19 cases among healthcare workers is mentioned. Please ensure that your data is consistent and correctly cited.

Methods:

Sampling strategy: Although convenience sampling can be a practical method, it's crucial to mention its limitations. Convenience samples may not be representative of the entire healthcare worker population at Korle-Bu Teaching Hospital, introducing a potential bias that could limit the generalizability of your findings. Consider discussing this aspect in the limitations of the study.
Self-reported data: The methodology relies heavily on self-reported data, which can introduce the risk of response bias, including social desirability bias and recall bias. Discussing these concerns in your methods section would contribute to a more balanced view of your results.
Inclusion and Exclusion criteria: You excluded healthcare workers with known mental health disorders. However, this exclusion could lead to an underestimation of the prevalence of stress, anxiety, and depression, as those with pre-existing mental health conditions may be more likely to experience these symptoms.
Survey design: More information on the design of the questionnaire might be helpful. For instance, was the DASS-21 questionnaire modified in any way for this study? Also, was it translated? If so, did it go through a rigorous translation-back translation process to ensure it retains its meaning?
Data cleaning: It might be worth mentioning if any data cleaning procedures were performed before analysis, as some responses might have been inconsistent or illogical.
Incidence of COVID-19: You provided data on the incidence of COVID-19 during the study period. How was this information collected and verified? Detailing this process could add more credibility to your study.
Confounding variables: The role of potential confounding variables and how these were controlled for in the study should be stated. For example, demographic variables such as age, sex, duration of work, occupation or profession, and working in an emergency unit might influence the psychometric properties of DASS-21.
Measurement invariance: You've tested measurement invariance across sex and professional groups. Did you consider other subgroups, such as age groups or levels of exposure to COVID-19 patients? This could provide more insights into the instrument's performance across different subpopulations.
Statistical analysis: The methodology would benefit from more information about how missing data were handled in your analyses. Although you mentioned that all answers to the questions were required, it is still possible that some participants did not complete the survey fully.

Discussion:

Comparison with other studies: Lack of comparison to other countries. The previous studies (9 references listed below) can help. Although you've compared the prevalence of depression, anxiety, and stress in your study with other countries, it might be beneficial to discuss why these differences might exist. For instance, are there certain factors unique to Ghanaian healthcare workers that could explain the lower prevalence rates?
Item 2 on the DASS-21: You've discussed the controversy regarding the "dryness of the mouth" item. However, it would be helpful to provide more context. How does this item's weak performance in your study contribute to this ongoing debate? Does this imply that this item may not be as relevant in the context of Ghanaian healthcare workers?
Implications for Practice: The application of the findings to practical scenarios, such as how it might influence policy or guide future research, needs more emphasis. How can healthcare organizations use this information to better support their employees?

Strengths and Limitations section:

Sampling Strategy: Your admission of potential selection bias due to the convenience sampling method and online survey is important. However, it may also be worthwhile to discuss ways you could mitigate these issues in future studies, such as using stratified or random sampling techniques.
Single Site Study: As the study was conducted in one hospital, the findings may not be applicable to other settings in Ghana or elsewhere. Future studies could aim to include multiple sites for a more comprehensive understanding.
Cross-Sectional Design: As a cross-sectional study, it captures the participants' mental health status at one point in time. It would be beneficial to acknowledge that this design doesn't allow for conclusions about cause-and-effect relationships or changes over time.

Conclusion section:

Claims About DASS-21 Applicability: Although DASS-21 demonstrated good psychometric properties in this study, it may be an overstatement to say it can be used as a screening tool in "health workers." This study focused on healthcare workers at a specific hospital in Ghana, and the results may not be directly applicable to health workers in different settings or countries.
Future Research Directions: The conclusion would benefit from a call to action for future research. How can other researchers build upon your findings? This might involve testing DASS-21 in a wider population of Ghanaian healthcare workers or comparing its performance with other mental health screening tools.

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

1. Thiyagarajan A, James TG, Marzo RR: Psychometric properties of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Malaysians during COVID-19: a methodological study.Humanit Soc Sci Commun. 2022; 9 (1): 220 PubMed Abstract | Publisher Full Text
2. Elsayed MEG, El-Abasiri RA, Marzo RR, Dardeer KT, et al.: Mental health, risk perception, and coping strategies among healthcare workers in Egypt during the COVID-19 pandemic.PLoS One. 2023; 18 (2): e0282264 PubMed Abstract | Publisher Full Text
3. Marzo RR, ElSherif M, Abdullah MSAMB, Thew HZ, et al.: Demographic and work-related factors associated with burnout, resilience, and quality of life among healthcare workers during the COVID-19 pandemic: A cross sectional study from Malaysia.Front Public Health. 2022; 10: 1021495 PubMed Abstract | Publisher Full Text
4. Marzo RR, Khaled Y, ElSherif M, Abdullah MSAMB, et al.: Burnout, resilience and the quality of life among Malaysian healthcare workers during the COVID-19 pandemic.Front Public Health. 2022; 10: 1021497 PubMed Abstract | Publisher Full Text
5. Hwaij R, Ghrayeb F, Marzo R, Alrifai A: Palestinian Healthcare Workers Mental Health Challenges during COVID-19 Pandemic: A Cross-Sectional Study. Medical Research Archives. 2022; 10 (10). Publisher Full Text
6. Rillera Marzo R, Villanueva Iii EQ, Chandra U, Htay MNN, et al.: Risk perception, mental health impacts and coping strategies during COVID-19 pandemic among Filipino healthcare workers.J Public Health Res. 2021; 10 (s2). PubMed Abstract | Publisher Full Text
7. Kamberi F, Sinaj E, Jaho J, Subashi B, et al.: Impact of COVID-19 pandemic on mental health, risk perception and coping strategies among health care workers in Albania - evidence that needs attention.Clin Epidemiol Glob Health. 2021; 12: 100824 PubMed Abstract | Publisher Full Text
8. Htay MNN, Marzo RR, Bahari R, AlRifai A, et al.: How healthcare workers are coping with mental health challenges during COVID-19 pandemic? - A cross-sectional multi-countries study.Clin Epidemiol Glob Health. 2021; 11: 100759 PubMed Abstract | Publisher Full Text
9. Htay MNN, Marzo RR, AlRifai A, Kamberi F, et al.: Immediate impact of COVID-19 on mental health and its associated factors among healthcare workers: A global perspective across 31 countries.J Glob Health. 2020; 10 (2): 020381 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Epidemiology, Health Promotion, Research Methodology, Communicable and Non-Communicable Diseases, Environmental Health, Global Sustainable Development, Health and Social Services, Nutrition, Ageing and Quality of Life, Social and Behavioural Health, Healthcare Management, Strategic Management, Health Services Management, Health Leadership Management, Quality Management, Medical Education

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Roy Rillera Marzo, Management and Science University, Shah Alam, Malaysia

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Reviewer Report

9 Views

27 Jun 2023 | for Version 1

Roy Rillera Marzo, Management and Science University, Shah Alam, Selangor, Malaysia

9 Views Cite this report Responses(0)

Approved With Reservations

The introduction of your manuscript titled "Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana" is detailed and provides an in-depth background of the study. However, here are a few suggestions for improvement:

Clarity and specificity: The current manuscript lacks a clear and concise explanation of the specific context of the study (i.e., the Delta variant). I would suggest emphasizing how the Delta variant has specifically impacted healthcare workers' mental health in Ghana, perhaps necessitating a re-evaluation or adjustment of the DASS-21 for this unique context.
Length: The introduction is quite lengthy. While it is rich in information, the reader could potentially get lost in the details. Consider pruning less critical information or consolidating points to make it more reader-friendly.
Consistency: Some figures provided appear inconsistent, especially in the part where the number of COVID-19 cases among healthcare workers is mentioned. Please ensure that your data is consistent and correctly cited.

Methods:

Sampling strategy: Although convenience sampling can be a practical method, it's crucial to mention its limitations. Convenience samples may not be representative of the entire healthcare worker population at Korle-Bu Teaching Hospital, introducing a potential bias that could limit the generalizability of your findings. Consider discussing this aspect in the limitations of the study.
Self-reported data: The methodology relies heavily on self-reported data, which can introduce the risk of response bias, including social desirability bias and recall bias. Discussing these concerns in your methods section would contribute to a more balanced view of your results.
Inclusion and Exclusion criteria: You excluded healthcare workers with known mental health disorders. However, this exclusion could lead to an underestimation of the prevalence of stress, anxiety, and depression, as those with pre-existing mental health conditions may be more likely to experience these symptoms.
Survey design: More information on the design of the questionnaire might be helpful. For instance, was the DASS-21 questionnaire modified in any way for this study? Also, was it translated? If so, did it go through a rigorous translation-back translation process to ensure it retains its meaning?
Data cleaning: It might be worth mentioning if any data cleaning procedures were performed before analysis, as some responses might have been inconsistent or illogical.
Incidence of COVID-19: You provided data on the incidence of COVID-19 during the study period. How was this information collected and verified? Detailing this process could add more credibility to your study.
Confounding variables: The role of potential confounding variables and how these were controlled for in the study should be stated. For example, demographic variables such as age, sex, duration of work, occupation or profession, and working in an emergency unit might influence the psychometric properties of DASS-21.
Measurement invariance: You've tested measurement invariance across sex and professional groups. Did you consider other subgroups, such as age groups or levels of exposure to COVID-19 patients? This could provide more insights into the instrument's performance across different subpopulations.
Statistical analysis: The methodology would benefit from more information about how missing data were handled in your analyses. Although you mentioned that all answers to the questions were required, it is still possible that some participants did not complete the survey fully.

Discussion:

Comparison with other studies: Lack of comparison to other countries. The previous studies (9 references listed below) can help. Although you've compared the prevalence of depression, anxiety, and stress in your study with other countries, it might be beneficial to discuss why these differences might exist. For instance, are there certain factors unique to Ghanaian healthcare workers that could explain the lower prevalence rates?
Item 2 on the DASS-21: You've discussed the controversy regarding the "dryness of the mouth" item. However, it would be helpful to provide more context. How does this item's weak performance in your study contribute to this ongoing debate? Does this imply that this item may not be as relevant in the context of Ghanaian healthcare workers?
Implications for Practice: The application of the findings to practical scenarios, such as how it might influence policy or guide future research, needs more emphasis. How can healthcare organizations use this information to better support their employees?

Strengths and Limitations section:

Sampling Strategy: Your admission of potential selection bias due to the convenience sampling method and online survey is important. However, it may also be worthwhile to discuss ways you could mitigate these issues in future studies, such as using stratified or random sampling techniques.
Single Site Study: As the study was conducted in one hospital, the findings may not be applicable to other settings in Ghana or elsewhere. Future studies could aim to include multiple sites for a more comprehensive understanding.
Cross-Sectional Design: As a cross-sectional study, it captures the participants' mental health status at one point in time. It would be beneficial to acknowledge that this design doesn't allow for conclusions about cause-and-effect relationships or changes over time.

Conclusion section:

Claims About DASS-21 Applicability: Although DASS-21 demonstrated good psychometric properties in this study, it may be an overstatement to say it can be used as a screening tool in "health workers." This study focused on healthcare workers at a specific hospital in Ghana, and the results may not be directly applicable to health workers in different settings or countries.
Future Research Directions: The conclusion would benefit from a call to action for future research. How can other researchers build upon your findings? This might involve testing DASS-21 in a wider population of Ghanaian healthcare workers or comparing its performance with other mental health screening tools.

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

1. Thiyagarajan A, James TG, Marzo RR: Psychometric properties of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Malaysians during COVID-19: a methodological study.Humanit Soc Sci Commun. 2022; 9 (1): 220 PubMed Abstract | Publisher Full Text
2. Elsayed MEG, El-Abasiri RA, Marzo RR, Dardeer KT, et al.: Mental health, risk perception, and coping strategies among healthcare workers in Egypt during the COVID-19 pandemic.PLoS One. 2023; 18 (2): e0282264 PubMed Abstract | Publisher Full Text
3. Marzo RR, ElSherif M, Abdullah MSAMB, Thew HZ, et al.: Demographic and work-related factors associated with burnout, resilience, and quality of life among healthcare workers during the COVID-19 pandemic: A cross sectional study from Malaysia.Front Public Health. 2022; 10: 1021495 PubMed Abstract | Publisher Full Text
4. Marzo RR, Khaled Y, ElSherif M, Abdullah MSAMB, et al.: Burnout, resilience and the quality of life among Malaysian healthcare workers during the COVID-19 pandemic.Front Public Health. 2022; 10: 1021497 PubMed Abstract | Publisher Full Text
5. Hwaij R, Ghrayeb F, Marzo R, Alrifai A: Palestinian Healthcare Workers Mental Health Challenges during COVID-19 Pandemic: A Cross-Sectional Study. Medical Research Archives. 2022; 10 (10). Publisher Full Text
6. Rillera Marzo R, Villanueva Iii EQ, Chandra U, Htay MNN, et al.: Risk perception, mental health impacts and coping strategies during COVID-19 pandemic among Filipino healthcare workers.J Public Health Res. 2021; 10 (s2). PubMed Abstract | Publisher Full Text
7. Kamberi F, Sinaj E, Jaho J, Subashi B, et al.: Impact of COVID-19 pandemic on mental health, risk perception and coping strategies among health care workers in Albania - evidence that needs attention.Clin Epidemiol Glob Health. 2021; 12: 100824 PubMed Abstract | Publisher Full Text
8. Htay MNN, Marzo RR, Bahari R, AlRifai A, et al.: How healthcare workers are coping with mental health challenges during COVID-19 pandemic? - A cross-sectional multi-countries study.Clin Epidemiol Glob Health. 2021; 11: 100759 PubMed Abstract | Publisher Full Text
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Epidemiology, Health Promotion, Research Methodology, Communicable and Non-Communicable Diseases, Environmental Health, Global Sustainable Development, Health and Social Services, Nutrition, Ageing and Quality of Life, Social and Behavioural Health, Healthcare Management, Strategic Management, Health Services Management, Health Leadership Management, Quality Management, Medical Education

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Validation of Depression, Anxiety and Stress Scale (DASS-21) among healthcare workers during the outbreak of delta variant of SARS-CoV-2 in Ghana

Abstract

Keywords

Introduction

Method

Participants

Eligibility criteria

Ethical approval

Study sample size

Procedure

Incidence of COVID-19 during the study period

Measures

Statistical analysis

Results

Population characteristics and descriptive statistics on depression, anxiety and stress

Table 1. Summary of the study population characteristics.

Confirmatory factor analysis

Table 2. Summary of fit index for DASS-21 CFA models.

Figure 1. Three-Factor oblique DASS-21, with standardized parameter estimates from the sample.

Figure 2. Modified Three-factor oblique DASS-21 model, with standardized parameter estimates from the sample.

Internal consistency and item-total correlation

Table 3. Internal consistency for the subdomain of DASS-21.

Convergent and discriminant validity

Table 4. Discriminant validity comparing AVE and square AVE with the latent construct correlation (the off-diagonal values are the correlations between latent variables, and the diagonal is the square root of AVE).

Factorial invariance

Table 5. Factorial invariance across sex and profession for the DASS-21 model.

Prevalence of depression, anxiety and stress

Table 6. Prevalence of depression, anxiety and stress using DASS-21.

Discussion

Psychometric properties of DASS-21

Measurement invariance

Depression, anxiety and stress during SARS-CoV-2 delta variant outbreak

Strength and limitations

Conclusions

Data availability

Underlying data

References

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