Health anxiety to COVID-19 virus infection and its relationship to quality of life in a sample of health care workers in Egypt: a cross-sectional study

Results: The frequency of health anxiety to COVID-19 virus among HCWs was 28%. Symptoms of depression, hostility, phobia and somatization, and history of chronic medical illnesses showed greater odds of health anxiety to COVID-19 virus (OR: 6.7, 9.1, 7.3, 7.7, and 12.6, respectively). Being physicians and the increased number of sleeping hours were less likely associated with health anxiety to COVID-19 virus (OR: 0.1 and 0.5, respectively). Health anxiety to COVID-19 virus was inversely correlated with all domains of QOL among HCWs.


INTRODUCTION
In March 2020, the COVID-19 outbreak was declared by the World Health Organization as a global pandemic. Severe acute respiratory syndrome coronavirus-2 COVID-19 (SARS-CoV-2), which was a newly emerging virus, was recognized as the offending agent of COV-ID-19 virus infection that began first in December 2019 in Wuhan, China and spread world-wide [1]. Globally, as of 7 August 2020, there have been around 19 million confirmed cases of COVID-19, including about 710 thousand deaths, affecting more than two hundred Countries and Territories across the world [2].
The current COVID-19 pandemic put healthcare workers (HCWs) around the world under extraordinary pressures. First, ensuring the safety and efficient protection of HCWs from being infected during the epidemic was very essential not only to maintain continuous and safe patient care but also to control outbreaks. [3] It was documented that HCWs who were caring for patients during the previous outbreaks like severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) Archives of Psychiatry and Psychotherapy, 2021; 1: [19][20][21][22][23][24][25][26][27][28] were under persistent stress due to the increased risk of infection, stigmatization, deficient training, limited numbers of medical staff, deficient medical equipment and uncertainty [4,5]. Second, the HCWs would have to make life-saving decisions under extreme pressures. These decisions included how to judiciously utilize the limited resources equally to patients, how to stabilize the balances between their own physical and mental wellbeing needs with those of their patients, and between their duty commitments to patients with those to their families and friends, and how to continue providing the medical care for all affected patients with limited or inadequate resources [6].
All these challenges may result in some to experience a wide array of psychological problems. It was stated that the HCWs were fearful, anxious, and frustrated and were at higher risk of emotional disturbances, during the last SARS and MERS epidemics [4,5]. The situation would be the same during Covid-19 pandemic; studies have found that HCWs working with patients with COVID-19 have greater risks of psychiatric disturbances, such as anxiety, depression, insomnia, and stress [7][8][9]. The extraordinary circumstances of sustained fear and apprehension may negatively affect the quality of life (QOL) among HCWs [10]. Work-related risks in combination with psychological quests, ethical dilemmas, and the patients' demands can be a burden on the professional's emotional state [11]. Numerous studies reported that the reluctance to work or contemplating resignation was usually seen among HCWs who feared contagion [12]. Furthermore, sustained anxiety and tensions could lead to lower quality of care, which in its turn could lower professional satisfaction and consequently their QOL [13].
The HCWs including physicians, nurses, technicians, and health workers are working at the frontlines facing COVID-19 pandemic in Egypt, with a sustained risk of being infected. To our knowledge, there is no sufficient data regarding the psychosocial impact of the COVID-19 virus infection on the QOL among HCWs during the pandemic in Egypt. The current study aimed to identify the sociodemographic as well as the clinical factors associated with the health anxiety to Covid-19 infection and to identify its relationship with the QOL among HCWs in Egypt.

Study Setting
The HCWs enrolled in this study, were working during the outbreak of the COVID-19 pandemic in the major three public hospitals in Sharkia Province, where separate isolation units were devoted to COVID-19 patients. Sharkia Province, located in the Eastern Nile Delta, is the 2 nd most populated province in Egypt, after the Great Cairo region, with about 8.0 million inhabitants.

Study design and sampling
This is a cross-sectional study conducted during the period from June 30 to July 16, 2020. The study was performed during the peak of the COVID-19 epidemic outbreak in Egypt among HCWs including physicians, nurses, technicians, and health workers. A total of 218 HCWs from all ages and both sexes were randomly enrolled in this study, calculated according to the Epi Info 6.0, at 80% power of the study, 95% confidence level [14], as the total number of Egyptian HCWs who are currently working in the general hospitals in Sharkia Province is 41898 [15]. A systematic random sampling method was assigned by item selection from an ordered population utilizing a skip or sampling interval. The data were collected via telephone due to lockdown measures, and the local health authorities banned face-to-face contact.

Data collection and assessment measures
Exposure Ascertainment: The main exposure variable was the health anxiety to COVID-19 virus infection among HCWs, assessed by the short health anxiety inventory (SHAI) [16]. The SHAI is an 18-item measure that contains two sections; the main section is a 14-item subscale evaluating the symptoms of health anxiety (hypochondriasis), and the second section is a 4-item subscale assessing people's attitudes to how awful it would be if they were to develop a particular illness (Covid-19 virus infection). Each SHAI item consists of four responses rated from "0 to 3", and the total score ranges from 0 to 54. A cut-off of 27 was applied to differentiate between hypochondriacal health anxiety and normal anxiety reaction [17]. The SHAI has established comparable reliability and validity [18].

Covariates:
Demographic and clinical variables and comorbid psychological symptoms were considered as potential confounders. A semi-structured checklist was designed to obtain the socio-demographic and clinical data including age, sex, education, occupation, marital status, residence, profession, and history of psychiatric and physical conditions. The Symptom Check List-90-Revised (SCL-90-R) is used to estimate a wide range of underlying psychological problems [20]. They include symptoms of somatization, obsessive-compulsion, interpersonal sensitivity, hostility, depression, paranoid ideation, phobic anxiety, and psychoticism. This 90-itemed self-report scale was rated on a 5-point Likert scale (from 0 "not at all" to 4 "extremely") for each item. Subscale scores ≥2 indicate potential psychological issues. Three additional global indices provide measures of overall psychological distress called the General Symptoms Index, the Positive Symptoms Index Total, and the Positive Symptoms Distress Index. The scale was broadly utilized as a clinical tool in several settings, particularly in the area of mental health [21,22].

Administrative design
The study was approved by the Zagazig University institutional review board (IRB no. 6215/29-6-2020). All study participants were interviewed via telephone by expert psychiatrists during their work duty hours to discuss the study objectives, confirm confidentiality, and obtain their informed written consent for participation. All study procedures were conducted within the ethical guidelines as outlined in the Declaration of Helsinki and its later amendments.

Statistical Analysis
SPSS (Statistical Package for Social Science) statistical software version 16.0 was used for data analysis. Quantitative data were represented as arithmetic means and standard deviations; the analysis of variance test (ANOVA) was used for continuous variables. Qualitative data were represented as frequencies and percentages; the Chi-square test (χ2) was carried out for categorical variables. The Pearson correlation coefficient was used to evaluate the degree of relationship between two variables with a linear relationship. To obtain odds ratios (OR) and 95% confidence intervals (CI), logistic regression analysis was used for the identification of the potential predictors of health anxiety to COVID-19 virus infection among HCWs. All results were considered statistically significant when the significant probability was less than 5% (p < 0.05).

RESULTS
This study included 218 HCWs from both sexes and all ages and professions. The mean age of the participants was 39.5 ± 8.5 years, and the mean numbers of weekly working days were 5.3 ± 1.1 days. The majority were females (n=156, 72%), nurses (n=111, 51%), and married (n=192, 88%). The lifetime prevalence rates of smoking, chronic medical illnesses, and chronic psychiatric illnesses among HCWs were 15%, 24%, and 6%, respec-tively. The frequency of health anxiety to COV-ID-19 virus infection as measured by the SHAI was 28%. The most prevalent positive psychological dimensions were obsessive-compulsive, depression, and psychoticism (20.6%, 20.6%, and 19.3%) respectively. Tables 1 & 2 describe the distribution of participant characteristics according to the health anxiety to COVID-19 virus infection. Categorization was based on "t" transformation of SCL R-90 scores. Positive dimensions were considered when "t" scores are higher than 60.
*GSI= Global Severity Index, **PST= Positive Symptoms Total, ***PSD= Positive Symptoms Distress Index Those who reported higher levels of health anxiety to COVID-19 virus infection were more likely to be identified as nurses (69.4%), working more days weekly (5.7 ± 0.8 days), having lower sleeping hours (6.8 ± 0.9 hours), and reporting a history of chronic medical illnesses (43.5%). The psychological dimensions associated with health anxiety to COVID-19 virus infection were obsessive-compulsive (35.5%), depression (33.9%), phobia (30.6%), somatization (29%), psychoticism (29%), and hostility (19.4%). Table 3 describes the results from the adjusted logistic regression identifying the predictors of the health anxiety to COVID-19 virus infection among HCWs. Those who had positive depression, hostility, phobia, and somatization dimensions, or reported a history of chronic medical illnesses showed greater odds of health anxiety to COVID-19 virus infection (OR 6.7, 9.1, 7.3, 7.7, and 12.6 respectively). Being physicians and an increased number of sleeping hours were less likely associated with health anxiety to COVID-19 virus infection (OR 0.11 and 0.5, respectively).    Table 5 describes the distribution of characteristics of HCWs according to their profession. Compared to other HCWs, physicians were more likely to be younger (34.5 ± 5.9 years), males (39.2%), unmarried (18.9), of urban residency (75.7%), working lesser numbers of days weekly, sleeping more hours daily, having depressive symptoms (28.4%), and reporting better physical health (55.2 ± 14.5). However, physicians were less likely to report chronic medical illnesses (10.8%), and somatization symptoms (0%).

DISCUSSION
HCWs are the first-line fighters during the battle against COVID-19 pandemic in Egypt. To meet their work requirements, HCWs are exposed to stressful work shifts and face an increased and sustained risk of being infected. Our study found that the majority of participants with higher levels of health anxiety to COVID-19 virus infection were nurses (69.4%), which was consistent with the results of a study investigating the mental health wellbeing among physicians and nurses during COVID-19 epidemic in China and found that about 60% of the participants experiencing psychological symptoms were nurses [23]. This may be explained as the nurses, who were mostly females, were facing a greater risk of exposure to COVID-19 patients as they spent more time onwards, provided direct care to the patients, and were responsible for the collection of sputum for virus detection.
During the COVID-19 epidemic, the numbers of HCWs, who spent long hours dealing with patients with limited periods of rest and sleep, were substantial which might contribute to symptoms of anxiety and depression among them. In this study, those who reported higher levels of health anxiety to COVID-19 virus infection were more likely to be identified as working more days weekly (5.7 ± 0.8 days) and having lower sleeping hours (6.8 ± 0.9 hours). Numerous studies investigated the relationship between increased working duty hours and the development of psychological symptoms. A study examined the associations between duty hours and emergence of anxiety and depressive symptoms among full-time employees and concluded that increased working hours (> 55 hours per week) was related to 1.65 and 1.68-fold risks of depressive and anxiety symptoms, respectively [24]. Moreover, several studies concluded that insomnia would be a potential predictor of psychological distress among medical staff [25][26][27][28][29].
Regarding the underlying psychological symptoms, the current study found the most prevalent symptoms associated with health anxiety to COVID-19 virus infection were obsessive-compulsive (35.5%), depression (33.9%), phobia (30.6), somatization (29%), psychoticism (29%), and hostility (35.5%). Similarly, a study found that the prevalence of psychological dis-tress, anxious symptoms, and depressive symptoms among the medical staff during the COV-ID-19 outbreak were 15.9%, 16%, and 34.6% respectively. [30] Another study, which compared the psychosocial problems using the Symptom Check List-90-revised (SCL-90-R) between the medical and non-medical health workers during the COVID-19 outbreak, found that the medical staff reported higher and significant rates of anxiety, depression, somatization, and obsessive-compulsive symptoms than nonmedical health workers [26].
Following logistic regression adjusted for potentially significant variables, this study found that symptoms of depression, hostility, phobic anxiety, somatization, reduced hours of sleep, and history of chronic medical illnesses were the most powerful predictors of health anxiety to COVID-19 virus infection among HCWs. These results confirmed the findings of a study that compared 927 medical HCWs (680 physicians and 247 nurses) to 1,255 nonmedical HCWs and found that the medical HCWs reported higher rates of insomnia, anxiety, depression, somatization, and obsessive-compulsive symptoms than nonmedical ones [26]. Also, the history of organic diseases was a common risk factor for anxiety among both medical and nonmedical health workers. Furthermore, it was found that medical HCWs had higher odds for mood disorders, anxiety disorders, sleep disorders, and any psychiatric disorders than nonmedical HCWs [31]. It was claimed that time pressure, insufficient support from supervisors and managers, increased workload, sleep deprivation due to night-shift work, confusion regarding decisions, and reduced autonomy would negatively affect HCWs' mental wellbeing [32].
In this study, health anxiety to COVID-19 virus was found to be inversely correlated with all domains of QOL among healthcare workers. Consistent with this finding, a study showed that frontline medical staff working with COV-ID-19 patients exhibited more depressive/anxiety symptoms and significantly lower scores on physical and social functioning, and mental health scales of SF-36 than medical staff working in other departments [33]. Another study was conducted to assess the relationship between the long-term psychiatric disturbances and QOL in severe acute respiratory syndrome (SARS) sur-vivors where 30% of the study participants were HCWs [34]. Though the study was conducted at 2.5 years post -epidemic, it was found that HCWs showed poorer performance in all domains of their QOL. The lack of information about the duration of the crisis, confusion about effective therapies, obligations to provide direct care to infected patients with COVID-19 with the fear of being infected, and shortages of health care resources would hurt different life aspects of HCWs which would be reflected upon assessing the QOL among them [35].
When the HCWs, in this study, were evaluated according to their profession, it was found that physicians were more likely to have depressive symptoms, work lesser numbers of days weekly, sleep more hours daily, and report better physical health than other HCWs. These results were consistent with those of Zhu et al., who estimated the prevalence of depressive symptoms in frontline medical staff (79 physicians and 86 nurses participated in the survey). The prevalence rate of depressive symptoms was higher among doctors (45.6%) than nurses (43.0%) [36]. Another study stated that HCWs who experienced worse self -reported physical health, reported more than sixty working hours weekly, and twice or more night shifts per week with subsequent insufficient sleep resulting in higher rates of anxiety symptoms than their counterparts, nonetheless this study did not compare between physicians and other HCWs [37].

Clinical implications and Recommendations
Mental health services like psychological support and counseling should be accessible to all health care members during the COVID-19 outbreak of HCWs to help them control the expected symptoms of depression, anxiety, insomnia, and psychological distress.