Level of anxiety among healthcare providers during COVID-19 pandemic in Saudi Arabia: cross-sectional study

Background The burden of the spread of the COVID-19 pandemic has impacted widely on the healthcare providers physically and mentally. Many healthcare providers are exposed to psychological stressors due to their high risk of contracting the virus. Aims This study aimed to measure the level of anxiety among healthcare providers during the COVID-19 pandemic in Saudi Arabia. In addition, this study aimed to measure the level of anxiety based on demographic characteristics. Method A cross-sectional survey was employed to recruit a convenience sample of healthcare providers. A pencil and paper self-administered questionnaires were used to collect data from demographic and generalized anxiety disorder GAD-7 data. However, this study received written informed consent from participants of the study. In addition, the study was approved by the Institutional Review Board at Dr. Sulaiman Al Habib Medical Group (IRB Log No. RC20.06.88-03). Results A total of 650 participants were recruited, results of GAD-7 showed that 43.5%, 28.9% and 27.5% of healthcare providers in Saudi Arabia experienced mild, moderate and severe anxiety, respectively, during the COVID-19 pandemic. Results indicated that age, health specialty, nationality, and sleeping disorders before COVID-19 were associated with anxiety levels. Conclusion The generalized anxiety among healthcare providers in Saudi Arabia was mild. Older healthcare providers were found to have a higher level of anxiety compared to other participating healthcare providers. Several factors may contribute to a higher level of anxiety including age, socioeconomic status, marital status, having chronic conditions, and sleeping disorder before the COVID-19 pandemic. To further understand the level of anxiety among healthcare providers during the COVID-19 pandemic in Saudi Arabia, longitudinal and mixed-method research is needed.

However, to our knowledge, there are limited studies evaluating anxiety among healthcare providers during the COVID-19 pandemic in Saudi Arabia. Therefore, the purpose of this study is to measure the level of anxiety among healthcare providers during the COVID-19 pandemic in Saudi Arabia. In addition, this study aims to measure the level of anxiety based on demographic characteristics. We hypothesized that levels of anxiety among healthcare providers were associated with their demographic characteristics during the COVID-19 pandemic in Saudi Arabia.

Aim of the study
To measure the level of anxiety among healthcare providers during the COVID-19 pandemic in Saudi Arabia. Besides that, this study aimed to measure the level of anxiety based on demographic characteristics.

Study design
A cross-sectional survey study was employed to recruit a convenience sample of healthcare providers during the COVID-19 pandemic in Saudi Arabia. Prior to data collection, and ethical approval to conduct the study was sought from the Institutional Review Board at Dr. Sulaiman Al Habib Medical Group . In addition, participants were ensured that taking part in the study is voluntary and that all gathered information will only be used for the study purposes and will be kept secured and confidential. For this cross-sectional study, no informed consent was deemed necessary and was waived by the IRB. Data were identified for the use of this publication and the study adhered to the ethical guidelines of the Declaration of Helsinki and good clinical practice.
Both Saudi and non-Saudi healthcare providers were invited to participate in the current study. Participants were included if they met the following criteria: 22 years old or above, responsible for providing direct patient care in an inpatient or outpatient healthcare setting, and spent at least six months in the current clinical unit. The sample size was estimated using G Ã Power3 and based on the confidence level of 95%, power of 80%, and medium effect size as determined by the literature review. The minimum required sample size was 356 subjects. A total of 900 questionnaires were distributed among healthcare providers who work in the private and public healthcare sector in Riyadh city in Saudi Arabia between April 1 and 15, 2020. A total of 650 participants returned the completed surveys giving a response rate of 72% (Fig. 1).

Data collection instrument
A pencil and paper self-administered questionnaire were used to collect data from the participants. The questionnaire consisted of socio-demographic characteristics including: age, gender, nationality, working area, profession, type of healthcare facility and years of working experience. The questionnaire also consisted of Generalized Anxiety Disorder GAD-7. The Generalized Anxiety Disorder Scale-7 CAD-7 was developed by Spitzer and colleagues (Spitzer et al., 2006). It is self-rated scales and consists of 7 items which have been used in multiple studies and had shown acceptable reliability and good validity for assessing anxiety disorder in clinical practice and research (Rutter & Brown, 2017). CAD-7 items are rated on a 4-point Likert Scale (0 = not at all, 1 = several days, 2 = over half the days and 3 = nearly every day). The scale items describe the diagnostic features of the generalized anxiety disorder. The scale scores can range from 0 indicating no anxiety symptoms to 21 indicating more sever anxiety symptoms.

Data analysis
In this study standard statistical procedures were applied, data was collated into an excel spread sheet and then imported into the Statistical Package for Social Sciences (SPSS, version 25). The data was validated for accuracy and completeness before conducting the statistical analysis. A detailed descriptive and inferential statistics for all the variables constituting the socio-demographic characteristics questionnaire and Generalized Anxiety Disorder GAD-7. A descriptive analysis for socio-demographic and perceptional variables was completed in order to capture frequencies, means and standard deviations. Frequency distributions for continuous variables were examined via Shapiro-Wilk test and appropriate statistical tests were applied accordingly. An inferential statistics chi-square analysis was employed to study the association between demographic profile and GAD-7. P-values of ≤ 0.05 were accepted as the significance level for all inferential statistical tests that were conducted.

RESULTS
Demographic profile has been analyzed and the findings are presented in Table 1. Several demographic profiles have been chosen, namely type of health care facility, age, gender, nationality, the health specialty, hospital department, experiences (years), sleeping

Level of anxiety
Level of anxiety has been divided into three levels: mild, moderate and sever anxiety.

Effect of demographic factors on level of anxiety
The Chi-square test showed that working experience and age groups were highly associate (p < 0.001). The results showed that older age groups were associate with longer working experience. The final results of ordinal logistic regression were summarized and presented in Tables 5 and 6. In the final model, only three significant factors were remained; gender, nationality, and sleeping disorder. They were found to significantly explain the odds of having general anxiety disorder. Based on summary statistic, final model was significant (X2 = 19.292, df = 3, p < 0.05). As for goodness of fit index, both Pearson (X2 = 10.897, df = 11, p > 0.05) and Deviance (X2 = 11.231, df = 11, p > 0.05) showed that the final model has good fit with the data. Lastly, the assumption of proportional odds (parallel lines test) showed that the assumption was met (X2 = 5.826, df = 3, p > 0.05). Therefore, the model results can be used for interpretation. Gender has

DISCUSSION
During the novel coronavirus pandemic healthcare providers are risking their lives and continue working with tremendous efforts towards their ethical and professional obligations. Not only do healthcare providers be under psychological distress during the epidemic, but also psychological consequences might accrue on the long-term (Al Al Mutair et al., 2020b). This study measured the level of anxiety based on demographic characteristics among healthcare providers during the COVID-19 pandemic in Saudi Arabia. Survey results showed that 43.5%, 28.9% and 27.5% of healthcare providers in Saudi Arabia experienced mild, moderate, and severe anxiety, respectively, during the pandemic. Even though, during MERS-CoV epidemic in Saudi Arabia, research show that hospital staff faced stressful times, and they felt anxious, nervous, and emotionally distressed (Al Mutair & Ambani, 2020). Also, Unlike SARS and Ebola versus there were psychological consequences among hospital staffs (Lin et al., 2007;Lehmann et al., 2015). However, same finding were found in a recent meta-analysis which showed that lower rates of anxiety and depression during COVID-19 than the reported rates among healthcare providers during and after MERS and SARS (Pappa et al., 2020). There were associations between some demographic characteristics and the level of anxiety. Age, health specialty, nationality, and sleeping disorders before COVID-19 were associated with anxiety levels, whereas other demographic characteristics, such as type of healthcare facility, gender, hospital department, years of experience, and mental disorders, did not influence anxiety levels. This study found that respondents between the ages of 31-40 years experienced significantly higher anxiety than respondents above 50 years old. A comparable study conducted in Saudi Arabia in March 2020 measured depression and anxiety among healthcare providers and found that participants between 30 and 39 years old were significantly associated with anxiety (7.40 ± 6.59, p < 0.001) (Al-Omari et al., 2020a). Contrary to previous studies (Al Mutair et al., 2017;Fernandez et al., 2020;De Kock et al., 2021) our study found that healthcare providers other than nurses showed higher anxiety levels (8.05 ± 6.01) compared to nurses (7.26 ± 5.68). A possible reason was the difference in demographic characteristics. The study sample mainly consisted of non-Saudi healthcare providers and many non-Saudi healthcare providers may live away from their loved ones. This may contribute to anxiety and depression level increase among healthcare providers, as non-Saudi mainly live alone and away from their family which may result in high level of anxiety and psychological distress (Al Mutair et al., 2020b). Our study further measured the level of anxiety based on nationality. Findings showed that anxiety levels among Saudi healthcare providers (8.33 ± 5.54) were significantly higher than non-Saudi providers (7.33 ± 5.88). Many factors may contribute to higher anxiety levels among Saudi healthcare providers, regardless of their professional designation. These include socioeconomic status, marital status, having a chronic health condition, fear of contracting the virus, living with an immunocompromised, chronically ill, or elderly person (AlAteeq et al., 2020;Lai et al., 2020;Alenazi et al., 2020). A Saudi-based study measuring the overall emotional wellbeing and its predictors of the Saudi population during the COVID-19 pandemic found that age, gender, marital status, and socioeconomic status are majors' predictors of emotional wellbeing (Al Mutair, Alhajji & Shamsan, 2021). Similar concerns and fears about transmitting the virus to their families were reported among healthcare providers during the severe acute respiratory syndrome (SARS) outbreak in 2003 (Al Mutair, Alhajji & Shamsan, 2021). Cultural norms and differences in living conditions among Saudi and non-Saudi healthcare providers may contribute to higher anxiety levels. In terms of sleeping disorders, this study found that healthcare providers who had sleeping disorders before COVID-19 exhibited higher anxiety (8.98 ± 5.32) compared to those who did not have sleeping disorders (7.04 ± 5.51) (X2 = 12.127, df = 2, p < 0.05). This is important because a systematic review and meta-analysis found that the prevalence of sleep disturbances during COVID-19 was approximately 34.8% among nurses in six of the reviewed studies and 41.6% among physicians in four of the studies reviewed (Maunder et al., 2003). Previous studies found that sleeping disorders among healthcare providers were associated with an 83% event of adverse safety outcomes, such as motor vehicle crashes, exposure to potentially infectious materials, and medical errors (Salari et al., 2020;Weaver et al., 2018). Moreover, screening positive for anxiety or depression increased the risk of adverse safety outcomes by 63% (Al Mutair et al., 2019;Bové et al., 2014). Anxiety among healthcare providers accompanied by sleeping disorders during the pandemic crisis may interfere with physical, mental, and emotional functioning, and result in adverse occupational safety outcomes. Possible limitations of this study include its cross-sectional design, as casual inferences should not be made. The limitations also relate to the GAD-7 scale, as it screens for an anxiety disorder and provides a probable diagnosis that must be confirmed with a physical examination or blood tests to rule out thyroid dysfunction (Al Mutair et al., 2020c;Brandt et al., 2014). Since recruitments were made via questionnaire, healthcare providers who responded may be more self-aware and interested in revealing their concerns. This study represented Saudi and non-Saudi healthcare providers, so there may be cultural norms and differences in living conditions that might have affected our findings. Future research may use a longitudinal study design to understand the pattern of the levels of anxiety among healthcare providers over time during the COVID-19 pandemic. In addition, further research may use a mixed-method design that allows qualitative and quantitative data integration, thus providing a broader, in-depth knowledge of the effect of COVID-19 on anxiety levels among healthcare providers. Future studies may also compare the effects of COVID-19 on anxiety levels among Saudi and non-Saudi healthcare providers.

CONCLUSION
In conclusion, this Saudi-based study identified that healthcare providers' overall generalized anxiety disorder during the COVID-19 pandemic was classified as mild.
Results showed that the 31-40 age group, healthcare providers other than nurses and physicians, Saudi nationality, and healthcare providers with sleeping disorders before COVID-19 were associated with anxiety levels. Several factors might contribute to higher anxiety levels among Saudi healthcare providers: such as marital status, socioeconomic status, having a chronic health condition, fear of contracting the virus, or living with a person at high risk for severe illness. To further understand the level of anxiety among healthcare providers during the COVID-19 pandemic in Saudi Arabia, longitudinal and mixed-method research is needed. When these factors were examined simultaneously, study found that gender, nationality, and sleeping disorder before Covid-19 are the main significant factors for anxiety levels. It was found that being a female, Saudi nationality, and having sleeping disorder before Covid-19 greatly increase the odds of having higher level of anxiety.

Consent for publication
Participation in the study was voluntary and participants were ensured that information gathered for the study would be kept confidential and will be used for the study purposes only.