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Background : Frontline healthcare workers (HCWs) are at risk of developing post-traumatic stress disorder (PTSD) due to the nature of their work and, due to the additional stress and mental fatigue brought on by the COVID-19 pandemic, this risk has increased significantly. A proper understanding of the risk factors for PTSD in this context is crucial to the development of both preventive and corrective measures that will improve the psychological and emotional health of HCWs and reduce their predisposition to PTSD in the short and long term. This study was conducted to determine the prevalence and associated risk factors of PTSD among frontline HCWs in Riyadh, Saudi Arabia, during the COVID-19 pandemic.
Methods: This cross-sectional survey study examined responses from emergency medical services personnel (paramedics, nurses, and physicians) in eleven large public hospitals in Riyadh, Saudi Arabia, between June 01 and July 01, 2020. The total number of respondents was 613. The PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (PCL-5), a self-administered tool, was used to diagnose PTSD. Additionally, demographic factors, such as age, gender, race, marital status, occupation, and years of experience, were identified, and the effects of these factors were assessed using statistical analysis.
Results: The results revealed a prevalence of PTSD of 33.4% among participants. The highest prevalence was found among paramedics and nurses, while physicians had the lowest prevalence. The study also found statistically significant differences in PTSD scores based on marital status, job title, and years of experience. Half of the participants were aware of the availability of psychological/emotional support and perceived the process for obtaining that support to be clear and accessible.
Conclusion: Frontline healthcare workers are at increased risk of developing PTSD, with the degree of risk significantly associated with marital status, job title, years of experience, and the accessibility of psychological/emotional support. Healthcare organisations within Saudi Arabia and elsewhere should use this information to strengthen their psychological and emotional support systems and reduce the risk of PTSD in their employees.
Keywords: PTSD, COVID-19, health care workers, Saudi Arabia
PTSD can result from directly experiencing a traumatic event, from witnessing the event, from learning that a close family member or friend has experienced such an event, or from experiencing repeated or extreme exposure to aversive events, as in the case of first responders collecting human remains [1].
On March 11, 2020, the World Health Orga- nization (WHO) declared COVID-19, the disease caused by the novel Coronavirus SARS-CoV2, a pandemic after a widespread outbreak of COVID-19 cases worldwide [2]. The severe impact of COVID- 19 resulted in more than 131,000,000 cases and approximately 2,854,276 deaths worldwide, as of April 6, 2021 [3]. In Saudi Arabia, COVID-19 surpassed 394,169 cases and 6,711 deaths as of the same date [4].
Previous infectious epidemics, such as severe acute respiratory syndrome (SARS), were found to elevate stress levels and cause significant psycholog- ical disturbances among HCWs in Hong Kong and Toronto [5,6]. Furthermore fear caused by a novel avian-origin influenza H7N9 was a cause of PTSD among HCWs [7], and an Ebola outbreak resulted in social isolation, emotional and physical exhaus- tion, depression, extreme stress, and stigmatisation among HCWs [8,9]. The extreme environment of the Ebola outbreak may also have caused burnout, which is linked to PTSD [10].
COVID-19 has had a substantial impact on both preexisting and new-onset behavioral health prob- lems, including a spike in the number of anxiety and depression cases worldwide [11,12]. Moreover, individuals with preexisting mental health disorders are at higher risk of becoming severely ill or suf- fering long-term complications due to COVID-19 [13,14]. Under these circumstances, WHO, along with many other health organisations, offered imme- diate support and guidance on mental health issues, particularly on how to overcome the disruption of mental health services during the COVID-19 crisis [12].
HCWs are not immune to mental health is- sues, particularly during disease outbreaks [11, 12]. Throughout the COVID-19 pandemic, they have provided patient care under stressful and uncertain circumstances, and experienced the deaths and se-
vere illness of patients and colleagues. The trau- matic nature of these events has been exacerbated by the stress associated with shortages of staff and medical equipment, recurrent risk of personal exposure, and the possibility of themselves or family members becoming infected [15]. Taken together, these factors increase the risk of HCWs developing PTSD [11, 16]. A range of psychological issues have been reported among HCWs during the current COVID-19 pandemic, including fear, anger, stress, stigma, anxiety, and isolation, which may also have negatively affected the quality of care provided to COVID-19 patients [11,17].
Studies have demonstrated a significant psycho- logical impact of the COVID-19 pandemic on HCWs in Saudi Arabia. A study conducted among HCWs in the Ministry of Health during the pan- demic found that more than half met the criteria for depressive disorder and generalised anxiety disor- ders (55.2% and 51.4%, respectively). Females, the 30-39 age group, and nurses had significantly higher scores for anxiety and depression [18]. Another study conducted between April and May 2020 found elevated scores on anxiety and depression measures among 35.6% and 27.9% of HCWs, respectively. The highest elevations were found among female HCWs and those with inadequate training [19].
In general, HCWs staffing the Emergency Depart- ment (ED) are more likely to experience significant stress compared with those working in other de- partments [20]. A cross-sectional study prior to the COVID-19 pandemic found that 26% of emergency medical services (EMS) personnel at one of the largest hospitals in Saudi Arabia screened positive for PTSD [21].
The PTSD risk among HCWs working in the ED during infectious outbreaks can be attributed to their role in being the first to confront an emerging public health crisis, when the cause, mode of transmission, and treatment are still uncertain. They are thus more prone to adverse psychological outcomes, such as PTSD, anxiety, and depression, when confronting emerging infectious diseases [22-24].
This study examined the prevalence of PTSD among HCWs in the ED during the COVID-19 pandemic in Saudi Arabia.
II. METHODS STUDY DESIGN
We conducted a cross-sectional study in eleven large public hospitals in Riyadh, Saudi Arabia, between June 01 and July 01, 2020. An online survey was used, targeting physicians, nurses, and paramedics working in adult emergency depart- ments.
A. Ethics approval and consent to participate: All participants provided written informed consent, and ethical approval was granted by the Institutional Review Board (IRB) at King Fahad Medical City, Riyadh, Saudi Arabia (no. 00010471).
B. Participants
A survey link was sent, via e-mail and WhatsApp (a multiplatform messaging application widely used in Saudi Arabia), to all emergency department chair- persons, head nurses, and EMS chairpersons at the eleven hospitals, asking them to participate and also to distribute the survey to their team members. All participation in the study was voluntary.
C. Measurement
The PTSD Checklist for the Diagnostic and Statis- tical Manual of Mental Disorders (DSM-5) (PCL-5), a 20-item instrument that measures the occurrence and severity of PTSD symptoms, was used in this study [25]. It is a self-screening tool developed by the U.S. Department of Veterans Affairs National Center for PTSD to assist in diagnosing PTSD [26]. The self-report rating scale is 0-4 for each symptom (0= "Not at all" and 4= "Extremely") with a total possible score ranging from 0 to 80. A total score of 33 or more suggested a provisional PTSD diagnosis [26]. Questions about demographic char- acteristics, including gender, age, nationality, posi- tion, years of experience, and marital status, were included, as were questions about access to mental health services. Participants were asked whether their hospitals provided resources for psychological and emotional support, and whether there was a clear process for accessing that support.
D. Sample size
There are approximately 2,980 HCWs employed in the emergency departments of governmental hos- pitals in Riyadh, distributed as follows: 722 physi- cians, 1881 nurses, and 377 paramedics. Of these, 613 participants responded to our survey.
E. Data Analysis
All statistical analyses were conducted using SPSS version 25. We used the Mann-Whitney test, the Kruskal Wallis test, the linear-by-linear associa- tion test, and the chi-square test to analyse the data. Categorical variables are presented as percentage and frequency.
A. Demographic Characteristics
The demographic characteristics of the 613 re- spondents are illustrated in Table 1. The distribution of physicians, nurses and paramedics in our sample was 39% physicians (n=239), 48% nurses (n=294), and 13.1% paramedics (n=80).
B. Posttraumatic stress disorder among partici- pants
33.4% of the participants scored 33 or higher (n=205) on DSM-5 (PCL-5), suggesting a pro- visional PTSD diagnosis. Subgroup analysis was conducted to investigate the effects of gender, age, marital status, race, and years of experience, in ad- dition to the possible influence of being a physician, a nurse, or a paramedic. Statistical analyses showed significant differences in PTSD scores according to marital status, job title, and years of experience. Married and divorced HCWs reported a higher score compared with other groups (Mdn= 1.2 and 1.25, respectively), while paramedics and nurses had higher scores (Mdn= 1.25 and 1.2, respectively) than physicians (Mdn=1.05). A simple linear regression was conducted to predict PTSD severity based on years of experience, and a significant regression was found (F=1,611)= 4.547, P<0.05 with R 2 = 0.007. Other factors, such as age, gender, and nationality, revealed no significant differences in PTSD scores.
C. Hospitals and PTSD
The percentage and number of PTSD cases among participants at different hospitals is shown in Table 2. The nonparametric Kruskal Wallis test indicated significant differences in the prevalence of PTSD among HCWs in different hospitals (p< 0.001), X 2 (10)= 37.625. HCWs in the Security Force Hos- pital were found to have the highest prevalence of PTSD (Mdn= 2.05), followed by King Faisal Spe- cialist Hospital (Mdn= 1.95). The lowest prevalence was found in King Saud Medical City and King Abdulaziz Medical City (Mdn= 0.65).
D. Accessibility of psychological/emotional support and clarity of the process
We investigated the accessibility of psychologi- cal/emotional support in the studied hospitals, and whether the process for accessing such support was clear to the healthcare providers relative to several demographic variables (Table 3). We found that 48.6% of respondents perceived the process to be clear and the support accessible (n=298). We also found significant differences in perceptions of the clarity and accessibility between HCWs from different hospitals. Respondents from King Saud University Medical City, King Faisal Specialist Hos- pital & Research Centre, King Fahad Medical City, and King Abdulaziz Medical City were more likely to report the process as clear and accessible than those from the other hospitals; χ 2= 75.42 (10), p < 0.05. A chi-square test of independence suggested that men were less likely to report the process of ob- taining psychological/emotional support as being clear and accessible compared with women; χ 2(1)= 6.233, p < 0.05. Moreover, nurses were more likely to report the process as being clear and accessible than physi- cians and paramedics; χ 2(1)=17.69, p < 0.05. The respondents' nationalities also influenced their per- ceptions: Saudis, Arabs, and Africans were more likely to deem the process unclear compared with Asians, Indians, Europeans, and Oceanians; Fisher's exact test=28.26, p < 0.05.
Age was not found to influence the percep- tion of clarity or accessibility of mental support; χ 2(4)=7.422, p > 0.05. Marital status also had
no influence; Fisher’s exact test=6.19, p > 0.05. Likewise, the number of years of experience did not differ between those who perceived the process to be accessible and clear and those who did not; linear-by-linear association test=0.076, p > 0.05.
The prevalence of PTSD among HCWs in our analysis is 33.4%. These findings are comparable to those reported in previous studies that describe sig- nificant mental health problems among HCWs dur- ing pandemics [11, 27-34]. The study also revealed that married and divorced HCWs, paramedics and nurses, and HCWs with fewer years of experience were more likely to experience PTSD. Such find- ings are generally consistent with previous studies conducted during the SARS outbreak [29-31, 35].
Furthermore, we found that almost half of the participants perceived the process of obtaining psy- chological/emotional support to be clear, and the support accessible – especially women, nurses, and participants who are Asian, Indian, European, or Oceanian. There is some variation in the level of knowledge about available mental health support among HCWs in different institutions. One explana- tion for this finding is that HCWs who reported the availability and process of psychological/emotional support to be accessible and clear are working for large hospitals that are well equipped to offer such support. Internal communication with physicians, nurses, and other staff may also play a crucial role in how HCWs perceive the availability and usefulness of mental health care at their hospitals. As discussed elsewhere, provision of employee support services by employers can have a positive impact on em- ployees' responses to a variety of disasters [36]. Interestingly, unlike previous studies that found an association between gender, age, and risk for PTSD [29,33,37], we did not find such a relationship.
It is noteworthy that PTSD mean scores were noted to be low among participants (M=1.27, SD= 0.88). This can be explained, again, by the fact that nearly half of the participants perceived the psychological/emotional support to be accessible. Another factor is the timely control interventions implemented by the Saudi government to prevent the spread of COVID-19 infection.
The study protocol was approved by the Institu- tional Review Board (IRB) of King Fahad Medical City, Riyadh, Saudi Arabia (no. 00010471). All
| Characteristic | Percentage (%) | N |
|---|---|---|
| Gender | ||
| Male | 43.4 | 266 |
| Female | 56.6 | 347 |
| Occupation | ||
| Physicians | 39 | 239 |
| Nurses | 48 | 294 |
| Paramedics | 13.1 | 80 |
| Age | ||
| 20-30 years old | 39.6 | 243 |
| 31-40 years old | 43.4 | 266 |
| 41-50 years old | 12.1 | 74 |
| Older than 50 years | 4.9 | 30 |
| Marital status | ||
| Married | 58.6 | 359 |
| Single | 38.8 | 238 |
| Divorced | 2.3 | 14 |
| Widowed | 0.3 | 2 |
| Nationality | ||
| Saudi Arabian | 44.5 | 273 |
| Arab but non-Saudi | 8.6 | 53 |
| Asian | 39.8 | 244 |
| Indian | 4.4 | 27 |
| African | 1.8 | 11 |
| European | 0 7 | 4 |
| Oceanian | 0.2 | 1 |
| Years of experience | ||
| Less than one year | 6.5 | 40 |
| 1-5 years | 30 | 184 |
| 5-10 years | 29.5 | 181 |
| More than 10 years | 33.9 | 208 |
| Hospitals | % of participants (n) | % of PTSD (n) |
|---|---|---|
| SFH | 3.26 (20) | 5.8 (12) |
| RMH | 4.24 (26) | 5.36 (11) |
| PMAH | 2.44 (15) | 1.95 (4) |
| KSUMC | 7.34 (45) | 5.36(11) |
| KSMC | 33.6 (206) | 37.56 (77) |
| KFSHRC | 3.59 (22) | 6.83 (14) |
| KFMC | 19.9 (122) | 15.6 (32) |
| KAAUH | 9.95 (61) | 4.87 (10) |
| KAMC | 9.62 (59) | 6.3 (13) |
| Al-Iman General Hospital | 5.54 (34) | 9.75 (20) |
| King Salman Hospital | 0.48 (3) | 0.49 (1) |
| Total | 100 (613) | 100 (205) |
| SFH: Security Forces Hospital; RMH: Riyadh Military | Hospital; PMAH: Prince | Mohammed bin Abdulaziz Hospital; |
| KSUMC: King Saud University Medical City; KSMC: | King Saud Medical City; | KFSHRC: King Faisal Specialist |
| Hospital & Research Centre; KFMC: King Fahad | Medical City; KAAUH: King | Abdullah bin Abdulaziz University |
| Hospital; KAMC: King Abdulaziz Medical City |
| and resources during such times, while continually | |
|---|---|
| Hospital Clear No | examining and assessing the clarity and accessibility |
| of such support. The present information can help to | |
| and accessible % (n) | evaluate HCWs' mental health needs, and direct and |
| strengthen psychological interventions during future | |
| support* % (n) | health outbreaks. |
| SFH 1.67 (5) 4.76 (15) | |
| VI. LIMITATIONS | |
| RMH 4.02 (12) 4.44 (14) | |
| This is the only study investigating the prevalence | |
| PMAH 1 (3) 3.8 (12) | of PTSD among HCWs in Saudi Arabia during the |
| COVID-19 pandemic, and is limited to those | |
| KSUMC 8.72 (26) 6.03 (19) | working in the emergency setting. As such, we note |
| KSMC 36.24 (108) 31.1 (98) | that one of this study's limitations is that the |
| findings from HCWs in the emergency setting might | |
| KFSHRC 4.02 (12) 3.17 (10) | not be generalisable to those working in other |
| departments. The lack of information about mental | |
| KFMC 22.14 (66) 17.7 (56) | health services provided to HCWs in each hospital |
| during the COVID-19 pandemic is another limita- | |
| KAAUH 3.69 (11) 15.87 (50) | tion. Further studies are warranted to investigate the |
| KAMC 16.1 (48) 3.49 (11) | availability of mental health resources and services |
| during health crises, as well as the perception of the | |
| Al-Iman General 2.01 (6) 8.88 (28) | accessibility of such services among HCWs during |
| such times. | |
| Hospital | |
| King Salman 0.33 (1) 0.63 (2) | VII. LIST OF ABBREVIATIONS |
| Hospital | |
| DSM-5: Diagnostic and Statistical Manual of | |
| Mental Disorders | |
| Total 48.6 (298) 51.4 (315) | ED: Emergency Department |
| SFH: Security Forces Hospital; RMH: Riyadh Military | EMS: Emergency medical services |
| Hospital; PMAH: Prince Mohammed bin Abdulaziz | HCWs: Healthcare workers |
| Hospital; KSUMC: King Saud University Medical City; | IRB: Institutional Review Board |
| KSMC: King Saud Medical City; KFSHRC: King Faisal | PCL-5: The PTSD Checklist for the Diagnostic |
| Specialist Hospital & Research Centre; KFMC: King | and Statistical Manual of Mental Disorders |
| Fahad Abdulaziz Medical University City; Hospital; KAAUH: King KAMC: Abdullah King Abdulaziz bin | PTSD: Posttraumatic stress disorder SARS: |
| Medical City | Severe acute respiratory syndrome WHO: |
| * Is the process clear and support accessible? | World Health Organization |
| V. CONCLUSION | VIII. ETHICS APPROVAL AND CONSENT |
| TO PARTICIPATE | |
| This study examined the prevalence of PTSD | |
| among HCWs working in the ED in Saudi Arabia | The study protocol was approved by the Institu- |
| i l R i B d (IRB) f Ki F h d M di l | |
| participants gave written informed consent to | [7] Ho SM, Kwong-Lo RS, Mak CW, Wong JS. |
| participate in the study. | Fear of severe acute respiratory syndrome (SARS) |
| among health care workers. Journal of consulting | |
| IX. AVAILABILITY OF DATA AND MATERIALS | and clinical psychology. 2005;73(2):344. |
| Data is available, upon request, from the corre- | [8] Gershon R, Dernehl LA, Nwankwo E, Zhi Q, |
| sponding author. | Qureshi K. Experiences and psychosocial impact of |
| X. CONFLICT OF INTERESTS | West Africa Ebola deployment on US health care |
| volunteers. PLoS currents. 2016;8. | |
| The authors have no potential conflict of interest | |
| to declare. | [9] Lehmann M, Bruenahl CA, Addo MM, Becker |
| S, Schmiedel S, Lohse AW, Schramm C, Löwe B. | |
| XI. FUNDING | Acute Ebola virus disease patient treatment and |
| No funding was obtained for this project. | health- professionals: related A quality controlled of life study. in health Journal care o f |
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