Mental Health Status of Healthcare Workers
During the Coronavirus Disease 2019 Pandemic:
A Survey of Hospitals in Shiraz, Iran
Arash Mani1, Mani Kharazi2, Mohammad Reza Yousefi2, Ali Akbary3, Morteza Banakar2, Hossein Molavi
Vardanjani2, Leila Zarei2, Mohammad Khabaz Shirazi2, Seyed-Taghi Heydari2, Kamran Bagheri-Lankarani2
1 Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
2 Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
3 Department of Psychiatry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Correspondence to:
Seyed Taghi Heydari, Health Policy Research Center,
Institute of Health, Shiraz University of Medical Sci-
ences, Shiraz, Iran.
Telephone Number: 989173034420
Email Address: heydari.st@gmail.com
Received 2022-06-25
Revised 2022-08-10
Accepted 2022-10-12
Abstract
Background: Healthcare workers (HCWs) directly or indirectly involved in the coronavirus
disease 2019 (COVID-19) treatment process may experience severe mental consequences of
the pandemic. Hence, this study aimed to evaluate the mental health status of HCWs in hospitals
aliated with Shiraz University of Medical Sciences, Iran. Materials and Methods: This
cross-sectional study was performed on 503 HCWs from ve hospitals in Shiraz, including
one COVID-19 front-line hospital, two COVID-19 second-line hospitals, and two without
COVID-19 wards. Then, to assess the levels of anxiety, depression, insomnia, and post-
traumatic stress disorder (PTSD) among HCWs, the Persian versions of the Hospital Anxiety
and Depression Scale (HADS), Insomnia Severity Index (ISI), and Global Psychotrauma
Screen (GPS) questionnaires were placed, respectively. Results: The mean age of participants
was 33.94±8.26 years, and 252 (50.1%) were females. Anxiety, depression, insomnia,
and moderate to high levels of PTSD were observed in 40.4%, 37.8%, 24.5%, and 71% of
participants, respectively. A history of mental disorders was associated with all four outcomes
(P<0.05). Females gender and living with elderly and/or children were correlated with anxiety
and PTSD (P<0.05). Working at COVID-19 front- and second-line hospitals were similarly
linked to higher insomnia and PTSD levels (P<0.05). Also, working in COVID-19 wards or
non-clinical settings was associated with anxiety and depression (P<0.05). Conclusion: Most
of the HCWs in this study may experience mental diculties. Some factors may increase their
risk of experiencing these diculties. Hence, in the crisis era, mental health monitoring and
identication of groups with predisposing factors are required to provide appropriate care as
quickly as feasible.[GMJ.2023;12:e2512] DOI:10.31661/gmj.v12i.2512
Keywords: COVID-19; Health Care Workers; Mental Health; Anxiety; Depression; Insomnia;
Post-Traumatic Stress Disorder
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Copyright© 2023, Galen Medical Journal.
This is an open-access article distributed
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Attribution 4.0 International License
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Email:info@gmj.ir
Mani A, et al. Mental Health Status of HCWs During the COVID-19
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Mental Health Status of HCWs During the COVID-19 Mani A, et al.
Introduction
In December 2019, a highly infectious acute
respiratory syndrome caused by a novel
coronavirus (SARS-CoV-2) was identied in
Wuhan, China. On March 11, 2020, the World
Health Organization declared coronavirus dis-
ease 2019 (COVID-19) a pandemic [1].
Nowadays, the pandemic is undoubtedly one
of the most stressful events, which poses a
signicant challenge to the social, economic,
and, above all, the psychological resources of
the populations [2-4].
Due to their direct contact with the disease,
healthcare workers (HCWs) are concerned
about disease transmission to their fami-
lies. Lack of personal protective equipment
in healthcare departments and long work-
ing hours make them especially vulnera-
ble to emotional distress during the current
COVID-19 pandemic [5].
Unfortunately, there have been reports of sui-
cide among HCWs due to the psychological
pressures of the pandemic [6]. The mental
well-being of HCWs can signicantly impact
their ability to provide standard services for
patients and the eciency of the healthcare
system, especially in situations such as the
current pandemic [7].
In a study in Italy, among HCWs who were di-
rectly or indirectly engaged in providing care
to COVID-19 patients, depression was report-
ed in 24.73%, anxiety in 19.8%, insomnia
in 8.27%, and post-traumatic stress disorder
(PTSD) in 49.38% [8].
Also, younger age, female gender, working
in front-line hospitals, and having a colleague
deceased or hospitalized due to COVID-19
were associated with more mental health
symptoms [8].
However, Lai et al. [9] showed that the prev-
alence of depression, anxiety, insomnia, and
PTSD was observed in 50.4%, 44.6%, 34%,
and 71.5% of HCWs, respectively. Also, fe-
male gender, and working in front-line hos-
pitals were associated with increased mental
health disorders [9].
In addition, a systematic review by Muller et
al. showed that the impact of the COVID-19
pandemic on the mental health of HCWs was
not limited to those working in the front-line
hospital, and HCWs in various elds, posi-
tions, and exposure risks were presented with
mental disorders [10].
Another study in Italy showed that prolonged
presence in front-line COVID-19 hospitals
was associated with increased mental health
symptoms [11]. Also, symptoms of depres-
sion, anxiety, and insomnia diminished
among HCWs from the pandemic onset over
time [11].
Iran is one of the countries most aected by
the COVID-19 pandemic, and its rst wave
was reported in late March 2020 [12]. Since
then, ve other waves have been ocially
reported, and the sixth and nal wave–during
which this study was performed–was caused
by the relatively more contagious variant of
Omicron (B.1.1.529) [13].
From the beginning of the pandemic in Iran,
the Iranian health policymakers decided to
dedicate some hospitals permanently and
exclusively to patients, which caused the
HCWs of these hospitals constantly exposed
to COVID-19 (the group with consistent ex-
posure).
Despite this decision, during the peaks of the
disease, authorities had to transform some
wards of other hospitals into COVID-19 units
to increase the hospitalization capacity of pa-
tients.
Naturally, as a wave subsided, these wards re-
turned to their former state.
As a result, HCWs of such units were only ex-
posed to COVID-19 patients at certain times
(the group with episodic exposure).
Although some other studies in Iran have tried
to evaluate the impact of the COVID-19 pan-
demic on the mental health of the HCWs, to
the best of our knowledge, no other study has
tried to evaluate the mental health status of
HCWs in Shiraz hospitals.
Furthermore, as far as we are aware, no oth-
er study in Iran has compared front- and
second-line hospitals with and without
COVID-19 wards.
In addition, few studies focused on assessing
the mental health of the hospital sta who
work in non-clinical sectors (such as admin-
istrative, security, and maintenance sta).
Therefore, this study aimed to evaluate the
impact of being directly or indirectly engaged
in treating patients on the mental health status
of HCWs in Shiraz hospitals.
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3
Materials and Methods
Study Design
In this cross-sectional study, ve hospitals in
Shiraz city, including Ali-Asghar, Namazi,
Faghihi, Hafez, and Dastgheib hospitals, all
aliated with Shiraz University of Medical
Sciences, were selected.
Ali-Asghar hospital is the front-line
COVID-19 hospital in Shiraz, and its sta has
been continuously exposed to COVID-19 pa-
tients during the past two years.
Due to the insucient capacity of Ali-Asghar
hospital at the peak of COVID-19 waves, it
was decided to temporarily allocate some
wards of Namazi and Faghihi hospitals (as
the second-line COVID-19 hospitals) for
COVID-19 patients.
Consequently, during some episodes over
the past two years, some hospital sta were
directly exposed to COVID-19 patients.
Also, Dastgheib and Hafez hospitals have no
COVID-19 wards.
Participants
Based on the Rayani et al. study [14], 40%
of healthcare experienced moderate and high
levels of anxiety; the sample size was calcu-
lated as 276 (α=0.05, β=0.8, and d=0.06). For
more accuracy, the sample size was consid-
ered as 503.
Random stratied sampling was used to re-
cruit 142 participants from Namazi, 140 from
Faghihi, 120 from Ali-Asghar, 51 from Hafez,
and 50 from Dastgheib hospitals, from Febru-
ary 1 to February 20, 2022, in the middle of
the sixth wave of COVID-19 in Iran caused
by the Omicron variant.
Also, HCWs younger than 18 or older than
65 years were excluded from the study. Par-
ticipants answered a mental health assessment
questionnaire in their workplace hospital with
a trained interviewer.
Data Collection
The baseline characteristics of participants
included gender, age, educational level, oc-
cupation, marital status, living with children
(under ten years old), living with the elderly
(over 60 years old), experiencing the death of
relatives or colleagues from COVID-19, his-
tory of psychiatric disorders, workplace hos-
pital, and workplace ward of HCWs.
Then, to assess the levels of anxiety, depres-
sion, insomnia, and PTSD among HCWs,
the Hospital Anxiety and Depression Scale
(HADS) [15], Insomnia Severity Index (ISI)
[16], and Global Psychotrauma Screen (GPS)
questionnaires were applied, respectively.
Kaviani et al. [17] proved the validity and re-
liability of the 14-item HADS questionnaire
and determined specic cut-o points, con-
sidering the cultural dierences of the Iranian
population.
Also, the reliability and validity of the Persian
ISI questionnaire were proved by Yazdi et al.
[18].
Also, the reliability and validity of the Per-
sian version of the 22-item GPS questionnaire
were proved by Haghi et al. [19].
The GPS questionnaire scores were interpret-
ed through a specic statistical method (latent
class analysis) to categorize participants with
the same pattern of responses to three groups
with low, moderate, and high levels of PTSD.
Ethical Considerations
This study was approved by the Research Eth-
ics Committee of Shiraz University of Med-
ical Sciences (approval code: IR.sums.med.
rec.1400.572).
At the beginning of the interview, after ex-
plaining the research objectives, written in-
formed consent was obtained from all par-
ticipants. The questionnaires were completed
anonymously, preserving all the principles of
condentiality.
Statistical Analysis
A data-driven approach was used to catego-
rize the level of PTSD assessed by the GPS
questionnaire.
A latent class analysis (LCA) was employed
to categorize participants with the same pat-
tern of responses to questionnaires. The LCA
assigns an individual to a class by examining
the pattern of categorical data using probabi-
listic methods.
Briey, in the rst step, several non-inclusive
classes with homogeneous participants were
dened. Then, LCA was done with the num-
ber of classes from 2 to 10.
The lower Bayesian information criterion
(BIC), Akaike’s information criterion (AIC),
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Mani A, et al. Mental Health Status of HCWs During the COVID-19 Mental Health Status of HCWs During the COVID-19 Mani A, et al.
and clinical interpretability determined the
number of extracted GPS classes. Therefore,
three classes for GPS with the lowest level of
BIC to ease the interpretation were selected.
Latent GOLD (version 5.0.0) was used to per-
form LCA.
Also, IBM SPSS Statistics for Windows,
version 21 (IBM Corp., Armonk, NY., USA)
was used to perform all statistical analyses.
Quantitative and qualitative variables were
described by mean±standard deviation (SD)
and frequency (percent), respectively.
Univariate and multiple logistic regressions
were performed to compute the odds ra-
tio (OR) and the corresponding 95% con-
dence interval (CI) for demographic features,
COVID-19 infection death, psychiatric disor-
der, hospital features with anxiety, depression,
and insomnia. A P-value less than 0.05 was
considered as statistically signicant.
Results
Of the 503 participants, 252 (50.1%) were
female, and the mean age was 33.94±8.26
years (ranged 20-60 years). The frequency of
anxiety, depression, and insomnia was 40.4%,
37.78%, and 24.5 %, respectively.
Additionally, based on the LCA method with
three classes, 146 (29%), 249 (49.5%), and
108 (21.5%) participants had low, moderate,
and high levels of PTSD, respectively. The
class with a low level of PTSD had a mean
score of 2.52±1.4 and a median of 2 (ranged
zero to 6). The class with a moderate level of
PTSD had a mean score of 8.11±1.95 and a
median of 8 (range 4 to 11).
The mean score of the class with a high level
of PTSD was 14.10±2.15, with a median of 14
(range 11 to 21). The reliability of HADS, ISI,
and GPS questionnaires were 0.886, 0.919,
and 0.826, respectively.
Mental Health Status
1. Anxiety
Based on univariate logistic regression, gender
(female: OR=1.72), occupational (non-clini-
cal sta vs. physician: OR=1.82), living with
the elderly (OR=1.57), death from COVID-19
in the relatives (OR=2.81), positive history of
psychiatric disorders (OR=2.66), workplace
hospital (Ali-Asghar vs. Hafez: OR=2.73),
and workplace ward (working in COVID-19
wards vs. non-COVID-19 wards: OR=4.07;
working only in non-clinical sectors vs. work-
ing in non-COVID-19 wards: OR=3.04) were
signicantly associated with anxiety (Ta-
ble-1).
However, as mentioned in Table-1, in multiple
logistic regression, gender (female: OR=2.49),
living with the elderly (OR=1.88), positive
history of psychiatric disorders (OR=3.6), and
workplace ward were signicantly associated
with anxiety.
2. Depression
Based on univariate logistic regression, age
(OR=2.12), occupation (non-clinical sta
vs. physician: OR=1.85), living with chil-
dren) (OR=1.53), positive history of psychi-
atric disorders (OR=1.73), workplace hospital
(Ali-Asghar vs. Hafez: OR=3.14), and work-
place ward were signicantly associated with
depression (Table-2).
Also, in multiple logistic regression, level of
education, positive history of psychiatric dis-
orders, and workplace ward were signicantly
associated with depression (Table-2).
3. Insomnia
As shown in Table-3, univariate logistic re-
gression revealed that death from COVID-19
in the relatives, positive history of psychiatric
disorders, workplace hospital, and workplace
ward) were signicantly associated with in-
somnia.In addition, multiple logistic regres-
sion indicated that level of education, positive
history of psychiatric disorders, and work-
place hospital were signicantly associated
with insomnia (Table-3).
4. PTSD
Based on multinomial logistic regression, liv-
ing with children (OR=2.27), living with the
elderly (OR=2.09), positive history of psy-
chiatric disorders (OR=3.13), and workplace
ward were signicantly associated with a
moderate level of PTSD (Table-4).
However, the high level of PTSD was sig-
nicantly associated with gender (female:
OR=3.8), living with children (OR=2.92),
working night shifts (OR=5.45), positive his-
tory of psychiatric disorders (OR=5.45), and
workplace hospital (Table-4).
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Mental Health Status of HCWs During the COVID-19 Mani A, et al.
Table 1. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with Anxiety among HCWs
Variables
Anxiety
Unadjusted OR
(95% CI)
P
value
Adjusted OR
(95% CI)
P
value
No or mild
n(%)
Moderate to High
n(%)
Gender
Female 134 (53.17) 118 (46.83) 1.72 (1.2-2.47) 0.003 2.49 (1.45-4.28) 0.001
Male 166 (66.14) 85 (33.86) 1-1-
Age (year)
Less than 30 125 (60.1) 83 (39.9) 1-1-
30-50 116 (60.42) 76 (39.58) 0.99 (0.66-1.47) 0.948 0.88 (0.41-1.89) 0.739
More than 50 59 (57.28) 44 (42.72) 1.12 (0.7-1.81) 0.635 1.14 (0.49-2.66) 0.756
Education level
High school diploma
and lower 32 (59.26) 22 (40.74) 1-1-
Academic education 268 (59.69) 181 (40.31) 1.02 (0.57-1.81) 0.952 0.5 (0.22-1.11) 0.089
Occupation
Physician 47 (70.15) 20 (29.85) 1-1-
Nurse 112 (60.22) 74 (39.78) 1.55 (0.85-2.83) 0.151 0.79 (0.33-1.91) 0.6
Non-clinical sta 141 (56.4) 109 (43.6) 1.82 (1.02-3.24) 0.044 0.65 (0.2-2.06) 0.458
Marital status
Single 116 (57.14) 87 (42.86) 1-1-
Married 184 (61.33) 116 (38.67) 1.19 (0.83-1.71) 0.347 1.34 (0.73-2.49) 0.348
Living with children
No 183 (59.61) 124 (40.39) 11-
Yes 117 (59.69) 79 (40.31) 1 (0.7-1.45) 0.985 0.93 (0.52-1.66) 0.809
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continue of table 1. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with Anxiety among
HCWs
Death from
COVID-19 in the
relatives
No 294 (60.49) 192 (39.51) 1 - 1 -
Yes 6 (35.29) 11 (64.71) 2.81 (1.02-7.72) 0.045 1.89 (0.47-7.65) 0.371
Death from
COVID-19 in the
colleagues
No 266 (60.32) 175 (39.68) 1 - 1 -
Yes 34 (54.84) 28 (45.16) 1.25 (0.73-2.14) 0.411 1.05 (0.52-2.11) 0.898
Night shift No 19 (54.29) 16 (45.71) 1 - 1 -
Yes 213 (61.38) 134 (38.62) 0.75 (0.37-1.5) 0.414 0.89 (0.38-2.06) 0.783
History of
psychiatric disorders
No 236 (66.67) 118 (33.33) 1 - 1 -
Yes 64 (42.95) 85 (57.05) 2.66 (1.79-3.93) <0.001 3.6 (2.1-6.18) <0.001
Workplace Hospital
Namazi 88 (61.97) 54 (38.03) 1.62 (0.8-3.27) 0.177 1.7 (0.66-4.39) 0.275
Faghihi 83 (59.29) 57 (40.71) 1.82 (0.9-3.66) 0.096 1.26 (0.48-3.33) 0.639
Ali-Asghar 59 (49.17) 61 (50.83) 2.73 (1.34-5.57) 0.006 1.08 (0.36-3.21) 0.895
Dastgheib 33 (66) 17 (34) 1.36 (0.58-3.18) 0.476 1.55 (0.53-4.52) 0.42
Hafez 37 (72.55) 14 (27.45) 1 - 1 -
Workplace ward
Constantly working
in COVID-19 wards 57 (48.72) 60 (51.28) 4.07 (2.08-7.98) <0.001 6.14 (2.23-16.89) <0.001
Episodically
working in
COVID-19 wards
64 (65.98) 33 (34.02) 1.99 (0.98-4.04) 0.055 2.31 (1-5.34) 0.049
Working in non-
clinical sectors 121 (56.02) 95 (43.98) 3.04 (1.62-5.69) 0.001 4.96 (1.69-14.58) 0.004
Working in non-
COVID-19 wards 58 (79.45) 15 (20.55) 1 - 1 -
CI: Condence interval; OR: Odds ratio
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Table 2. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with Depression among HCWs.
Variables
No or mild
n(%)
Depression Unadjusted OR
(95% CI) P-value Adjusted OR
(95% CI) P-value
Moderate to High
n(%)
Gender Female 163 (64.68) 89 (35.32) 0.81 (0.57-1.16) 0.26 1.15 (0.67-1.96) 0.617
Male 150 (59.76) 101 (40.24) 1 - 1 -
Age, y
Less than 30 144 (69.23) 64 (30.77) 1 - 1 -
30-50 116 (60.42) 76 (39.58) 1.47 (0.98-2.23) 0.07 0.82 (0.39-1.72) 0.594
More than 50 53 (51.46) 50 (48.54) 2.12 (1.31-3.45) <0.001 0.75 (0.32-1.71) 0.489
Education level
High school
diploma and
lower
28 (51.85) 26 (48.15) 1 - 1 -
Academic
education 285 (63.47) 164 (36.53) 0.62 (0.35-1.09) 0.1 0.45 (0.2-0.98) 0.046
Occupation
Physician 47 (70.15) 20 (29.85) 1 - 1 -
Nurse 126 (67.74) 60 (32.26) 1.12 (0.61-2.05) 0.72 0.53 (0.21-1.29) 0.159
Non-clinical
sta 140 (56) 110 (44) 1.85 (1.03-3.3) 0.04 0.43 (0.13-1.35) 0.148
Marital status Single 134 (66.01) 69 (33.99) 1 - 1 -
Married 179 (59.67) 121 (40.33) 1.31 (0.91-1.9) 0.15 1.02 (0.55-1.89) 0.96
Living with children No 203 (66.12) 104 (33.88) 1 - 1 -
Yes 110 (56.12) 86 (43.88) 1.53 (1.06-2.21) 0.02 1.47 (0.84-2.6) 0.179
Living with the elderly No 241 (63.09) 141 (36.91) 1 - 1 -
Yes 72 (59.5) 49 (40.5) 1.16 (0.77-1.77) 0.48 1.07 (0.58-1.97) 0.836
Living with the
elderly
No 238 (62.3) 144 (37.7) 1 - 1 -
Yes 62 (51.24) 59 (48.76) 1.57 (1.04-2.38) 0.031 1.88 (1.03-3.44) 0.041
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continue of table 2. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with Depression
among HCWs.
Death from COVID-19 in
the relatives
No 305 (62.76) 181 (37.24) 1 - 1 -
Yes 8 (47.06) 9 (52.94) 1.9 (0.72-5) 0.2 0.92 (0.23-3.65) 0.908
Death from COVID-19 in
the colleagues
No 281 (63.72) 160 (36.28) 1 - 1 -
Yes 32 (51.61) 30 (48.39) 1.65 (0.97-2.81) 0.07 1.88 (0.97-3.63) 0.06
Night shift No 23 (65.71) 12 (34.29) 1 - 1 -
Yes 226 (65.13) 121 (34.87) 1.03 (0.49-2.13) 0.95 1.27 (0.55-2.94) 0.569
History of psychiatric
disorders
No 234 (66.1) 120 (33.9) 1 - 1 -
Yes 79 (53.02) 70 (46.98) 1.73 (1.17-2.55) 0.01 2.16 (1.28-3.66) 0.004
Workplace hospital
Namazi 89 (62.68) 53 (37.32) 1.94 (0.93-4.02) 0.08 1.24 (0.47-3.27) 0.668
Faghihi 89 (63.57) 51 (36.43) 1.86 (0.9-3.88) 0.1 1.07 (0.4-2.86) 0.895
Ali-Asghar 61 (50.83) 59 (49.17) 3.14 (1.5-6.58) <0.001 2.11 (0.71-6.25) 0.177
Dastgheib 35 (70) 15 (30) 1.39 (0.57-3.38) 0.460 1.29 (0.43-3.83) 0.653
Hafez 39 (76.47) 12 (23.53) 1 - 1 -
Workplace ward
Constantly working in
COVID-19 wards 63 (53.85) 54 (46.15) 3.96 (1.96-7.98) <0.001 2.9 (1.05-8) 0.04
Episodically working
in COVID-19 wards 69 (71.13) 28 (28.87) 1.87 (0.89-3.94) 0.1 1.64 (0.7-3.82) 0.254
Working in non-clinical
sectors 121 (56.02) 95 (43.98) 3.62 (1.88-6.99) <0.001 3.25 (1.13-9.36) 0.029
Working in non-
COVID-19 wards 60 (82.19) 13 (17.81) 1 - 1 -
CI: Condence interval; OR: Odds ratio
Mani A, et al. Mental Health Status of HCWs During the COVID-19 Mental Health Status of HCWs During the COVID-19 Mani A, et al.
Table 3. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with Insomnia among HCWs.
Variables
No
n(%)
Insomnia Unadjusted OR
(95% CI) P-value Adjusted OR (95%
CI) P-value
Yes
n(%)
Gender
Female 197 (78.17) 55 (21.83) 0.75 (0.5-1.13) 0.17 1.11 (0.62-1.99) 0.73
Male 183 (72.91) 68 (27.09) 1 - 1 -
Age, y
Less than 30 157 (75.48) 51 (24.52) 1 - 1 -
30-50 149 (77.6) 43 (22.4) 0.89 (0.56-1.41) 0.617 0.84 (0.37-1.94) 0.685
More than 50 74 (71.84) 29 (28.16) 1.21 (0.71-2.06) 0.49 1.1 (0.44-2.74) 0.84
Education level
High school diploma
and lower 36 (66.67) 18 (33.33) 1 - 1 -
Academic education 344 (76.61) 105 (23.39) 0.61 (0.33-1.12) 0.111 0.42 (0.18-0.98) 0.045
Occupation
Physician 52 (77.61) 15 (22.39) 1 - 1 -
Nurse 144 (77.42) 42 (22.58) 1.01 (0.52-1.98) 0.974 1.09 (0.41-2.9) 0.861
Non-clinical sta 184 (73.6) 66 (26.4) 1.24 (0.66-2.36) 0.504 0.95 (0.27-3.36) 0.938
Marital status Single 150 (73.89) 53 (26.11) 1 - 1 -
Married 230 (76.67) 70 (23.33) 0.86 (0.57-1.3) 0.478 0.66 (0.33-1.31) 0.231
Living with children No 235 (76.55) 72 (23.45) 1 - 1 -
Yes 145 (73.98) 51 (26.02) 1.15 (0.76-1.74) 0.514 1.55 (0.81-2.94) 0.186
Living with the elderly
No 292 (76.44) 90 (23.56) 1 - 1 -
Yes 88 (72.73) 33 (27.27) 1.22 (0.76-1.94) 0.408 1.26 (0.66-2.4) 0.487
Death from COVID-19
in the relatives
No 371 (76.34) 115 (23.66) 1 - 1 -
Yes 9 (52.94) 8 (47.06) 2.87 (1.08-7.6) 0.034 1.78 (0.42-7.62) 0.435
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continue of table 3. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with Insomnia among
HCWs
Death from COVID-19
in the colleagues
No 336 (76.19) 105 (23.81) 1 - 1 -
Yes 44 (70.97) 18 (29.03) 1.31 (0.73-2.36) 0.371 1.2 (0.58-2.5) 0.619
Night shift
No 25 (71.43) 10 (28.57) 1 - 1 -
Yes 258 (74.35) 89 (25.65) 0.86 (0.4-1.87) 0.707 1.15 (0.46-2.86) 0.77
History of psychiatric
disorders
No 284 (80.23) 70 (19.77) 1 - 1 -
Yes 96 (64.43) 53 (35.57) 2.24 (1.46-3.43) <0.001 3.67 (2.09-6.44) <0.001
Workplace hospital
Namazi 113 (79.58) 29 (20.42) 2.36 (0.86-6.48) 0.095 4.03 (1.02-15.97) 0.047
Faghihi 98 (70) 42 (30) 3.94 (1.46-10.62) 0.007 6.18 (1.56-24.44) 0.009
Ali-Asghar 87 (72.5) 33 (27.5) 3.49 (1.28-9.55) 0.015 4.63 (1.06-20.25) 0.042
Dasgheib 36 (72) 14 (28) 3.58 (1.18-10.86) 0.024 7.48 (1.76-31.85) 0.006
Hafez 46 (90.2) 5 (9.8) 1 - 1-
Workplace ward
Constantly working
in COVID-19 wards 81 (69.23) 36 (30.77) 2.8 (1.29-6.07) 0.009 1.78 (0.59-5.44) 0.308
Episodically working
in COVID-19 wards 75 (77.32) 22 (22.68) 1.85 (0.82-4.19) 0.142 1.32 (0.52-3.35) 0.561
Working in non-
clinical sectors 161 (74.54) 55 (25.46) 2.15 (1.03-4.48) 0.041 2.14 (0.66-6.89) 0.205
Working in non-
COVID-19 wards 63 (86.3) 10 (13.7) 1 - 1 -
CI: Condence interval; OR: Odds ratio
Table 4. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with PTSD among HCWs.
Variables
Low
n(%)
PTSD Unadjusted
OR (95% CI) P-value Adjusted OR (95%
CI) P-value
Moderate
n(%)
High
n(%)
Gender Female 62 (24.6) 130 (51.59) 60 (23.81) 1.43 (0.77-2.68) 0.257 3.8 (1.7-8.47) 0.001
Male 84 (33.47) 119 (47.41) 48 (19.12) 1 - 1 -
Age, y
Less than 30 57 (27.4) 96 (46.15) 55 (26.44) 1 - 1 -
30-50 57 (29.69) 96 (50) 39 (20.31) 2.18 (0.83-5.76) 0.116 0.86 (0.21-3.42) 0.827
More than 50 32 (31.07) 57 (55.34) 14 (13.59) 0.79 (0.39-1.62) 0.52 0.61 (0.24-1.52) 0.288
Education level
High school diploma and
lower 17 (31.48) 27 (50) 10 (18.52) 1 - 1 -
Academic education 129 (28.73) 222 (49.44) 98 (21.83) 0.91 (0.36-2.31) 0.841 0.65 (0.19-2.29) 0.504
Occupation
Physician 22 (32.84) 24 (35.82) 21 (31.34) 1 - 1 -
Nurse 51 (27.42) 95 (51.08) 40 (21.51) 0.69 (0.19-2.58) 0.585 0.95 (0.18-4.98) 0.952
Non-clinical sta 73 (29.2) 130 (52) 47 (18.8) 1.7 (0.65-4.42) 0.277 0.59 (0.18-1.94) 0.383
Marital status
Single 49 (24.14) 100 (49.26) 54 (26.6) 1 - 1 -
Married 97 (32.33) 149 (49.67) 54 (18) 0.77 (0.39-0.35) 0.446 0.27 (1.59-1.31) 0.656
Living with
children
No 96 (31.27) 143 (46.58) 68 (22.15) 1 - 1 -
Yes 50 (25.51) 106 (54.08) 40 (20.41) 2.27 (1.18-4.35) 0.014 2.92 (1.23-6.96) 0.015
Living with the
elderly
No 119 (31.15) 181 (47.38) 82 (21.47) 1 - 1 -
Yes 27 (22.31) 68 (56.2) 26 (21.49) 2.09 (1-4.36) 0.049 1.98 (0.78-5.03) 0.152
Death from
COVID-19 in the
relatives
No 144 (29.63) 242 (49.79) 100
(20.58) 1 - 1 -
Yes 2 (11.76) 7 (41.18) 8 (47.06) 0.9 (0.14-5.92) 0.91 3.22 (0.42-24.48) 0.258
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continue of table 4. Association Between Socio-Demographic Features, Death from COVID-19, Psychiatric Disorders, and Workplace Features with PTSD among
HCWs.
Death from
COVID-19 in the
colleagues
No 130 (29.48) 222 (50.34) 89 (20.18) 1 - 1 -
Yes 16 (25.81) 27 (43.55) 19 (30.65) 1.14 (0.48-2.72) 0.77 2.16 (0.8-5.86) 0.13
Night shift
No 12 (34.29) 20 (57.14) 3 (8.57) 1 - 1 -
Yes 101 (29.11) 162 (46.69) 84 (24.21) 1.24 (0.5-3.06) 0.638 5.45 (1.15-25.81) 0.033
History of
psychiatric
disorders
No 132 (37.29) 173 (48.87) 49 (13.84) 1 - 1 -
Yes 14 (9.4) 76 (51.01) 59 (39.6) 3.13 (1.49-6.56) 0.003 10.62 (4.6-24.49) <0.001
Workplace
hospital
Namazi 39 (27.46) 71 (50) 32 (22.54) 1.33 (0.51-3.44) 0.557 16.72 (2.74-101.9) 0.002
Faghihi 42 (30) 62 (44.29) 36 (25.71) 1.16 (0.44-3.06) 0.767 13.01 (2.05-82.72) 0.007
Ali-Asghar 26 (21.67) 61 (50.83) 33 (27.5) 1.26 (0.4-3.95) 0.69 9.13 (1.18-70.56) 0.034
Dastgheib 18 (36) 27 (54) 5 (10) 1.52 (0.54-4.32) 0.43 2.93 (0.35-24.62) 0.323
Hafez 21 (41.18) 28 (54.9) 2 (3.92) 1 - 1 -
Workplace ward
Constantly working in
COVID-19 wards 26 (22.22) 52 (44.44) 39 (33.33) 3.33 (1.13-9.84) 0.03 2.73 (0.68-10.91) 0.155
Episodically Working in
COVID-19 wards 23 (23.71) 50 (51.55) 24 (24.74) 4.08 (1.72-9.7) 0.001 1.51 (0.52-4.44) 0.45
Working in non-clinical
sectors 62 (28.7) 121 (56.02) 33 (15.28) 4.68 (1.5-14.58) 0.008 0.94 (0.19-4.57) 0.937
Working in non-
COVID-19 wards 35 (47.95) 26 (35.62) 12 (16.44) 1 - 1 -
PTSD: Post-traumatic stress disorder; CI: Condence interval; OR: Odds ratio
Discussion
The current study showed that mental health
symptoms had a relatively high prevalence
among HCWs of Shiraz hospitals during the
sixth COVID-19 wave in Iran. Moderate to
high levels of anxiety, depression, and insom-
nia among the participants. Noorbala et al.
(2015) showed that the prevalence of anxiety
and depression in the general Iranian popu-
lation were 29.5% and 10.39%, respectively
[20]. Although previous studies revealed that
the outbreak of COVID-19 has also destabi-
lized the general populations mental health,
HCWs are at higher risk of presenting mental
disorders [19, 20].
Regarding previous studies, Iranian HCWs
have expressed their prime sources of concern
during the current pandemic as follows: fear
of being infected by SARS-CoV-2 or trans-
mitting the disease to their relatives, moral
injury caused by being forced to share lim-
ited available resources among critically ill
patients, lack of protective equipment, and
failure to make the necessary arrangements
and preparations to face the pandemic by the
ocials, which can be due to the current eco-
nomic problems of Iran [21-25].
Regarding Hassannia et al. [25] study, anxiety
and depression among HCWs were reported at
68.53% and 51.72%, respectively. Also, Azizi
et al. [26] showed that 43% and 44.8% of Ira-
nian HCWs during the COVID-19 pandemic
presented anxiety and depression symptoms,
respectively. However, in the current study,
the prevalence of anxiety and depression were
lower in HCWs.
Accordingly, it seems that over time, from the
onset of the pandemic, mental health symp-
toms could diminish among HCWs. Studies
in dierent countries have reported relatively
dierent prevalence rates in assessing insom-
nia. While in our study, insomnia prevalence
was 24.5%, a systematic review reported
the prevalence of insomnia among Chinese
HCWs at 38.9% [9].
However, another study in Italy estimated
insomnia prevalence among HCWs as only
8.27% [8]. This relatively notable variance
can be due to the dierences in work shifts,
workloads, and rest facilities provided to
HCWs in hospitals in dierent countries.
Also, our study estimated the prevalence of
moderate to high PTSD levels at 71%, which
is similar to the 71.5% prevalence reported in
the study conducted by Lai et al. [9].
However, Rossi et al. [8] and Lasalvia et al.
[27] estimated a relatively lower prevalence
of PTSD among HCWs (49.38% and 53.8%,
respectively). These ndings could be due to
cultural dierences and the level of psycho-
logical and social support in dierent coun-
tries.
In our study, based on multiple logistic re-
gression, female gender, positive history of
psychiatric disorders, and constant or epi-
sodic working in COVID-19 wards over the
past 12 months were associated with higher
anxiety levels, which are consistent with the
results of previous studies [8, 9, 25, 28]. Fear
of transmitting the disease to relatives could
explain the association of living with the el-
derly, particularly vulnerable to the disease,
with more anxiety symptoms [21, 27]. A fas-
cinating point observed in the current study
was the signicantly higher level of anxiety
in non-clinical sectors sta. This group of
employees had even higher anxiety levels
than the HCWs who worked episodically in
COVID-19 wards.
In contrast to our study, Lasalvia et al. indi-
cated that the administrative sta had signi-
cantly lower anxiety symptoms [27]. The high
prevalence of anxiety among non-clinical sta
in our study may be due to their less scientic
knowledge about COVID-19 and its transmis-
sion routes. Also, in contrast with some other
studies that reported younger age as an asso-
ciated factor with higher anxiety levels, our
study found no such association [8, 25].
Regarding our ndings, some factors associ-
ated with more depressive symptoms includ-
ed a positive history of psychiatric disorders,
working continuously in COVID-19 wards,
and working in non-clinical sectors. The asso-
ciation of the depression level with a positive
history of psychiatric disorder and working as
a front-line HCW was consistent with previ-
ous studies [9, 25, 26].
Also, working in non-clinical sectors of hos-
pitals was associated with more symptoms.
On the other hand, a higher education level
was associated with lower levels of depres-
sion. Cohen et al., using cohort data from
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Mani A, et al. Mental Health Status of HCWs During the COVID-19
the National Longitudinal Survey of Youth
from 1979 in the United States, showed the
signicant eect of higher education levels
on reducing the incidence of depression [29].
Unlike other studies, which mainly report-
ed that the female gender, being single, and
younger age were associated with more de-
pressive symptoms, no such correlations were
observed [2, 8, 9, 25, 26].
Multiple logistic regression showed that
HCWs with a history of mental disorders were
more likely to suer from insomnia. Howev-
er, a higher education level was associated
with a lower incidence of insomnia.
Previous studies conrmed that sleep disor-
ders are associated with educational level and
past psychiatric disorders [29-31]. However,
HCWs who worked at Ali-Asghar, Namazi,
Faghihi, and Dastgheib hospitals showed sig-
nicantly more insomnia.
According to previous research, sta at Ali-
Asghar hospital (a front-line COVID-19 hos-
pital) and Namazi and Faghihi hospitals (sec-
ond-line COVID-19 hospitals) have a higher
incidence of insomnia [9]. Also, our ndings
revealed that the sta of Dastgheib hospital
and both front- and second-line hospitals sig-
nicantly had more insomnia symptoms than
Hafez hospital’s sta. Although Dastgheib
hospital has no COVID-19 ward, it is the
largest referral center for patients with thal-
assemia in southern Iran. In comparison, it
has a relatively higher workload than Hafez
hospital.
Hence, the higher workload, in addition to
direct exposure of HCWs to COVID-19 pa-
tients, could eect on insomnia prevalence.
Based on our results, female gender, living
with vulnerable groups (children or the el-
derly), working at night shifts, positive his-
tory of psychiatric disorders, constantly or
episodically working in COVID-19 wards,
working in non-clinical sectors, and working
in the front-line (Ali-Asghar) and second-line
(Namazi and Faghihi) hospitals were associat-
ed with higher levels of PTSD.
In line with previous studies, female gender,
positive history of psychiatric disorders, and
working in COVID-19 front- and second-line
hospitals were associated with PTSD [2, 8, 9,
25, 26, 32]. In addition, since one of the most
important concerns of HCWs is transmitting
the disease to their relatives, the association
between living with vulnerable groups and
higher levels of PTSD seems reasonable [22,
33]. Previous studies have also conrmed the
role of history of psychiatric disorders as a
predictive factor for the risk of PTSD [34, 35].
Also, in contrast with Azizi et al. study, work-
ing in non-clinical sectors was associated with
higher PTSD levels [26].
While Di Tella et al. [2] found that older age
can signicantly increase the risk of PTSD,
Rossi et al. [8] and Azizi et al. [26] report-
ed younger age as an associated factor with
higher PTSD levels. However, in the current
study, there was no correlation between PTSD
and age.
Our ndings demonstrated that both HCWs
who worked permanently and those who
worked episodically in the COVID-19 wards
had signicantly more mental health symp-
toms than the non-COVID-19 wards sta.
However, the HCWs who worked episodical-
ly in the COVID-19 wards suered from few-
er psychiatric disorders.
Regarding current study results, most mental
health disorders could have been associated
with a prior history of psychiatric disorders, a
high workload, and working on the front-line
and/or even in non-clinical sectors.
Therefore, by performing periodic mental
health assessments for HCWs and identifying
at-risk groups, the necessary supportive and
preventive measures can be taken at the right
time.
Regarding Rouhbakhsh et al. study, provid-
ing adequate protective equipment, apprecia-
tion for the HCWs services, welfare facilities
for the sta to stay and rest in the hospitals,
training programs to deal with COVID-19
patients, and psychologist counseling for the
personnel were reported by HCWs as the im-
portant factors [35].
Limitations
As one of the most important limitations of
our study, we could not access participants
mental health status before and at the begin-
ning of the COVID-19 pandemic. In addi-
tion, despite the advantages of face-to-face
interviews, there was a limited possibility of
selecting a larger sample size due to being
time-consuming and costly.
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Mental Health Status of HCWs During the COVID-19 Mani A, et al.
Conclusion
Our study showed that mental disorders
among HCWs in Shiraz hospitals was rela-
tively high. Therefore, by conducting periodic
mental health assessments, at-risk groups can
be identied to be prioritized to receive sup-
portive measures. It is suggested that specif-
ic supporting structures should be placed in
healthcare systems to prevent psychological
complications among HCWs.
Indeed, providing psychological and social
support, and appropriate welfare facilities for
the HCWs are suggested to ensure that the
quality of health care services does not de-
cline.
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Acknowledgments
The authors were grateful to employees of
hospitals aliated with the Shiraz University
of Medical Sciences who participated in this
study. Also, we thank of the Research Deputy
of Shiraz University of Medical Sciences for
nancial support of the current study (grant
number: 25145)
Conict of Interest
The authors have declared no conict of
interest. Also, the funding body of the study
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