The invisible frontiers: Mental health and turnover intention among Egyptian social workers

Abstract

Research on the impact of the COVID-19 pandemic on social workers is limited, especially from low-income countries. Hence, this study examined the effect of this international health crisis on the mental health of 261 social workers in health care settings in Egypt. Generalized anxiety and stress generated by fear of COVID-19 directly influenced social workers’ intention to leave their current job. The findings show the vulnerability of social workers employed in health care settings during the COVID-19 pandemic. Their mental well-being is less than optimal, which might contribute to a high turnover rate.

Keywords

Anxiety COVID-19 social workers stress turnover

Introduction

The COVID-19 pandemic has affected the well-being of people and nations worldwide (Copeland et al., 2021; Wang et al., 2020). As of May 2022, slightly more than 510 million people have been diagnosed with COVID-19, and over 6 million have died (World Health Organization, 2022).

Despite many studies that have documented the harmful effect of COVID-19 on the mental health of health care professionals (Pappa et al., 2020; Preti et al., 2020), there is a dearth of knowledge about its impact on social workers, especially those who work in health care settings. The absence of this line of research is a significant concern, considering that social workers play a critical role in the modern health care system. The present study aims to begin to fill this gap by exploring the impacts of the COVID-19 pandemic on the mental health of a sample of social workers in Egypt.

Over the past 2.5 years, the COVID-19 pandemic has become a significant source of worry and stress at the micro, meso, and macro levels. Ongoing stress generated by COVID-19 might proliferate, resulting in additional stressors affecting various aspects of life (Pearlin, 1989). Continuous exposure to stress may trigger anxiety disorders (Ray et al., 2017). For individuals working in health care settings, COVID-19 has been a daily stressor, especially at the beginning of the pandemic.

Health care workers (HCWs), especially those who are directly involved in the diagnosis, treatment, and care of COVID-19 patients, are at a higher risk of getting infected with COVID-19 and developing mental health issues (Badahdah et al., 2020b; Ni et al., 2021). A Chinese study of 34 hospitals found that 50.4 percent of HCWs experienced anxiety, 44.6 percent experienced depression, and 34 percent experienced insomnia (Lai et al., 2020). Similar observations have been reported in other countries, such as Italy (Mazza et al., 2020) and the United States (Tull et al., 2020). Research has also shown that fear of COVID-19 induces a high level of stress (Lathabhavan and Vispute, 2021), which leads to an increase in the level of anxiety (Rodríguez-Hidalgo et al., 2020).

During the pandemic, mental health concerns of HCWs pressed many to contemplate leaving their practice (Labrague and de Los Santos, 2020). Evidence shows that burnout, lack of work–family balance, and fear of COVID-19, among other factors, are linked to a lower level of job satisfaction and to turnover intention (Irshad et al., 2021; Zhang et al., 2021). In the United Kingdom, almost half (47%) of advanced practice nurses have thought about leaving their job (Wood et al., 2021), while in the United States, 11 percent of nurses (Raso et al., 2021) and a quarter of clinicians reported that they planned to leave their profession (Abbasi, 2022). Moreover, a study of 20,655 HCWs in the United States found that one in five physicians and two in five nurses were planning to leave their current place of work within 2 years (Sinsky et al., 2021).

Social workers have always been present and prepared to help when natural, health disasters and large industrial accidents occur (Cheung, 2020). A hundred years ago, social workers responded to the needs of sick and disadvantaged people and their families during the 1918 flu pandemic (Kerson, 1979). Similarly, during the SARS, H1NI, and MERS epidemics, social workers played an essential role in providing support and education to people infected with and affected by these diseases (Cheung, 2022; Hui et al., 2004; Park and Lee, 2016; Yuen-Tsang et al., 2004). During these health crises, social workers and health care providers experienced fear of infection, isolation, anxiety, stress, fatigue, and stigma (Gearing et al., 2007; Maunder, 2004; Maunder et al., 2003; Rowlands, 2007). In China, a year after the 2003 SARS outbreak, Wu et al. (2009) found that hospital staff experienced high levels of posttraumatic stress disorder (PTSD; 10%) and depression (23%).

During the COVID-19 pandemic, social workers have been heavily involved in providing social, psychological, and practical support to COVID-19 patients and their families. However, little research has been conducted to examine the impact of the COVID-19 pandemic on their mental health (Holmes et al., 2021). In a qualitative study in England, child and family social workers reported adverse emotions due to their workload, making work–life balance more difficult to attain (Cook and Zschomler, 2020). In the United States, 26 percent of social workers during the COVID-19 pandemic met the diagnostic criteria for PTSD, compared with 3.7 percent of licensed social workers in 2015. Furthermore, 16 percent of social workers reported severe feelings of grief (Holmes et al., 2021).

The role of social workers during health crises

Social workers are committed to an interdisciplinary, collaborative, community-based practice and are uniquely qualified to lead in many interprofessional settings, including health care. Their primary mission is to enhance the well-being of their clients, particularly vulnerable and marginalized people (Miller and Lee, 2020). The role of social workers in health care settings extends beyond intervention for immediate medical issues to include other aspects of the broader ecological system impacting health outcomes. Social workers have been providing significant help to their clients during the COVID-19 crisis, including assisting individuals who have recently recovered from the virus (Ben-Ezra and Hamama-Raz, 2020) and providing remote counseling for infected people and their families (Brown, 2020). In addition to responding to the current international health crisis, social workers must also deal with their own concerns and challenges as many are experiencing the impacts of COVID-19 in their homes, workplaces, and neighborhoods, placing them at a higher risk for psychological stress (Bright, 2020).

Social work in Egypt

Social work began in Egypt in 1909 while the country was still under British occupation. In its formative years, social work focused on protecting the welfare of women and children. Later, its scope expanded to include care for the elderly (Awad, 2013). The beginning of professional social work in Egypt is associated with the establishment of the first school of social work in 1936 (Badran, 1971). Master’s and doctoral programs were offered beginning in 1968 and 1972, respectively, and by 1975, social work education had become an integral part of higher education (Graham and Al-Krenawi, 2022). Since then, significant efforts have been made to adapt and localize social work within the Egyptian and Arabic contexts. The practice of multidisciplinary social work is widespread. For example, at Ain Shams University the model of a psychiatric center was built on the concept of the psychiatric team. Patients receiving comprehensive treatment at this center have benefited from teams comprised of psychiatrists, psychiatric social workers, clinical psychologists, and nurses (Megahead, 2019).

Research on COVID-19 among HCWs in Egypt

As of 8 April 2022, there had been 509,117 confirmed cases of COVID-19 in Egypt and 24,473 deaths (World Health Organization, 2022). Approximately 55 percent of COVID-19 cases have been in people over the age of 50 years, and 25 percent of cases have been in people between 15 and 35 years. Approximately 10,000 Egyptian HCWs (6.5%) have had COVID-19 and 500 have died (Ahramonline, 2021).

Several studies of COVID-19 among HCWs have been conducted in Egypt. In one study of 407 HCWs, 83.1 percent reported having higher levels of fear of COVID-19 (Abdel Wahed et al., 2020). Another study reported that female HCWs, compared with male HCWs, were more likely to experience anxiety, depression, and stress (Elkholy et al., 2020). Similar findings were reported by other researchers (Ahmed et al., 2021; Amer et al., 2021; Arafa et al., 2021; Youssef et al., 2020). Said and El-Shafei (2021) found that one in four nurses (25%) intended to leave nursing. Suicidal thoughts were expressed by 2.2 percent of HCWs in a study by Elgohary et al. (2021).

Given the dearth of empirical work on the mental health status of social workers in health care settings during the COVID-19 pandemic, the current study has two overall objectives: (1) to investigate the prevalence of fear of COVID-19, anxiety, and stress among Egyptian social workers and (2) to examine differences in the prevalence of these variables and social workers’ intent to leave their job based on gender, marital status, and experience working with families of COVID-19 patients. We propose the following three hypotheses:

Hypothesis 1: Fear of COVID-19 is positively associated with anxiety and stress in social workers.

Hypothesis 2: Stress is positively associated with anxiety in social workers.

Hypothesis 3: Fear of COVID-19, stress and anxiety are positively associated with social workers’ intent to leave their job.

Method

The data used for this study were part of a larger cross-sectional survey on the impact of the COVID-19 pandemic conducted in some Arab countries. Data were collected between 10 May and 18 June 2020, using the QuestionPro platform. Emails and WhatsApp messages that included the purpose of the study and a link to the study were sent to social workers in four governorates in Egypt that have over 40 public hospitals. Only social workers who had worked for at least 1 year in one of the hospitals in the four governorates were eligible to join the study. Respondents were asked to read the informed consent and decide whether to participate. The confidentiality of information was assured, and participants were informed that participation was entirely voluntary. Only participants who consented were allowed to access the survey. A proposal to conduct the study was reviewed and approved by Faqous Central Hospital, Egypt.

Participants

Data were collected from a convenience sample of 216 social workers (49.3% males and 50.7% females) in public and university-associated health care settings in Egypt. The mean number of years working as a social worker was 12.01 (SD = 8.77). The mean age of the participants was 35.39 (SD = 11.23).

Measures

The survey had two sections. The first section covered sociodemographic information, including age, gender, marital status, and the number of years working as a social worker. The second section included four scales to measure fear of COVID-19, anxiety, stress, and participants’ intent to leave their current job.

Fear of COVID-19 scale

This scale consists of four items selected from previous research outside (e.g. Ahorsu et al., 2020) and within the Arab world (Alsalhe et al., 2020). An example of an item was, ‘I feel uncomfortable thinking about COVID-19’. All items were rated on a 5-point Likert-type scale ranging from 1 (totally agree) to 5 (totally disagree). A principal components analysis with the Promax procedure (k = 4) revealed that all items loaded on one factor explained 62.65 percent of the variance. The Cronbach’s alpha reliability was .79. Higher scores indicate a higher amount of fear.

Generalized Anxiety Disorder Scale-7

The Generalized Anxiety Disorder Scale (GAD-7) is a widely used 7-item self-rated scale to assess the severity of anxiety (Spitzer et al., 2006). A validated Arabic version of the GAD-7 (Sawaya et al., 2016) that has been used in previous research on COVID-19 (e.g. Badahdah et al., 2020a) was used in this study. An example of an item was ‘not being able to stop or control worrying’. Items were rated on a 4-point Likert-type scale ranging from 0 (not at all) to 3 (nearly every day), with higher scores indicating a greater level of anxiety. A cutoff score of ⩾10 indicates a high degree of anxiety. The Cronbach’s alpha reliability was .92.

Perceived Stress Scale-10

This scale is a self-reported global measure of stress and people’s reaction to stressful life events (Cohen et al., 1983). It has been validated in Arabic settings (e.g. Chaaya et al., 2010) and used in studies in Arab countries during the COVID-19 pandemic (e.g. Badahdah et al., 2020a). An example item was, ‘In the last month, how often have you felt that you were on top of things?’ Items were rated on a 5-point Likert-type scale ranging from 0 (never) to 4 (very often). The total scores can be divided into three categories: low (0–13), moderate (14–26), and high (27–40) perceived stress. Higher scores indicate a higher level of stress. The Cronbach’s alpha reliability was .78.

Intention to leave job

Several turnover intention measures have been used in the literature. Some used composite measures (Xuebing et al., 2021) while others used a single item (Raso et al., 2021; Said and El-Shafei, 2021). In this study, like other previous work (e.g. Chang et al., 2019) we used two items rated on a 5-point Likert-type scale ranging from 1 (totally agree) to 5 (totally disagree). The items were ‘I have been thinking of changing my job because of COVID-19’ and ‘I believe most medical social workers will leave their job because of COVID-19’. The relationship between the two items was .30 (p = .000). A higher score implies more interest in leaving the current job.

Statistical analysis

Descriptive statistics, reliability tests, differences between subgroups, and factor analysis were conducted with IBM SPSS Statistics Package 27. Bivariate comparisons were performed through either Chi-square test or ANOVA. The relationship between the variables was tested using structural equation modeling with maximum likelihood estimation in AMOS. Because the recommended number of 10–12 participants per estimated parameter was not met (Weston and Gore, 2006), the Perceived Stress Scale (PSS), which has the largest number of indicators, was parceled. The 10 items of the PSS were divided into two parcels: the odd items in one parcel and the even items in another parcel (Little et al., 2013).

The model fit was evaluated by the goodness of fit (GFI), the comparative fit index (CFI), the Tucker–Lewis index (TLI), the incremental fit index (IFI), and the root mean square error of approximation (RMSEA). GFI, CFI, TLI, and IFI greater than .90 and an RMSEA ⩽ .08 is considered acceptable (Hair et al., 2010). All tests were considered statistically significant if p ⩽ .05.

Results

Slightly more than half (53.3%) of the 216 social workers were married, 36 percent were single, and 10.8 percent were divorced or widowed. Male social workers were on average older (M = 38.67, SD = 9.47) than females (M = 32.41, SD = 11.95; F(1, 145) = 12.30, p = .001). Almost one-third (31.9%) reported working with families who have a family member diagnosed with COVID-19. The proportion of male social workers who worked with family members with COVID-19 was higher than female social workers (57.4% vs 24.6%; χ²(1) = 27.61, p = .000).

The mean score on the fear of COVID-19 scale was 4.07 (SD = .81); 68.5 percent of the participants scored at or above the mean. No difference in fear of COVID-19 was found between female social workers (M = 4.17, SD = .76) and their male counterparts (M = 3.98, SD = .86; F(1, 213) = 2.94, p = .09). Social workers who worked with COVID-19-positive families did not differ in their fear of COVID-19 from those who did not (F(1, 214) = 3.32, p = .07). Age was significantly related to fear of COVID-19 (r = −.18, p = .03). Married participants scored lower (M = 3.94, SD = .91) on the fear scale than non-married ones (M = 4.22, SD = .65; F(1, 212) = 6.12, p = .01).

Slightly more than half of the participants (51.4%) scored ⩾10 on the GAD-7, a cutoff point indicating a high degree of anxiety. Specifically, 24.1 percent reported a mild level of anxiety, 33.3 percent experienced a moderate level of anxiety, and 18.1 percent had a severe level of anxiety. Chi-square analysis showed no significant difference between the proportion of females and males who scored ⩾10 (χ²(1) = 1.69, p = .19). Nevertheless, social workers who had no interaction with families of COVID-19 patients scored below the cutoff point (⩽9) on the GAD-7 compared with those who interacted with COVID-19 families (85.7% vs 14.3%, χ²(1) = 29.31, p = .000). A larger percentage of married social workers (62.9%) scored below the cutoff score than their non-married counterparts (37.1%; χ²(1) = 7.61, p = .004).

The scores on the PSS-10 ranged from 2 to 33 (M = 19.55; SD = 6.15). Most of the social workers reported a moderate level of stress (73.1%), while a smaller percentage reported a high level of stress (10.2%). A one-way ANOVA analysis showed no gender difference in stress levels (F(1, 213) = 3.63, p = .06). However, participants who worked with families that had a member with COVID-19 scored higher (M = 22.26, SD = 5.02) than those who did not (M = 18.27, SD = 6.23; F(1, 214) = 21.67, p = .000). In addition, married participants scored lower (M = 18.69, SD = 6.17) on the PSS-10 than non-married ones (M = 20.42, SD = 6.02; F(1, 212) = 4.27, p = .04).

The mean score on the intention to leave job scale was 2.75 (SD = .91). Female social workers were less likely to think about leaving their job (M = 2.60 SD = .83) than male social workers (M = 2.91, SD = .96; F(1, 213) = 6.36, p = .01). Those who worked with families of COVID-19 patients were more likely (M = 3.20, SD = .97) to think about leaving their job than those who did not (M = 2.54, SD = .80; F(1, 214) = 27.38, p = .000). Married social workers did not differ from non-married ones in their intention to leave their job (F(1, 212) = 1.35, p = .25).

The proposed model, shown in Figure 1, fits the data perfectly, χ²/df = 1.91; GFI = .92; CFI = .95; TLI = .94; IFI = 96 and RMSEA = .06.

Figure 1.

Standardized path coefficients of the hypothesized model.

The paths from fear of COVID-19 to stress and anxiety were significantly positive and in the expected direction (β = .33, p = .000; β = .46, p = .000, respectively). Similarly, stress positively influenced anxiety (β = .41, p = .000) and both stress and anxiety predicted social workers’ intent to leave their job (β = .34, p = .000; β = .44, p = .000, respectively). The path from fear of COVID-19 to intent to leave job, however, was not statistically significant (β = .18, p = .14).

Discussion

Research on the effect of COVID-19 on social workers in health care settings has been generally understudied. This study intended to remedy this oversight by investigating the impact of COVID-19 on the mental health of social workers and their intention to leave their job.

This study revealed that the mental health of social workers, like other HCWs, has been negatively affected by the COVID-19 pandemic. The proportion of participants who reported fear of COVID-19 was extremely high: 7 in 10 scored at or above the mean score of the fear of COVID-19 scale. Female social workers did not differ from their male counterparts in their fear of COVID-19, which is different from the results of some other studies (Enea et al., 2021; Tzur Bitan et al., 2020). The inconsistency may be due to the use of different measures to gauge fear of COVID-19 (Ahorsu et al., 2020; Lee et al., 2020). Lack of significant difference in the amount of fear of COVID-19 between those who cared for families of COVID-19 patients and those who did not might be an indication that fear of COVID-19 is widespread among social workers.

Slightly more than half of the participants experienced a high degree of anxiety, with one in five reporting severe anxiety. Like other frontline HCWs, the impact of the pandemic is harder on social workers who worked with families with COVID-19 patients (Al Ammari et al., 2021; Liang et al., 2020). To illustrate, an Egyptian study found that 15.9 percent and 24.4 percent of frontline HCWs experienced moderate and severe anxiety, respectively (Elkholy et al., 2020). Unlike other studies (e.g. Al Ammari et al., 2021; Elkholy et al., 2020; Pappa et al., 2020), this study observed no gender difference in the reported level of anxiety. This might be attributed to the widespread anxiety associated with COVID-19 in our sample. Like most HCWs, social workers are not immune from anxiety during this international health crisis.

COVID-19 has been a very significant source of stress for many people for the past 2.5 years. The pandemic is an especially acute source of stress for HCWs compared with the public and non-clinical staff (Chen et al., 2020; Spoorthy et al., 2020). Although there are no predefined cutoff values for the PSS-10, a score of 27 and above has been suggested as a marker of a high level of stress (Cohen et al., 1983; Gambetta-Tessini et al., 2013). In this study, we found that 10.2 percent of social workers scored at or above this cutoff value, which is similar to the stress levels reported by Lebanese HCWs during the COVID-19 crisis (Bizri et al., 2021). The lack of gender difference in the level of stress is congruent with some studies of HCWs in the Arab world (e.g. Badahdah et al., 2020a) but inconsistent with others (e.g. Elkholy et al., 2020). Miller and Grise-Owens (2022) found that female social workers were more likely to experience a higher level of stress than their male counterparts.

Like other HCWs (Lai et al., 2020), social workers who worked closely with COVID-19 patients and their families experienced a higher level of stress than those who did not.

The relationship between marital status and mental health among HCWs during COVID-19 has received little attention. In our study we found that married social workers reported lower levels of fear of COVID-19, GAD, and perceived stress than their single counterparts. Available research supports our findings (Badahdah et al., 2020a; Suryavanshi et al., 2020). Research on the relationship between health and marriage argues that married people report greater subjective well-being compared with non-married people (DeMaris, 2018). The causation model (Kiecolt-Glaser and Newton, 2001) suggests that marriage is a protective factor against mental illness, especially in societies where marriage is highly valued Married people reap the benefits, for example, of greater economic resources, availability and convenience of psychological and emotional support, companionship, a supportive social network, and avoidance of risky behavior. However, another interpretation, called selection model, argues that the positive relationship between mental health and marriage might be because healthy people are more likely to get married and stay married than non-healthy ones (DeMaris, 2018).

Although male social workers did not differ from their female counterparts on fear of COVID-19, anxiety, and stress, they were more likely to consider leaving their practice than their female counterparts. One possible explanation for higher levels of intention to leave job among male social workers is that they were more likely to interact with COVID-19 affected families than were females.

Research on the relationship between marital status and job turnover suggests that married employees in general are less likely to leave their job than single people (Kipkebut, 2013). The absence of relationship between these two variables in our study has been supported by some studies but not others during the COVID-19 pandemic. For example, married frontline nurses in the United States scored higher on turnover intention (Cole et al., 2021), while other studies report no relationship (Al-Mansour, 2021; Nashwan et al., 2021).

As shown in the ‘Results’ section, the direct effect of fear of COVID-19 on the intention to leave a job was mediated through anxiety and stress. That is, fear of COVID-19 had no direct impact on intention to a leave job. Rather, stress and anxiety were directly and positively related to participants’ intention to leave their job. The prolonged stress, anxiety, emotional exhaustion, and burnout among social workers during COVID-19 might have pushed some of them to rethink their career choice. These factors are often cited in the health care literature as the main reasons for turnover (Johnson et al., 2018; Kelly et al., 2021). Lack of support from supervisors and hospital administrators, which we did not examine in our study, might be an additional source of stress for social workers during this pandemic. Moreover, concern about the impact of COVID-19 on their own lives and their loved ones while working to provide support for people infected and affected by COVID-19 might become too much to manage for some social workers.

The study findings show the effects of COVID-19 on social workers’ well-being and address the gap in the literature by giving social workers the attention they deserve. The findings also emphasize the essential role of the social work profession in health care settings and the importance of keeping the public informed and aware of social workers’ roles and responsibilities as members of health care teams.

Social workers who work closely with COVID-19 patients and their families need support and interventions from hospital leaders and administrators to manage their COVID-19 personal and work-related stressors. It is important also to address the mental health of social workers through intervention programs and approaches that have been implemented during COVID-19 in several health care settings. Examples include frequent breaks, resilience training, shorter working hours, training that addresses work–family balance, and psychological support (Crittenden et al., 2021; Schwartz et al., 2020).

Limitations

This study, the first to address the impact of the COVID-19 pandemic on social workers’ well-being in Egypt, has some limitations that future work should strive to overcome. First, the data are cross-sectional, which helped identify the relationships between the study variables but not causality. Second, the nonrandom nature of the sample and self-selection bias limits the generalizability of the findings. These limitations do not, however, undermine the fundamental conclusions that the COVID-19 pandemic has negatively impacted social workers’ mental health, especially those who work with families of COVID-19 patients. Hence, we suggest replicating this study using a larger sample while adding other variables such as job satisfaction and burnout and coping strategies.

Conclusion

During this global health crisis, the role of social workers has been more crucial than ever before. They have experienced the impacts of the crisis on their mental health. Social workers perform heroic work on the frontlines, and their adherence to their profession’s core values has propelled them into action during the COVID-19 pandemic. They serve as a vital link between COVID-19 patients and their families and HCWs.

This study found that social workers have been greatly affected by the COVID-19 pandemic, especially those who work with families of COVID-19 patients. Furthermore, anxiety and stress have influenced participants’ intention to leave their job. Psychological support is needed to help social workers deal with the devastating impacts of COVID-19 and further retain skilled social workers during this crisis.

Footnotes

Acknowledgements

The third author wishes to thank her two Graduate Assistants, Ryan Weldon and Liana Maher, MSW students at Adelphi University School of Social Work, for their technical support.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Abdallah Badahdah

Wahiba Abu-Ras

Author biographies

Abdallah Badahdah is an Associate Professor of Sociology at South Dakota State University. His research interests include health and stigma, families, and social aspects of HIV.

Mohamed M Shahin is a Professor of Clinical Social Work at the Higher Institute of Social Work, Egypt. He currently works at the Family Consulting Center (Wifaq) in Qatar.

Wahiba Abu-Ras is a Professor at Adelphi School of Social Work. She received her PhD from Columbia University. Her research area focuses on Muslim and Arab mental health and well-being.

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