Factors associated with anxiety disorders among healthcare workers (HCWS) involved in the first wave of the COVID-19 pandemic

Abstract

BACKGROUND:

In a context of reorganization of the activity, of increase of the psychological, emotional and physical constraints of the nursing staff induced by the first wave of the COVID-19 pandemic, an increase of the anxiety disorders could occur.

OBJECTIVE:

This study aims to assess the prevalence of anxiety disorders in healthcare workers (HCWs) by wards and to investigate medical, personal, and occupational factors associated with anxiety disorder.

METHODS:

In France, in May 2020, a monocentric observational cross-sectional study was proposed to 285 HCWs of the University Hospital of Saint Etienne, working in 3 types of randomly selected care wards. Information was collected using an anonymous self-questionnaire offered to eligible HCWs. Validated questionnaires were used to assess anxiety (Hospital anxiety and Depression Scale) and burnout (Maslach Burnout Inventory).

RESULTS:

Of the 164 HCWs who participated in the study (57% participation rate), 69 (42%) caregivers had anxious symptomatology. The prevalence of anxiety disorders did not differ significantly by type of wards. Anxiety disorders are significantly associated with occupational factors (increased COVID-19 stress level, increased emotional load, increased mental load, high work/life stress during confinement, emotional exhaustion and loss of empathy), with medical factors (medical history of anxiety disorders, psychotropic treatment and impaired sleep quality) and personal factors (concern about working conditions and/or media reports).

CONCLUSIONS:

Preventive actions focusing on organizational factors could be carried out to reduce the emotional and mental load, the level of stress and the burnout of HCWs.

Keywords

First wave of the COVID-19 pandemic healthcare workers mental health occupational stress burnout

1 Introduction

Anxiety disorders include six clinical entities: generalized anxiety disorder (GAD), panic disorder with or without agoraphobia, social anxiety disorder, specific phobia, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). According to the International Classification of Diseases, the dominant symptoms of Generalized anxiety disorder are variable: complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort [1]. Symptoms of anxiety disorders can lead to work capacity impairments: difficulty concentrating, lower intellectual performance, inability to make plans [2, 3]. Several risk factors have been found to be associated with increased likelihood of having a generalized anxiety disorder such as age, being female, having several chronic medical conditions, being single, divorced, or separated (compared to being married), lower education, impaired subjective health and stressful life events [4, 5].

Before the Covid 19 pandemic, a cross-sectional survey included Chinese nurses, highlighted the association between anxiety disorders and workload, time pressure [6]. Previous studies showed that health professionals are particularly at high risk of developing mental health problems during COVID 19 pandemic [7]. During the outbreak of the coronavirus disease (COVID-19) pandemic, several studies underlined that the lack of personal protective equipment, the reorganization of units and services with the integration of new teams, the fear of being infected or infecting family members or patients, the need to make difficult ethical choices about prioritizing care, the increased workload feeling of helplessness, the lack of effective treatment or guidelines and the loss of social support due to lockdown, could have a psychological impact on healthcare workers [8 –10]. Moreover, the need to reorganize care activities to support the optimal management of COVID-19 infected patients can lead to increased mental, physical and emotional demands on caregivers [11]. Pappa et al. conducted a systematic search of literature databases up to April 17th, 2020. Thirteen studies were included in the analysis with a combined 33,062 participants. Anxiety was assessed in 12 studies, with a pooled prevalence of 23·2% [11].

Is the prevalence of anxiety disorders associated to the intensity of SARS-CoV-2 exposure in Health Care Workers (HCWs)?

A cross sectional survey collected data from 1257 HCWs from January 2020 to February 2020, reported symptoms of anxiety especially frontline health care workers [12]. A systematic review, meta-analysis and meta-regression approaches are used to approximate the prevalence anxiety within front-line healthcare workers caring for COVID-19 patients between December 2019 to June 2020. Of the 29 studies with a total sample size of 22,380, 23 studies have reported the prevalence of anxiety [25.8% (95% CI 20.5– 31.9%)] [13].

The objectives of this study were to assess, during the first wave of COVD-19 pandemic, the prevalence of anxiety disorders in healthcare workers [HCWs] by wards with and without patients infected with SARS-CoV-2 and to investigate medical, personal, and occupational factors associated with anxiety disorder. We felt the need to explore the risk factors associated with anxiety disorders in HCWs by distinguishing wards with and without patients infected with SARS-CoV-2 in order to provide evidence to support an appropriate intervention program.

2 Material and methods

The study design was a cross-sectional questionnaire survey.

2.1 Target population

The data have been collected from 6 may to 26 may 2020. During the study period, the healthcare institutions were actively involved in the care of COVID-19 patients; The target population was HCWs from University Hospital of Saint Etienne working. HCWs, including physicians, surgeons, midwives, medical residents, nurses, auxiliary nurses, and pediatric auxiliary nurses, included in three types of wards by COVID-19 were invited to voluntarily participate in the self-administered online survey. Eligible subjects received clear and comprehensible information on study objectives and procedure, and were free to decline participation. Approval by ethics committee was obtained before starting the study.

2.2 Study sample

Departments from University Hospital of Saint Etienne were randomly sampled from each type of wards by COVID-19: COVID-19 wards (Type 1), mixed wards (type 2) and COVID-19 free wards (type 3), and all HCWs in these departments were asked to participate in this study. The eligible HCWs were contacted via their email address. Those who are off work or on leave at the time of inclusion in the study were not involved in the survey. The participants answered an online questionnaire via the lime survey software.

2.3 Measurements

We developed a self-questionnaire to collect data on demographic, occupational and medical characteristics. The duration of the questionnaire was approximately 10 minutes.

The main endpoint (anxiety disorders) was assessed on the validated French version of the Hospital Anxiety and Depression Scale (HAD) (14). The “Anxiety” dimensions are rated on 3 level: no symptoms (score≤7), doubtful (8–10), and certain (≥11). Cut-off points to 8 were classified as clinical signs suggestive of anxiety disorders. Bjelland et al. performed a review of the 747 identified papers that used HADS. It was divided into an Anxiety subscale (HADS-A) and a Depression subscale (HADS-D). The correlations between the two subscales varied from .40 to .74 (mean.56). Cronbach’s alpha for HADS-A varied from .68 to .93 (mean .83) and for HADS-D from .67 to .90 (mean .82) [14]. The HADS has good reliability and discriminant validity. The HADS questionnaire is pertinent for detecting symptoms of anxiety and depression in a population of people at work [15].

The self-administered questionnaire covered 3 areas.

Sociodemographic: gender, age, number of children in the household

Occupational: occupational groups, work share, type of wards, self-estimated level exposure to COVID-19, increase of working load, of mental burden or of emotional burden were researched. Perceived stress related to personal life or to occupational life before and during the lockdown were assessed on a visual analogue scale (VAS) [16]. Cut-off points to 7 were classified as clinical signs suggestive of stress. Maslach and Jackson’s Burnout Inventory is one of the descriptive models, assessing psychological impact at work in terms of the consequences of chronic stress [17]. The burnout was assessed on the French version of the Maslach Burnout Inventory (MBI) [17]. Analysis of the relationship between the French version of the MBI and other health measures measured among nurses reveals a high degree of convergence, demonstrated first and foremost by moderate to high correlations (r = .38 to .67) of the MBI with mental health indicators [18]. Regarding the internal consistency of the complete 22-item scale for The French version of the Maslach Burnout Inventory, Lheureux et al. found alpha coefficients of .90 (Emotional Exhaustion), .71 (Depersonalization) and .78 (Personal Acomplishment) [19].

The 3 score dimensions are assessed independently.

Emotional exhaustion: questions 1, 2, 3, 6, 8, 13, 14, 16, 20.

Here, burnout is light for total score≤17, moderate for 18–29 and severe for ≥30.

Loss of empathy or depersonalization: questions 5, 10, 11, 15, 22. Here, burnout is light for total score≤5, moderate for 6–11 and severe for ≥12.

Personal accomplishment: questions 4, 7, 9, 12, 17, 18, 19, 21. Here, burnout is light for total score >40, moderate for 34–39 and severe for <33.

Medical: previous anxiety disorders, intake of psychotropic treatment, psychological follow-up, change in frequency of physical activity, change in alcohol consumption, change in smoking consumption, quality of sleep, infection by virus SARS-CoV-2, concerns related to the risk of infection, concerns about a personal health situation, concerns about a loved one’s health situation, concerns about work conditions, concerns related to information transmitted by the media, concerns about the end of the lockdown.

2.4 Analysis

A descriptive analysis was made of the sample’s sociodemographic, occupational and medical characteristics.

Then a univariate analysis assessed the association between anxiety disorders and sociodemographic, occupational and medical factors. Chi² and Fisher tests were applied as appropriate. The significance threshold was set at 5%. Variables significantly associated with anxiety disorders were introduced into a stepwise logistic regression model. Variables with p-value≤0.1 were included in the multivariate model on a descending procedure, and variables with p-value < 0.05 were kept in the model. Analyses used SAS 9.4 software.

3 Results

Description of sociodemographic, occupational and medical characteristics (Tables 1 and 2)

Table 1
Relations between anxiety disorders and occupational factors

Anxiety Disorders

No (N = 95) Yes (N = 69) Total (N = 164)

N % N % N % p-value

Gender Female 72 55.4 58 44.6 130 79.3 0.19

Male 23 67.6 11 32.4 34 20.7

Family situation In Couple 72 56.2 56 43.8 128 78.0 0.68

Single 17 65.4 9 34.6 26 15.9

Separated divorced or Widowed 6 60.0 4 40.0 10 6.10

Number of children in household 0 32 62.7 19 37.3 51 31.5 0.44

1 15 50.0 15 50.0 30 18.5

2 38 61.3 24 38.7 62 38.3

3 5 38.5 8 61.5 13 08.0

4 4 66.7 2 33.3 6 3.70

Occupational group Auxiliary nurses 16 53.3 14 46.7 30 18.3 0.7

Paediatric Auxiliary Nurses 4 40.0 6 60.0 10 6.1

Nurses 29 54.7 24 45.3 53 32.3

Physicians 26 60.0 14 40.0 40 24.4

Midwives 6 60.0 4 40.0 10 06.1

Surgeon 4 66.7 2 33.3 06 03.7

Medical residents 7 58.4 5 41.7 12 07.3

Other healthcare workers 3 100.0 0 0.0 03 1.8

Work share (number hours per week) <25 h/w 4 66.7 2 33.3 6 3.7 0.87

[26 h/w – 35 h/w] 33 54.1 28 45.9 61 37.2

Between 36 h/w and 48h/w 34 60.7 22 39.3 56 34.1

>48h/w 24 58.5 17 41.5 41 25.0

Increase working time No 68 58.6 48 41.4 116 71.6 0.81

Yes 26 56.5 20 43.5 46 28.4

Level of self-estimated occupational exposure to COVID-19 Light 27 67.5 13 32.5 40 32.3 0.16

Moderate or high 68 54.8 56 45.2 124 67.7

Types of wards by COVID-19 sectors COVID-19 free sector (secteur1) 14 58.3 10 41.7 24 14.6 0.78

COVID-19 mixed sector 68 56.7 52 43.3 120 73.2

COVID-19 full sector 13 65.0 7 35.0 20 12.2

Increase stress related COVID-19 No 45 72.6 17 27.4 62 37.8 0.0030

Yes 50 49.0 52 51.0 102 62.2

Increase workload since the beginning of lockdown No 65 52.4 59 47.6 124 75.6 0.00119

Yes 30 75.0 10 25.0 40 24.4

Increase emotional burden since the beginning of lockdown No 77 67.5 37 32.5 114 69.5 0.0002

Yes 18 36.0 32 64.0 50 30.5

Increase mental burden since the beginning of lockdown No 51 67.1 25 32.9 76 46.3 0.03

Yes 44 50.0 44 50.0 88 53.7

Increase physical burden since the beginning of lockdown No 69 61.6 43 38.4 112 68.3 0.16

Yes 26 50.0 26 50.0 52 31.7

Level of stress related to personal life before the lockdown Light 92 59.4 63 40.6 155 94.5 0.17

High 3 33.3 6 66.7 9 05.5

Level of stress related to personal life during the lockdown Light 85 66.9 42 33.1 127 74.4 < 0.0001

High 10 27.0 27 73.0 37 22.6

Level of stress related to occupational life before the lockdown Light 88 62.0 54 38.0 142 86.6 0.008

High 7 31.8 15 68.2 22 13.4

Level of stress related to occupational life during the lockdown Light 78 72.9 29 27.1 107 65.2 < 0.0001

High 17 29.8 40 70.2 57 34.8

Emotional exhaustion Light 76 66.6 36 33.3 114 72.6 < 0.0001

Moderate 13 40.6 19 59.4 32 20.4

High 0 0 11 100 11 07.0

Loss of empathy Light 24 88.9 3 11.1 27 17.1 0.0013

Moderate 57 50.4 56 49.6 113 71.5

High 10 55.5 8 44.4 18 11.4

Personal accomplishment High 24 75.0 8 25.0 32 19.5 0.0848

Moderate 41 55.4 33 44.6 74 45.1

Light 30 51.7 28 48.3 58 35.4

		Anxiety Disorders
Gender	Female	72	55.4	58	44.6	130	79.3	0.19
	Male	23	67.6	11	32.4	34	20.7
Family situation	In Couple	72	56.2	56	43.8	128	78.0	0.68
	Single	17	65.4	9	34.6	26	15.9
	Separated divorced or Widowed	6	60.0	4	40.0	10	6.10
Number of children in household	0	32	62.7	19	37.3	51	31.5	0.44
	1	15	50.0	15	50.0	30	18.5
	2	38	61.3	24	38.7	62	38.3
	3	5	38.5	8	61.5	13	08.0
	4	4	66.7	2	33.3	6	3.70
Occupational group	Auxiliary nurses	16	53.3	14	46.7	30	18.3	0.7
	Paediatric Auxiliary Nurses	4	40.0	6	60.0	10	6.1
	Nurses	29	54.7	24	45.3	53	32.3
	Physicians	26	60.0	14	40.0	40	24.4
	Midwives	6	60.0	4	40.0	10	06.1
	Surgeon	4	66.7	2	33.3	06	03.7
	Medical residents	7	58.4	5	41.7	12	07.3
	Other healthcare workers	3	100.0	0	0.0	03	1.8
Work share (number hours per week)	<25 h/w	4	66.7	2	33.3	6	3.7	0.87
	[26 h/w – 35 h/w]	33	54.1	28	45.9	61	37.2
	Between 36 h/w and 48h/w	34	60.7	22	39.3	56	34.1
	>48h/w	24	58.5	17	41.5	41	25.0
Increase working time	No	68	58.6	48	41.4	116	71.6	0.81
	Yes	26	56.5	20	43.5	46	28.4
Level of self-estimated occupational exposure to COVID-19	Light	27	67.5	13	32.5	40	32.3	0.16
	Moderate or high	68	54.8	56	45.2	124	67.7
Types of wards by COVID-19 sectors	COVID-19 free sector (secteur1)	14	58.3	10	41.7	24	14.6	0.78
	COVID-19 mixed sector	68	56.7	52	43.3	120	73.2
	COVID-19 full sector	13	65.0	7	35.0	20	12.2
Increase stress related COVID-19	No	45	72.6	17	27.4	62	37.8	0.0030
	Yes	50	49.0	52	51.0	102	62.2
Increase workload since the beginning of lockdown	No	65	52.4	59	47.6	124	75.6	0.00119
	Yes	30	75.0	10	25.0	40	24.4
Increase emotional burden since the beginning of lockdown	No	77	67.5	37	32.5	114	69.5	0.0002
	Yes	18	36.0	32	64.0	50	30.5
Increase mental burden since the beginning of lockdown	No	51	67.1	25	32.9	76	46.3	0.03
	Yes	44	50.0	44	50.0	88	53.7
Increase physical burden since the beginning of lockdown	No	69	61.6	43	38.4	112	68.3	0.16
	Yes	26	50.0	26	50.0	52	31.7
Level of stress related to personal life before the lockdown	Light	92	59.4	63	40.6	155	94.5	0.17
	High	3	33.3	6	66.7	9	05.5
Level of stress related to personal life during the lockdown	Light	85	66.9	42	33.1	127	74.4	< 0.0001
	High	10	27.0	27	73.0	37	22.6
Level of stress related to occupational life before the lockdown	Light	88	62.0	54	38.0	142	86.6	0.008
	High	7	31.8	15	68.2	22	13.4
Level of stress related to occupational life during the lockdown	Light	78	72.9	29	27.1	107	65.2	< 0.0001
	High	17	29.8	40	70.2	57	34.8
Emotional exhaustion	Light	76	66.6	36	33.3	114	72.6	< 0.0001
	Moderate	13	40.6	19	59.4	32	20.4
	High	0	0	11	100	11	07.0
Loss of empathy	Light	24	88.9	3	11.1	27	17.1	0.0013
	Moderate	57	50.4	56	49.6	113	71.5
	High	10	55.5	8	44.4	18	11.4
Personal accomplishment	High	24	75.0	8	25.0	32	19.5	0.0848
	Moderate	41	55.4	33	44.6	74	45.1
	Light	30	51.7	28	48.3	58	35.4

Table 2

Relations between anxiety disorders and medical factors

		Anxiety Disorders
		No (N = 95)		Yes (N = 69)		Total (N = 164)
Facteurs médicaux		N	%	N	%	N	%	p-value
Previous anxiety disorders	No	90	62.5	54	37.5	144	87.8	0.0015
	Yes	5	25.0	15	75.0	20	12.2
intake of psychotropic treatment	Non	93	60.4	61	39.6	154	93.9	0.018
	Oui	2	20.0	8	80.0	10	06.1
psychological follow-up	No	93	59.2	64	40.8	157	95.7	0.13
	Yes	2	26.6	5	71.4	7	04.3
Quality of sleep	severely degraded or degraded	40	45.5	48	55.5	88	53.7	0.0009
	No change	52	73.2	19	26.8	71	43.3
	Substantial improvement	3	60.0	2	40.0	05	03.0
change in alcohol consumption during the lockdown	None consumption	30	56.6	23	43.4	53	32.3	0.11
	No change	11	91.7	1	8.3	12	07.3
	Discrease of consumption	33	55.0	27	45.0	60	36.60
	Increase of consumption	21	53.8	18	46.2	39	23.80
Change in smoking consumption	None consumption	72	57.6	53	42.4	125	76.2	0.96
	Discrease of consumption	3	75.0	1	25.0	04	02.4
	No change	5	57.7	4	42.3	09	05.5
	Increase of consumption	15	57.7	11	42.3	26	15.9
Change in frequency of physical activity	None physical activity	18	60.0	12	40.0	30	18.3	0.17
	Discrease in physical activity	39	54.2	33	45.8	72	43.9
	No change	16	80.0	4	20.0	20	12.2
	Increase in physical activity	22	52.4	20	47.6	42	25.6
Did you contract the COVID-19 infection?	No	94	59.5	64	40.5	158	96.3	0.037
	Yes	1	16.6	5	83.4	6	3.7
Concerns related to the risk of infection	No	67	54.4	56	45.5	123	75.0	0.12
	Yes	28	68.3	13	31.7	41	25.0
Concerns about a personal health situation	No	89	60.1	59	39.9	16	9.8	0.0815
	Yes	6	37.5	10	62.5	148	90.2
Concerns about a loved one’s health situation	No	58	57.4	43	42.6	63	38.4	1.0
	Yes	37	58.7	26	41.3	101	61.6
Concerns about work conditions	No	76	63.3	44	36.7	44	26.8	0.0206
	Yes	19	43.2	25	56.8	120	73.2
concerns related to information transmitted by the media	No	78	62.4	47	37.6	125	76.2	0.0378
	Yes	17	43.6	22	56.4	39	23.8
Concerns about the end of lockdown	No	58	59.2	40	40.8	66	40.2	0.69
	Yes	37	56.1	29	43.9	98	59.8

164 of the 285 eligible HCWs (130 female, 34 male) responded: response rate, 57%. The average age is 39 years (SD = 10.1). One quarter reported working more than 48 hours a week. More than three-quarters reported experience moderate to intense exposure to risk of contracting COVID-19 and working in mixed wards with COVID-19. Almost two thirds reported an increase in stress levels and more than half reported an increase in mental workload. One third has high emotional exhaustion.

3.1 Prevalence of anxiety disorders (Table 1)

Sixty-nine respondents (42%) presented anxiety disorders.

Relations between anxiety disorders and occupational factors, univariate analysis (Table 1)

Anxiety disorders were significantly associated with personal or occupational stress levels, with mental and emotional workload and with the loss of empathy and emotional exhaustion dimensions of burnout. However, anxiety disorders were not significantly associated with the self-estimated occupational exposure to COVID-19 and with the type of wards.

3.2 Relations between anxiety disorders and medical factors, univariate analysis (Table 2)

Anxiety disorders were significantly associated with medical history of anxiety disorders, with psychotropic treatment, with quality of sleep, with the COVID 19, with work-related anxiety, with concern related to working conditions or to media reports on COVID 19.

3.3 Relations between anxiety disorders and occupational and medical factors, multivariate analysis (Table 3)

Table 3
Medical and occupational factors significantly related to anxiety disorders (univariate and multivariate analysis)

Anxiety Disorders

OR IC ORadj CI

Previous anxiety disorders No 1.0

Yes 2.0 1.44–2.78

intake of psychotropic treatment No 1.0

Yes 2.02 1.40–2.91

Quality of sleep severely degraded or degraded 0.67 0.21–2.09

No change 1.36 0.46–4.05

Substantial improvement 1

Did you contract the COVID-19 infection? No 1

Yes 2.06 1.37–3.09

Concerns about working conditions No 1

Yes 1.55 1.09–2.19

Concerns related to information transmitted by the media No 1

Yes 1.50 1.05–2.14

Increase stress related COVID-19 No 1

Yes 1.86 1.19–2.90

Increase of work load No 1

Yes 1.90 1.08–3.36

Increase of emotional burden No 1 1

Yes 1.97 1.41– 2.76 1.42 1.06– 1.92

Increase of mental burden No 1

Yes 1.52 1.04–2.23

Level of stress related to personal life during the lockdown Light 1

High 2.21 1.61–3.02

Level of stress related to occupational life before the lockdown Light 1

High 1.79 1.26–2.56

Level of stress related to occupational life during the lockdown Light 1 1

High 2.59 1.82–3.69 2.21 1.46–3.37

Emotional exhaustion Light

Moderate

High

Loss of empathy Light 1

Moderate 4.46 1.51–13.1

High 4.00 1.22–13.09

	Anxiety Disorders
Previous anxiety disorders	No	1.0
	Yes	2.0	1.44–2.78
intake of psychotropic treatment	No	1.0
	Yes	2.02	1.40–2.91
Quality of sleep	severely degraded or degraded	0.67	0.21–2.09
	No change	1.36	0.46–4.05
	Substantial improvement	1
Did you contract the COVID-19 infection?	No	1
	Yes	2.06	1.37–3.09
Concerns about working conditions	No	1
	Yes	1.55	1.09–2.19
Concerns related to information transmitted by the media	No	1
	Yes	1.50	1.05–2.14
Increase stress related COVID-19	No	1
	Yes	1.86	1.19–2.90
Increase of work load	No	1
	Yes	1.90	1.08–3.36
Increase of emotional burden	No	1		1
	Yes	1.97	1.41– 2.76	1.42	1.06– 1.92
Increase of mental burden	No	1
	Yes	1.52	1.04–2.23
Level of stress related to personal life during the lockdown	Light	1
	High	2.21	1.61–3.02
Level of stress related to occupational life before the lockdown	Light	1
	High	1.79	1.26–2.56
Level of stress related to occupational life during the lockdown	Light	1		1
	High	2.59	1.82–3.69	2.21	1.46–3.37
Emotional exhaustion	Light
	Moderate
	High
Loss of empathy	Light	1
	Moderate	4.46	1.51–13.1
	High	4.00	1.22–13.09

OR: Odds Ratio; ORadj: Odds Ratio adjusted (Variables with p-value≤0.1 were included in the multivariate model on a descending procedure, and variables with p-value < 0.05 were kept in the model). CI: confidence interval.

Multivariable logistic regression analysis showed that, after controlling for confounders, anxiety disorders remained associated with an increase of emotional workload and occupational stress levels during the lockdown.

4 Discussion

4.1 Discussion of the results

Infectious disease outbreaks are known to have psychological impact on HCWs as well as the general population [20]. Assessing mental health for HCW during the COVID-19 epidemic is an inevitable precondition for coping with stress and important measures for fighting disease [21].

The main objective of our study was to assess the prevalence of anxiety disorders among HCW during the first wave of the COVID-19 health crisis.

Our study found a 42% prevalence of anxiety disorders among HCW. According to Muller et al. who performed a systematic review, the percentage of HCWs with anxiety disorders ranged from 9% to 90% with a median of 24% [22]. Our findings [42%] are consistent with those of Lai et al. who showed that 560 out of 1257 HCWs have anxiety disorders [44.6%] [23]. Previous studies have reported that psychological symptoms, such as anxiety, depend on the epidemic phase [24].One month after the start of COVID-19 epidemic, at the peak of the epidemic period, Xiao et al. examined the prevalence anxiety among 958 HCW across 26 provinces in China. They showed that 54.1% of HCW had symptoms of anxiety [25]. Besides Deng et al. observed in a meta-analysis (34 articles included) a different prevalence changing trends among healthcare workers before and after the peak of COVID-19 in China: Prevalence of anxiety was 38 % (95% CI: 12%–63%) before 8th February, 2020 and was 22% (95% CI: 12%–63%) after before 8th February, 2020 [26]. Vanhaecht et al. found that increased anxiety was related to exasperated work pressure and heightened work stress, which led to adverse mental health [27]. A few evidences may suggest that the prevalence changing trend among healthcare workers may be related to different level of cognition about the Coronavirus Disease 2019, about better availability of protective equipment (respirators in particular)and about better adaptation of healthcare workers to changes in work organization [26].

The second objective of our study was to assess whether the prevalence of anxiety disorders differed according to the intensity of SARS-CoV-2 exposure.

Our results didn’t show that the prevalence of anxiety is higher in COVID-19 wards compared to other wards whereas previous studies found that medical workers who provided direct treatment or care for infected patients suffered higher anxiety scores, compared to those who were not caring for COVID-19 patients [28]. Our findings could be explained by HCWs interviewed were be able to access to adequate personal protective equipment. Xiao et al showed that different levels of anxiety were also found between sub-groups of protective measures [sufficient, general, deficient and no protected measures] [p = 0.001 for anxiety] as well as contact history (contact with diagnosed, contact with suspected, contact with specimen of patients and no contact) (p < 0.01) [25].

The third objective of our study was to investigate personal, medical, and occupational factors associated with anxiety disorder.

Regarding related factors in anxiety and depression, Xiao et al. found significant differences in anxiety and depression levels between males (45.5%) and females (58.2%) (p < 0.01) but our findings did not find any significant differences in anxiety between males (32.4% and females (44.6%) [25]. The lack of evidence of significant gender difference (p = 0.19) may be related to the low proportion of men (21%) in our sample and to its size (n = 164). Moreover the proportion of men in the sample is higher (20.7%) than the target population of French health care workers (15%) [29].

Our results highlighted a significant association between anxiety disorders and medical factors such as previous anxiety disorders and sleep disorders. People with a history of psychiatric illnesses are at risk of higher levels of stress and psychological distress, [30]. It is therefore consistent that we find a significant association between anxiety disorders and a personal history of previous anxiety disorders. Besides we found that a significant association between anxiety disorders and concerns related to information transmitted by the media. Social media including both the printed and the digital media has a significant role in the spread of information in France. The wide-spread news coverage about COVID-19 may heighten anxiety and fear among HCWs. Arafa et al. showed that watching/reading COVID-19 news ≥2 h/day was associated with depression, anxiety, stress, and inadequate sleeping [31]. Sleep deficiency during stress states increases exposure to anxiety [32]. A close relationship between the occurrence of sleep disorders and anxiety disorders in the general population has been demonstrated [33]. In our study, more than half of HCWs reported difficulties in sleeping during the pandemic. Previous pandemic experiences showed that these reactions reflect a sense of fearful waiting, or even terror, about what the future may hold for all humankind while an unfamiliar and uncomfortable quiet fills the halls [34].

Our results highlighted a significant association between anxiety disorders and occupational factors such as stress and emotional burden related to occupational life during the lockdown.

COVID 19 epidemic has spread to the entire country, and the number of confirmed and suspected patients has increased rapidly in a short period of time. HCWs feel anxiety and helplessness due to so many patients. According to El Hage et al., during COVID 19 crisis, stress may be caused by concerns about not being able to provide competent care, lack of access to up-to date information, lack of specific drugs, the shortage of ventilators and intensive care unit beds necessary to care and an overwhelming workload [35]. Many studies observed high rates of anxiety, stress symptoms, among the HCWs during the pandemic. We found that 62.2% of HCW had elevated stress levels during the COVID-19 epidemic which corroborates the findings of Xiao et al. (55.1%) [25]. The long-term effects of stress can result in anxiety. Higher anxiety has been reported to correlate positively with stress among healthcare workers during the COVID-19 pandemic [36].

HCWs are involved with infected patients’ care faced with an unknown threat to their own life. Excessive workload, fear of contagion, feeling of being under pressure, lack of specific drugs, and isolation of community were the major issues faced by healthcare workers during the time of the COVID-19 outbreak [37]. During this crisis, the intensive work drained HCWs physically and emotionally [28]. An increase in the workload of HCWs during the COVID-19 pandemic was reported in countries [28]. In our study, consistent with other studies long working time per week increased stress, which is correlated with anxiety disorders [38, 39]. Despite, we underlined that an increase workload was associated with anxiety disorders among HCWs involved in health crisis Covid 19.

Our findings underlined the association between anxiety disorders and two dimensions of burnout: exhaustion and loss of empathy among HCWs during the health crisis COVID-19. These results corroborate those of previous studies who showed that anxiety and stress developed in the physicians during the outbreaks found to have a positive correlation with Maslach burnout inventory scores [40]. Shah et al. identified excessive workload and work hours as contributing factors to burnout in coronavirus pandemic [41].

4.2 Study limitations

First, the cross-sectional design restricted our ability to distinguish between preexisting and new symptoms and to study whether the psychological symptoms of HCWs have been worsening or not, therefore, a longitudinal study is warranted.

Second, because of the lockdown, we had to solely rely on the online survey to access HCWs. This method of data collection can be accompanied by non-response bias that could undermine the generalizability of the study because non-respondents might carry different characteristics compared with the respondents. To avoid this bias, we extended the survey collection period to10 days so that HCWs were able to choose when to respond according to their busy schedule, and reminders were sent after the first 5 days.

5 Conclusions

Healthcare staff are at increased risk of moral injury and mental health problems when dealing with challenges of the covid-19 pandemic. Healthcare managers need to proactively take steps to protect the mental wellbeing of staff. Based on our findings, we recommend a few points to safeguard the mental health of HCWs. Preventive actions focusing on organizational factors could be carried out: Restrict excessive workload by scheduling breaks, limit work hours, and provide regular psychosocial support, and training on how to relax should be properly arranged to help staff reduce stress in the context of a health crisis related to COVID-19.The employers of the medical institutions should pay more attention to the mental health of the healthcare worker in their routine work, in general, and during the outbreak of an epidemic, such as COVID-19, in particular.

Recent studies have highlighted the benefits of early detection of anxiety disorders among HCWs following the COVID-19 health crisis, as a complement to the implementation of team support measures [42, 43]. This early detection could be supported by occupational health services tasked with prevention missions [44]. Moreover, new research should explore resilience-building interventions to improve coping mechanism and mental-well-being among HCWs, assessing the effectiveness of a such program in reducing anxiety disorders [43].

Ethical approval

Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the University Hospital Center of Saint Etienne (IRBN662020/CHUSTE).

Informed consent statement

Informed consent was obtained from all subjects involved in the study.

Conflicts of interest

The authors declare no conflict of interest.

Footnotes

Acknowledgments

The authors would like to thank all the participants HCWs.

Funding

No funding source to report

Author contributions

Conceptualization, C.P and L. F.; Data curation, C. P., M. V., M. M. and L. F.; Formal analysis, C. P.; Investigation, C. P. and M. V.; Methodology, C. P., M. V., M. M. and L. F.; Project administration, C. P., M. V., M. M., P. C. and L. F.; Resources, C. P.; Software, C. P.; Supervision, C. P. and L. F.; Validation, C. P., M. V., M. M., P. C. and L. F.; Visualization, C. P.; Writing – original draft, C. P.; Writing – review & editing, C. P., M. V., M.M., P.C. and L. F.

All the authors have read and agreed the published version of the manuscript”

Data availability statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to the confidentiality of participants.

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	Anxiety Disorders
		OR	IC	ORadj	CI
Previous anxiety disorders	No	1.0
	Yes	2.0	1.44–2.78
intake of psychotropic treatment	No	1.0
	Yes	2.02	1.40–2.91
Quality of sleep	severely degraded or degraded	0.67	0.21–2.09
	No change	1.36	0.46–4.05
	Substantial improvement	1
Did you contract the COVID-19 infection?	No	1
	Yes	2.06	1.37–3.09
Concerns about working conditions	No	1
	Yes	1.55	1.09–2.19
Concerns related to information transmitted by the media	No	1
	Yes	1.50	1.05–2.14
Increase stress related COVID-19	No	1
	Yes	1.86	1.19–2.90
Increase of work load	No	1
	Yes	1.90	1.08–3.36
Increase of emotional burden	No	1		1
	Yes	1.97	1.41– 2.76	1.42	1.06– 1.92
Increase of mental burden	No	1
	Yes	1.52	1.04–2.23
Level of stress related to personal life during the lockdown	Light	1
	High	2.21	1.61–3.02
Level of stress related to occupational life before the lockdown	Light	1
	High	1.79	1.26–2.56
Level of stress related to occupational life during the lockdown	Light	1		1
	High	2.59	1.82–3.69	2.21	1.46–3.37
Emotional exhaustion	Light
	Moderate
	High
Loss of empathy	Light	1
	Moderate	4.46	1.51–13.1
	High	4.00	1.22–13.09