Psychological Effects on Healthcare Workers in Syria During COVID-19

as COVID-19.


Introduction
Since the announcement of coronavirus disease 2019 (COVID-19) as a global pandemic by the world health organization (WHO) on March 12th, 2020 (1), this dramatic and sudden increase has created a remarkable burden on health care facilities and health care workers (HCWs) from all specialties. HCWs were, sometimes, facing moral dilemmas when making decisions regarding patients admitted to medical facilities (2).
There have been reports from different countries about symptoms related to anxiety and depression related to the current pandemic, health care workers were among those at higher risk of such symptoms (3).
Few studies have been conducted to evaluate the psychological effects of the pandemics on workers in health care elds (2). This is particularly important when there is an increase in workload and stress related to the probability of infection (2), not to mention the lack of proper personal protection equipment (PPE) and the shortage in medical supplies that stroke almost all heavily damaged areas (4,5). The health care system in war-torn Syria is facing two main challenges. On one hand, the health issues related to the longlasting con ict since 2011 (6), while on the other hand the current pandemic which created an additional burden on both the community, due to the quarantine measurements, and healthcare system due to the signi cant reduction of available resources and functional facilities (7,8).
The situation in Syria can be considered as complicated, compared to other countries. Long-lasting con ict and economic collapse are among additional factors that affect efforts against the pandemic (9).
During the Syrian crisis, some researchers have tried to explore post-traumatic stress disorder (PTSD) illnesses or psychological support (10).
Despite the high risk of infection, health care workers are on the front line during the pandemic (11,12), therefore, it is important to study the Psychological Effects on Healthcare Workers in a war-torn country. This study focuses on three main aspects related to mental health among HCWs in Syria during the current pandemic. Generalized anxiety disorder, sleep quality, and psychological distress, and compare it with the situation of Syrian HCP outside Syria.

Materials And Methods
Ethical approval: Ethical approvals have been obtained from the higher committee for research at Damascus university.

Study Participants:
The study included 660 participants in two phases (phase one N=76, Phase two= 584). Participants were included in the study if they stated that they were health care workers, e.g nurses, medical doctors, medical residents, dentists, pharmacists, or laboratory doctors.
Participants were excluded from the study if they were medical students, don't work in the medical eld. All study participants agreed to be a part of the study. Informed consent was collected from every participant on the rst electronic page of the questionnaire.
A rigorous policy of full participation willingness was adopted, withdrawal from the study was accepted in any phase. Withdrawn individual questionnaires were excluded from the study immediately, as described before. (13) Study Design: This study is a cross-sectional observational study. It was conducted using online surveys (based on Google Forms) due to the restrictions which made it very di cult to conduct face-to-face data collection, the survey was published on social media platforms. The survey included demographical, social, and workplace-related information. Validated clinical questionnaires and scoring systems were used to evaluate levels of anxiety, sleep quality, and psychological distress. (14)(15)(16) This study has two phases: the rst questionnaire was published on February 14 th , 2020, and the data collection was done in 1 week period, thus, before the announcement of the rst COVID-19 case in Syria. 76 people participated in this phase and this group was used as a baseline comparison group.
The questionnaire was published again, in a second phase, on April 14th, 2020, thus two months after the rst phase, and after the announcement of the rst case of COVID-19 in Syria. In this phase, 584 HCWs participated in this survey.
The surveys were published on social media platforms known to contain or be followed by a large number of Syrian HCWs and groups that included them. It may also be referred to and disseminated by health care workers themselves. No identifying information of participants was included in any of the surveys.
Demographic, social, and workplace-related information: Demographic and social data collected from participants included age, location, marital status, profession, and department.
Work-related information was an evaluation of the work environment including direct or indirect interaction with COVID-19 patients, the psychological effect of interacting with a COVID-19 patient on the participant, the preparedness of the workplace to cut transmission chain of infection, providing the basic needs of the participant, daily work hours, and ability to diagnose and manage a COVID-19 patient.
The evaluation of providing the basic needs of the participant was based on a scale from 0 to 10 where 10 represented (excellent) and 0 represented (very bad). Whereas the evaluation of the preparedness of the workplace to prevent the transmission of infection was a yes/no question.
The Pittsburgh Sleep Quality Index (PSQI) (15): The PSQI survey is used to evaluate the quality of sleep among older adults. It determines the quality of sleep by measuring seven aspects: subjective sleep quality, sleep latency, sleep duration, habitual sleep e ciency, sleep disturbances, use of sleep medication, and daytime dysfunction over the last month. Each aspect is given a score between 0 and 3, so the total score will be ranging between 0 and 21. The higher the score, the lower the sleep quality (15).

Kessler Psychological Distress Scale (K10) (16):
The (k10) survey is used to evaluate distress based on questions related to symptoms of anxiety and depression that a person has suffered from during the last month. The survey consists of 10 questions, each question has ve choices related to the frequency of a symptom, ranging from "none of the time" to "all the time". Scores will range from 10 to 50. The higher the score, the more likely it that the individual has a mental disorder (16).

GAD-7 (Generalized Anxiety Disorder-7) (14):
The GAD-7 questionnaire is used as a quick screening tool to detect the presence of a clinically signi cant anxiety disorder, especially in outpatient settings. The questionnaire consists of 7 questions related to anxiety each has a set of 4 answers related to the frequency of each symptom ranging from "not at all' to "nearly every day". A higher score means that the symptoms are increasing in severity. Scores above 10 require further assessment including diagnostic interviews and the examination of mental status (14).

Results
The data collection for the research was on two stages, the rst stage collected data from medical staff before the announcement of any COVID-19 related cases in Syria, therefore, it can best descript the normal status of the Syrian medical staff, several questionnaires collected was (91), and 15 participants were excluded because they were not from medical staff, and the nal number for the rst sample was 76.
The second stage collected data after two months of the rst phase, which can best describe the status of medical staff during the pandemic, 619 questionnaires were collected, and 35 were excluded, therefore, the nal sample size was 584 participants. (participant ow chart).
The rst sample consisted of 76 participants, (59.2%) of them had the age between 24-32, over 50% had direct contact with COVID-19 patients, and 36.6% of the sample were not sure about the diagnosis of COVID-19, moreover, 52.6% found that their workplace did not provide them with equipment to protect you from getting infected with COVID-19 (Table N.1).    Q2: Does your workplace provide equipment to protect you from getting infected with COVID-19?
Spearman's correlation test was done to test if there is a signi cant correlation between the three indices, only one signi cant positive correlation was noticed between Kessler index and GAD index (correlation coe cient = 0.681, P-value = 0.000), a scatterplot represents the correlation between the two indices (Graph N.2).

Discussion
The relationship between the mental health of physicians and the quality of medical services has been highlighted (17). This has been directly connected to the prevalence of burnout syndrome and work-related stress (17). In a previous study among medical residents in Syria which is a war-torn County, there has been a signi cant prevalence of burnout due to the collapsed medical system and high workload (18). Thus, it is vitally important to focus on the mental and physical well-being of HCWs in any environment but more critically in fragile or hostile settings. The Syrian healthcare system was ravaged by war. Causing the lack of preparedness and protection for the workers. In addition to the lack of diagnostic tools and the lack of availability of equipment. According to a report by the London School of Economics regarding Syria's response and healthcare capacity, the maximum number of COVID-19 cases that the Syrian healthcare system can properly treat is around 6500 patients (19). Thus, there has been a notable difference in terms of psychological distress between healthcare providers inside and outside Syria.
Many high-income countries are facing problems in providing adequate instruments and preparation of staff. This can easily predict the devastating results that many low-and middle-income countries will face during the pandemic (20). In war-torn countries with a fragile health system and very limited human resources, the problem will be more evident.
The results of our study would give an assumption on the situation in other low-and middle-income countries (21).
Most low-and middle-income countries suffer from the same shortages. for example, shortage of diagnostic and protective tools, intensive care unit beds, oxygen supply, infusion pumps, and mechanical ventilators. (22) These countries typically have overpopulated capitals and urban centers with a mediocre public transport system where social distancing becomes almost impossible. Also, due to the deteriorated economic status, morbidity rates in these countries are higher, thus, hospitals are already suffering affected turnover rate. This in return leads to a lack of capacity to receive new cases, especially during pandemics when a signi cant number of cases are admitted to hospitals in a short period. All those reasons contribute to the accumulation of a heavy workload on HCWs in these countries (20) Generalized anxiety disorder (GAD) had a signi cant relationship with the rst announcement of COVID-19 cases in Syria. During the period between the declaration of the pandemic by the WHO and the diagnosis of the rst case of COVID-19, there was a considerable amount of uncertainty and confusion about the ability of the healthcare system and the availability of equipment, especially that many facilities went out of service due to the armed con ict (23). It was still unclear whether the healthcare system was ready to manage COVID-19 and absorb the impact of the rst wave of cases (7).
There were no adequate o cial statements regarding the plan or preparedness. It was a time where misinformation and fake news took control.
Some media made things may be worse, as it split very acutely, where different media tools were racing to spread news which made people even more confused, lost, and misinformed.
The panic wave stroke health care workers the most, since they were the rst-line responders and had no clear idea of the capabilities of the health system. It was not clear what was the plan, after the announcement of the rst case of COVID-19 in Syria, there was even more confusion and panic. A new wave of misinformation strokes the Syrian Society again. Some organizations expected a widespread of cases in Syria like many other countries and with the poor health system preparedness, the pressure was increasing on the medical staff (24), and it was decided that medical staff will have more continuous working hours. For that reason, it may be noted that the psychological distress and sleep quality index had a close relationship with the availability of equipment, as shown in results.
There was no difference in results between HCWs from inside and outside Syria concerning the rest of the measures. This could be because the sample size for professionals from outside Syria was not su cient to re ect a statistically signi cant difference since there were only 118 participants, compared to 466 from inside Syria.
It may also be explained by the fact that approximately 5 million Syrian refugees ed to Lebanon, Turkey, Jordan, and other nearby countries (25). Therefore, staff members who answered the survey from outside Syria, are most likely to be in a nearby country, thus a country that is not signi cantly better in preparedness and equipment.
Another reason could be the relatively low number of con rmed cases in Syria compared to other countries with a higher number of cases. Nonetheless, the psychological effect was not different leading to the conclusion that the healthcare system and thus the healthcare workers are already emotionally exhausted due to the heavy burden during the ongoing war. Therefore, Syrian healthcare professionals have already the same psychological issues that other healthcare professionals in countries with many more cases have reached (19).
It is noted from the results that the outcomes of the rst and second samples had no statistically signi cant differences in both PSQI and GAD scores. This can be explained by the fact that HCWs are already burned out due to the ongoing con ict since 2011. in addition to the possible signi cant effect of the further deterioration of social and economic status which was signi cant during the con ict but became worse during the lockdown (24).
This study has some limitations, the study design which is a cross-sectional study can predict a correlation between the variables but not causality, using three different scales. We opted for this to explore, in-depth, all possible mental well-being aspects. Having no timer may be considered a challenge. This was extensively discussed, thus, the mediocrity of internet connection in some areas forced avoiding such tools. Being an online-based questionnaire had may be provided high reachability. It may also be more adequately used in social distancing circumstances. However, within those limitations, this research can re ect the challenges of working as a healthcare provider in a war-torn country.

Conclusions
Within the limitation of this study, the results can give an overview of the current situation of the medical staff and HCP working in the Syrian health system.
The high workload was noticeable among the participants both during the rst phase of the research and the sconed phase, the current pandemic further raised the psychological pressure on the healthcare providers working in the Syrian health system, and that was clear by the signi cant difference in Kessler Psychological Distress scale between the rst and the second sample participated in the research. Moreover, higher results of anxiety were accompanied by higher levels of psychological disorder.
The results of this research can play a major role in any plan to provide psychological support for the Syrian healthcare providers. Declarations