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 field. All study participants agreed to be a part of the study. Informed consent was collected from every participant on the first 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 Withdrawn individual questionnaires were excluded from the study immediately, as described before.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 difficult 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. (14-16)
This study has two phases: the first questionnaire was published on February 14th, 2020, and the data collection was done in 1 week period, thus, before the announcement of the first 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 first phase, and after the announcement of the first 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 efficiency, 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 five 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 significant 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).