The prediction ability of coping strategies in mental ill-health indicators among frontline workers during coronavirus pandemic

Background: Many frontline workers are at high risk of the infection of coronavirus and they might develop mental ill- health indicators particularly fear of coronavirus and Posttraumatic stress disorders. Literature reviews revealed that this depends on their coping strategies which are rarely discussed and investigated within Jordanian context. This study aims at investigating the prediction ability of the coping strategies in mental ill-health indicators among frontline workers during coronavirus pandemic. Participants are 408 volunteer frontline workers; 17.2%females and 82.8%males. Ages ranged between (less than 25 and over than 25) years, work place (Ministry of Health 54.5% and Civil Defense 45.5%), Major (doctors 18.6%, nurses 21.6%, paramedic 33.3%, others 26.5%). Participants are asked to ll out online self-report measures of brief coping, fear of coronavirus and Posttraumatic stress disorders. Results: The results show that coping strategies predicted 28.8% of the variance in fear of coronavirus and 43.6% of the variance in Posttraumatic stress disorders. Moreover, there is a low level of fear of coronavirus and Posttraumatic stress disorders also there are no signicant differences in the level of fear of coronavirus in favor to study variables. At the same time, there are signicant differences in the level of Posttraumatic stress disorders in favor to males: but not for other study variables. Conclusion: Mental ill-health indicators are predicted by coping strategies that frontline workers use.


Coping Strategies
It has been indicated that the ability to cope with di culties like coronavirus pandemic may affect mental ill-health indicators (Secer, et al.,2020). Shechter, et al. (2020) found that the most common source of high distress among health care workers is perceiving lack of control. Furthermore, they found that healthcare workers use empirically-supported coping behaviors but they also reported interest in additional wellness resources.
Moreover, literature reviews indicated that research on coping strategies of frontline workers during coronavirus pandemic are still limited (Heath, Sommer eld & Ungern-Sternberg, 2020). Carmassi et al. (2020) reviewed studies related to other virus diseases outbreak concerning the risk and coping factors for PTSD among healthcare workers. The results show that some factors regarded as risk and coping factors at the same time include; exposure level, working role, years of work experience, social and work support, job organization, age, gender and coping styles. In the same line, Brooks, Amlot, Rubin & Greenberg (2018) found that there are multiple protective factors that play crucial roles in developing mental ill-health indicators those are: training, perceived competence, social support and effective coping strategy.
Coping strategies are classi ed into three different types; task-oriented, emotion-oriented, and avoidanceoriented strategies and they all aim to decrease stress and manage individuals' reactions to stressors and di culties. Task-oriented strategies focus on direct solutions, i.e. action planning, problem solving, positive reappraisal correlate with adaptive psychological wellbeing, sense of control, and self-e cacy.
On the other hand, emotion-oriented strategies focus on regulating emotional state (e.g., emotional disclosure, seeking social-emotional support). In the cases of lack of constructive emotional regulation; emotion-oriented strategy can take the form of increased use of negative emotions (e.g., rumination, suppression, self-blame). The third coping strategy is avoidance-oriented which is concerned about the denying or distortion of stressful situations like; self-distractions, substance use, etc. Literature reviews revealed that the sense of control over the stressors or unpredictable situations such as coronavirus pandemic and the con dence in one's coping resources may increase the use of task-oriented strategies. In contrast, low perceived coping resources and feelings of powerlessness would promote greater use of emotion-oriented and avoidance-oriented strategies. But these strategies may help the individual for a short and immediate time not for a long time (Smith, et al., 2016).

Mental ill-health indicators
Frontline workers, who serve during the COVID-19 pandemic, are at high risk of developing many mental ill-health indicators particularly fear of infection of COVID-19 and posttraumatic stress disorders PTSD (Xiao, et al., 2020). Moreover, in many studies frontline workers reported having neuropsychiatric issues. Frontline workers' duties are to identify the persons who are infected, respond to their treatment and carry out sever cases to hospitals which in turn may put them at the risk of developing fear of coronavirus in addition to the possibility of getting infected by coronavirus disease at any time (Secer, et al.,2020).
Amin (2020) conducted a study to examine the impacts of COVID-19 on health care professionals' psychological wellbeing. The results indicated the presence of corona phobia among them which in turn leads to multiple mental ill-health symptoms. Moreover, Huang., Han., Luo & Ren (2020) investigated mental health among clinical rst-line medical staff and found that about 23.04% of them suffer severe anxiety in favor to female medical staff.
Fear is a defensive mechanism against dangerous situations which in its minimum degrees help us to survive and protect ourselves against threating situations. But intense degrees of fear can lead to psychopathology. The results of limited studies show that fear of COVID-19 leads to extreme emotional and behavioral consequences like; anxiety disorders, suicide and PTSD (Secer, et al., 2020).

Posttraumatic stress disorders (PTSD)
Posttraumatic stress disorders PTSD is the most common mental ill-health indicator studied after the crises like coronavirus pandemic. Moreover, Shechter, et al. (2020) found that PTSD is normal and expected during traumatic events. The results of most studies that were conducted to investigate its ratio among frontline workers during coronavirus pandemic revealed that it has occurred in high rates among them ( There are many features that have the ability to in uence the risk for PTSD among frontline worker such as confronting relatively large numbers of critically ill patients, high mortality rates and lack of effective treatment. Second, they work in highly stressful situations and frequently witness death and trauma (Albott, et al., 2020; Carmassi, et al., 2020).

Coping strategies and mental ill-health indicators (fear of coronavirus, PTSD)
Some studies are conducted to investigate the relationships between coping strategies and mental ill-health during coronavirus pandemic; Secer, et al., (2020) conducted a study to investigate the impact of COVID-19 on 370 healthcare professionals in Turkey on psychological adjustments skills. Results showed that the fear of COVID-19 has a negative effect on the psychological adjustment. And it is found that psychological resilience has a protective function that limits this effect. Moreover, Lotzin, et al. (2020) in their study which was conducted in Austria, Croatia, Georgia, Germany, Italy, Lithuania, Netherlands, Poland, Portugal, and Sweden to investigate the relationship between mental ill-health indicators and coping strategy. It was found that mental ill-health indicators; fear and PTSD correlate to coping strategy. . The result showed that relaxation techniques were implemented on health care workers who take care of patients during severe coronavirus pandemics.
Also, Bhat, Mir, Hussain & Shah (2020) in their study revealed that younger people, females living in urban conditions and those using maladaptive coping skills are likely to have anxiety symptoms. And, liao, Cowling, Lam, Ng & Fielding (2014) found in their study that anxiety and worry were strongly associated with coping in proactive behaviors. Moreover, Zhu, Wei, Meng & Li (2020) found that medical staff have high level of anxiety during COVID-19 and coping styles mediate the association between social support and anxiety.

Questions of the study
The current study aims at examining the prediction ability of coping strategies and mental ill-health indicators (fear of coronavirus, PTSD) among frontline workers. The study attempts to answer the following questions: 1. What are the prominent coping strategies in light of some variables (gender, work place, age and major) among frontline workers? 2. What are the levels of mental ill-health indicators (fear of coronavirus, PTSD) in light of some variables (gender, work place, age and major) among frontline workers?
3. What is the prediction ability of coping strategies on mental ill-health indicators (fear of coronavirus, PTSD) among frontline workers?

Participants
Participants were randomly chosen during the course of this study over the period from September /2020 until the end of December/ 2020. The sample of the current study is comprised of 408 volunteer frontline workers in Jordan who are dealing with COVID cases; (Ministry of Health 54.5% and Civil Defense, 45.5%), (82.8% males, 17.2%o female), The age ranged between (less than 25 and over than 25) years, Major (doctors 18.6%, nurses 21.6%, paramedic 33.3%, others 26.5%). Participants lled out three online selfreport measures.

Instruments
All measures were translated and customized to Jordanian environment and their psychometric characteristics were investigated for Jordanian versions. For the purpose of the current study; PTSD was translated into Arabic language after receiving permission from the scale's correspondent developer. Then, it was back-translated into its original language to ensure consistency. The scale was then modi ed to be more appropriate to the Jordanian environment and psychometric characteristics were derived for the scale. 10 reviewers specialized in counseling, psychometric and psychiatry provided their notes and recommendations on the Jordanian version considering items suitability. The Jordanian version consisted of 8 items. The respondent had to rate how likely he/she would agree or disagree with each statement on a 5-point Likert scale ranging from 1"Never" to 5 "Almost Always". Items Distinction semantics validity for the Jordanian version of the scale were calculated; items values ranged between (0.54-0.88) which indicated an adequate items discrimination validity and Cronbach's coe cient alpha was ( =85). These values are statistically signi cant. Hence, PTSD has adequate psychometric characteristics.

Brief Cope
Coping was measured using Brief COPE scale. It has adequate psychometric characteristics; (a=.68).The original version of the scale involved 28 statements (e.g., I've been refusing to believe that it has happened). (Carver, 1997).
For the purpose of the current study; Brief COPE scale was translated into Arabic and then it was backtranslated into its original language to ensure consistency. The scale was then modi ed to be more appropriate to the Jordanian environment and psychometric characteristics were derived for the scale. 10 reviewers specialized in counseling, psychometric and psychiatry provided their notes and recommendations on the Jordanian version considering items suitability. Finally, the Jordanian version consisted of 28 items. The respondent has to rate how likely he/she would agree or disagree with each statement on a 5-point Likert scale ranging from 1"Never" to 5 "Almost Always". Items Distinction semantics validity for the Jordanian version of the scale were calculated; items values ranged between (.40-.72) which indicated an adequate items discrimination validity. In addition, Cronbach's coe cient alpha was ( =81). These values are statistically signi cant. Hence, Brief COPE scale has adequate psychometric characteristics.

Statistical analysis
Descriptive statistic measures: means and standard deviations were calculated to determine the prominent coping strategies, the levels of fear of coronavirus, PTSD. Then liner regression (Stepwise) and the four -way ANOVA without interaction was calculated to examine the prediction ability of coping strategies to mental ill-health (fear of COVID-19 and PTSD) and the signi cance level was set to (a = 0.05).

Results
The results show that the most prominent coping strategies are substance abuse (M= 4.3444, SD= .96163) and the lowest is venting (M= 2.9608, SD= 1.04314) as shown in (Table 1)  Furthermore, to examine the signi cance of the differences in coping strategies due to the difference in the levels of study variables; a multiple four-way ANOVA was used as shown in (Table 2) below. The results show that the signi cance of the differences in coping strategies was due to the gender, age, major but not to workplace. Moreover, the study shows that coping strategies predicted 28.8% of the variance in fear of COVID-19 as shown in ( Furthermore, the study shows that coping strategies predicted 43.6% of the variance in PTSD as shown in (Table 5) below. Then in (Table 6) below.  It is obvious in table 6 that, the high degree of substance abuse, denial, behavioral disengagement, humor, self-blame lead to low degree of fear of PTSD. Also the high degree of self-distraction and planning give rise to degree of fear of PTSD.

Discussion
The results show that the most prominent coping strategies descending orderly are: substance abuse (ex. medical drugs, smoking), religion, acceptance, planning, humor, behavioral disengagement, positive reframing, active-coping, use of instrumental support, denial, use of emotional support, self-blame, selfdistraction and venting. These result are reasonable because previous research indicated that individuals use more substance abuse (ex. medical drugs, smoking) during crises like coronavirus pandemic to regulate their emotions and decrease mental ill-health like stress and negative emotions (ex. fear of coronavirus infection), pain and depression (Madanifare, Namaei& Jafaring, 2016).
Moreover, the results revealed that the signi cance of the differences in coping strategies was due to gender, age, major but not to workplace. To illustrate more, females reported higher degree than males on self-distraction, active-coping, use of emotional support, venting, positive reframing, planning, humor, and are similar to males on the use of instrumental support.
Workplace didn't make any signi cance differences on the sort of coping strategies. This could be due to the same tasks frontline workers held on their shoulders regardless of the institute they work at. Moreover, the Jordanian government gives many facilities to all institutions and ministries particularly the ministry of health. Furthermore, the individual's personality and their demographic variables would make more signi cant differences like their age, gender etc.
Also, considering the ages which are classi ed into less than 25years and more than 25 years. The result indicated that less than 25 years reported using more active coping, use of emotional support, using of instrumental support, humor, religion and self-blame whereas the ages more than 25 years used coping strategies like self-distraction, denial, substance abuse, behavioral disengagement, venting, positive reframing, planning and acceptance.
The results of the present study considering the major showed that descending orderly; administrative, paramedic, doctors, biological, nurses are using self-distraction. This can be explained by; doctors are using denial more than other medical staff and most of them are more than 25 years also they use behavioral disengagement which consists with denial. Obviously, the ones who use behavioral disengagement are males their ages are more than 25 years. Moreover, doctors reported high degree in using substance abuse (ex. medical drugs, smoking) and lack of using acceptance and active coping.
These results can be illustrated in Chew, et al. (2020) study which aimed at exploring the changes in psychological responses (perceived stress, coping, PTSD) among healthcare workers. They found that using avoidance coping is associated with both perceived stress and PTSD.
Furthermore, the results revealed a moderate use of self-distraction, use of emotional support among females who are less than 25 years), in addition to the use of venting and planning comparing with others. Also, the results revealed that female nurses who are more than 25 years use positive reframing more than doctors and the other majors. And the result showed that male nurses who are less than 25 years use more self-blame than other majors. These results are in accordance with Bhat, et al. (2020) the results of their study revealed that younger people, females and those using maladaptive coping skills are likely to have anxiety symptoms. Also, Zhu, et al. (2020) found that medical staff has high level of anxiety during COVID-19 and coping styles mediate the association between social support and anxiety.
Another way of discussing this nding is through the fact that coronavirus pandemic in Jordan is still under control and there are few numbers of dangerous cases. Moreover, the results showed the prominent coping strategy is using substance abuse (ex. medical drugs, smoking) that may help them to moderate their bad feelings, in otherwise the results showed that participants respectively use religion as a coping strategy; Jordanian citizens have faith in God and most of them possesses spiritual faith of fate and destiny that may help them to lessen the pandemic effects on them. Moreover, the results of the study can be explained by, Counted, Pargament, Bechara, Joynt and Cowden (2020) who examined the role of religion as coping strategy during coronavirus pandemic. Result showed that religious coping is related to well-being this means that it decreases the fear of Covid-19.
Furthermore, the study showed that coping strategies predicted 28.8% of the variance in fear of COVID-19. The

Conclusion
Our study goes in accordance with previous ndings and it recommends to conduct more studies regarding its variable among different samples. Declarations