Psychological effect of COVID-19 pandemic on healthcare professionals of Yemen and coping strategies

Background: COVID-19 pandemic has triggered psychological stress such as anxiety and depression among people around the globe. Due to the nature of the job, healthcare professionals are at high risk of infection and are facing social stigma as well. In such a scenarios, it has aggravated their mental health and they are applying various measures to cope with such adverse scenario. Therefore, this research is conducted with the objective to evaluate the psychological inuence of the COVID-19 pandemic among healthcare professionals of Yemen and the coping strategies adopted thereof. Methods: A web-based, as well as face-to-face cross-sectional study, was carried out from July 2020 to December 2020 among healthcare professionals currently working in different provinces of Yemen using a standard questionnaire. The generalized anxiety disorder scale (GAD-7), patient health questionnaire (PHQ-9), and Brief-COPE scales were applied for evaluation of anxiety, depression, and the coping strategies among them. Results: A total of 197 healthcare professionals (N=197) participated in the study where the majority were male 68.5% (n=135) in gender and physicians 42.13% (n=83) by profession. The prevalence of both anxiety (6.84±5.67 for male and 7.37±4.44 for female) and depression (8.06±6.51 for male and 9.56±6.46 for female) were found of mild category among the respondents. A signicant statistical difference was observed between physician versus nurse regarding anxiety and depression based on the working area (p=0.017). Trained professionals demonstrated less anxiety (6.29±5.33) and depression (7.90±6.78) as compared to untrained ones. Source of stress varied in a different province where high fear of self-health and family members was found more in female (3.90±1.00) and such fear was found more in province Sanaa, Lahij, and Abyan (4.75±0.96), (4.57±1.27) (4.50±2.12) respectively. Religion was indicated as a highly adopted coping strategy meanwhile emotional support was found the least used. Conclusions: COVID-19 pandemic has aggravated the psychological stress among healthcare professionals of Yemen. Our ndings illustrate This study investigated the level of anxiety, stress, depression, and the coping behavior thereof in healthcare professionals in Yemen. COVID-19 pandemic has caused a mild impact on the mental health status of Yemeni healthcare professionals. The most frequently adopted coping strategies in most provinces in Yemen were found faith-based religion. The trained professionals demonstrated less level of psychological stress. Our ndings indicate the requirement of adequate plans and policies from administrative to clinical and welfare viewpoint in preparedness and preventive behaviors from the regulatory body that alleviates the psychological stress of such professionals for the ecient provision of better healthcare services throughout the nation.


Background
The COVID-19 pandemic has become a serious public health threat worldwide. The World Health Organization (WHO), on 30 January 2020, announced the occurrence of the novel coronavirus and declared a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations (IHR) [1]. Later, it was declared a pandemic on 11 March 2020 [2].
In such a critical situation, life has been changed due to the restrictions of movement and social contacts. In fact, healthcare professionals (HCPs) wholeheartedly continued providing service with a high risk of getting infected with COVID-19 in such a grave situation. Therefore, HCPs are regarded as one of the most susceptible types of professionals to get psychological problems and mental catastrophe amid COVID-19 pandemic [3]. Different studies are consistently showing that the HCPs experience more stress related to work as compared to the general public [4].
As a standard procedure of containment strategy in such pandemics, a lockdown approach is usually imposed to bound the disease spread and lessen new potential cases by maintaining social distancing [5]. Though it is somewhat feasible for general people to assume such measures, the HCPs are, by the nature of their profession, left exposed to deal with the health-related issues that arise due to such situation and they have to be exposed to the situation. HCPs experience unexpectedly lengthy o ce hours as they have to deal with a load of cases due to such pandemic with the available resources and infrastructure that may not be up to the standard in such an emergency [6]. They often face physical distress and from time to time di culties in breathing while wearing personal protective equipment (PPE), which is mandatory for safety measures to get saved from viral exposure [7].
Because little is known about the COVID-19, and subsequently, without the proven therapy, many HCPs are unrehearsed to perform duties [8]. The fear of autoinoculation, social stigma, and the risk of transmitting the disease to the family members and friends are adding extra burden to them that de nitely impact their mental health [8][9][10].
Thus, it is particularly signi cant to assess the HCPs who are at greater risk of exhaustion and are probable to get suffered from anxiety, depression, and stress in such a pandemic. It is also equally essential to recognize and manage the responsible factors for such mental stress. The mental health status of HCPs of Yemen and their coping strategies have not yet been fully studied. Therefore, this study is conducted with the objectives to assess the anxiety and depression faced by Yemeni HCPs and to determine the coping strategies implemented amid COVID-19 pandemic.

Methods
The study was conducted in Yemen which is a country with a low-income economy and the poverty and the decade-long civil war has seriously affected the country. Many healthcare substructures are vulnerable and the basic healthcare facility is unobtainable to many people. Moreover, the shortage of medicines and medical equipment, the fragile healthcare status, and the limited healthcare resources are the challenging factors for the healthcare delivery amid COVID-19 pandemic in Yemen [11].
Inclusion/Exclusion criteria All the healthcare professionals comprising physicians, pharmacists, nurses, and others who provided care at the medical center were included in this study.
The professionals who refused to participate, from a non-healthcare profession and those who cannot read and write were excluded from the study.

Study questionnaire
The study questionnaire was categorized into four sections. All the questions were in understandable language and the participant was required to answer the questions on their own.
The rst section of the questionnaires was about the demographics of participants that provided personal and organizational information of the health employee.
The second section of the questionnaire comprised of total of seven questions linked to the generalized anxiety scale (GAD-7) for anxiety assessment [12]. It had seven items with a score 0 (not at all) to 3 (nearly every day) that provided a 0 to 21 score. The total score was classi ed into four severity groups, namely; minimal to none (≤ 4), mild (5-9), moderate (10)(11)(12)(13)(14), and severe (≥ 15).
The sources of distress from the current pandemic were measured with a 14-item scale designed from an earlier study on anxiety among university students amid SARS outbreak [14]. It was based on a two-point Likert-scale. The items were categorized under 4 scales such as the health of self, family, and loved ones (possible score: 3 to 6); transmission (possible score: 3 to 6); containment (possible score: 3 to 6); measures taken by authority (possible score: 3 to 6); and effects on daily activities (possible score: 3 to 6).
The fourth section was all about 28-questions of the Brief-COPE scale [15]. It aimed to identify the coping strategies implemented amid COVID-19 pandemic. It consisted of four response choices ranging from the importance of doing activities to cope with the outbreak; (a) not doing this at all, (b) a little bit, (c) moderate amount, (d) doing this a lot. That scale was developed to discover the 14 coping methods: self-distraction, active coping, denial, and substance use, use of emotional support, venting, behavioral disengagement, acceptance, positive reframing, planning, humor, use of instrumental support, religion, and selfblame. Likely scores for every subscale were in a range of 2 to 8, where higher scores indicated propensity to appliance the analogous coping style.

Ethical approval
The study has been reviewed and approved by The Human Ethical Committee, University of the Punjab, Lahore. The ethical and professional considerations were followed throughout the study to keep the data and investigational information strictly con dential.

Statistical analysis
The data were coded, entered, and analyzed from SPSS (IBM, version 22). Results were articulated by using descriptive statistics where continuous data were expressed as mean and standard deviation (SD) whereas categorical data were presented as numbers and percentages. A p-value of less than 0.05 was considered statistically signi cant. Independent t-test and ANOVA test were executed, wherever applicable, for comparison of the difference of scores related to anxiety, depression, source of distress, and coping strategies among demographic variables. Furthermore, for trior polychotomus variables, a series of post-hoc analysis with Bonferroni adjustment was implemented to evaluate signi cance among intergroup variables.

Results
There was a total of 197 respondents (n=197) in our study. The demographic of respondents with anxiety and depression scores are depicted in table 1. The majority of the participants were of age between 20-30 years (n=111) followed by 30-40 years (n=44) and ≥ 40 (n=42). Most of the participants were male (68.5%) and almost half of the respondents were physicians (n=83) followed by other health professionals (n= 41), pharmacists (n = 37), and nurses (n = 36). Approximately 21% of total HCPs were working in COVID-19 isolation wards and 11% were performing duties in COVID-19 intensive care unit (ICU). Meanwhile, 13.7% of respondents were working in quarantines, and the rest of the 53.3% were in other healthcare areas. The mean anxiety level for males (6.84±5.67) and females (7.37±4.44) was found to be of mild category. Similarly, the depression was also rated as mild type in both genders (male = 8.06±6.51, female = 9.56±6.46). Out of total respondents, 116 HCPs who were trained regarding COVID-19 management had shown less anxiety (6.29±5.33) as compared to the non-trained (8.04±5.12) ones. Similarly, depression score of trained HCPs was found less (7.90±6.78) as compared to untrained (9.43±6.06) ones.
The comparison of scores related to anxiety and depression in the categories of age, occupation, experience, posting, and training are shown in table 2. The anxiety and depression score for all age groups were not statistically signi cant, meanwhile, signi cant statistical differences of depression score were reported in occupation wise comparison between physician versus nurse (p= 0.017).   Table 4 indicates the coping strategies embraced by the respondents amid COVID-19 pandemic. The religious coping strategy was reported highest in province Aldhaleh (3.33±0.87) followed by acceptance (3.14±0.69) in province Lahij, and humor (3.00±1.41, 3.00±0.82) in province Abyan and Lahij respectively, whereas it was the lowest for behavioral disengagement (0.00±0.00) in province Abyan and active coping (0.00) in province Hajjah. Table 4 Coping Strategies Adopted by the Participants Most of the coping strategies followed by the HCPs is vary from one province to another, in which maximum used strategy in most provinces in Yemen is faith-based religion, meanwhile, emotional support shows less strategy to be followed in many provinces.
Multiple comparisons of coping strategies among selected variables were illustrated in table 5. Bonferroni correction revealed no signi cant differences in coping style among age categories except in the age group of 20-30 years as compared to 30-40 years that was statistically signi cant in self-blame (p= 0.046) as a coping strategy. While comparing coping strategies occupation-wise, a signi cant relationship was demonstrated only in nurse versus pharmacist comparison on venting (p=0.026). As compared to >10 years experienced HCPs, the HCPs with 5-10 years of experience showed high signi cance on selfblame (p=0.034). Furthermore, no statistically signi cant difference was reported in comparing posting areas regarding coping strategies among all HCPs. A total of 197 HCPs from different provinces of the country participated in this study where a male to female ratio was found to be 2.18 with 68.5% male HCPs. Such ndings of this study are in line with the study conducted in Nepal, where 54.2% of male participants were included [21]. Among the respondents, physicians were the majority HCPs whereas the nurses were found more vulnerable towards anxiety and depression. In gender-wise analysis, female HCPs were reported less in number as well as more depressed and anxious as compared to the male counterparts. This nding is in agreement with the outcome of a study conducted in Saudi Arabia by Al-Hanawi et al. (2020) [22]. The cultural perspective and the more concerns towards taking care of family members might be the contributing factors in this regard. More exposure towards the patients within the ward and workload are the leading cause of susceptibility of psychological stress among nurses [23].
Out of 22 provinces, the maximum number of HCPs participated from province Taiz (29.95%) as it is the largely populated province of Yemen. Though it was a nationwide survey, no HCPs participated from 11 provinces because of inaccessibility in getting contacted due to COVID-19 pandemic and civil war effects.
Our nding of anxiety and depression in both gender were found to be of mild category which is in line with other previous studies such as studies conducted our nding showed no difference in the anxiety of HCPs in working areas, which also contrasts with the previous studies in China that had revealed almost twice the risk of anxiety in different working areas [27]. Some studies have compared the mental disorders experienced by HCPs in areas where the pandemic was widely experienced compared to other regions. Anxiety, fear, and depression were much higher in HCPs in those areas because the HCPs working there are always more susceptible to infection [27].
A stressor such as health of self/family/loved-ones, transmission, containment, a measure taken by the authority, and effects on daily activities was found varying from province to province. The highest measures taken by the authority were in province eight meanwhile the status of the other remaining provinces was poor. This may be attributed to the poor health care facilities in Yemen to tackle such pandemic, where majorities of health care centers are not provided with the proper preventive facilities [28].
Our nding highlighted the importance to provide adequate psychological support to HCPs, as well as implement preventive measures to control the stressor among HCPs. Such ndings correlate with the ndings from Si et al. (2020) in China [4].
The general preparedness and capability to tackle COVID-19 were reported very poor by the majority of HCPs in our study, which corresponds with the various studies conducted in Yemen by different researchers that demonstrated the fragile healthcare system of Yemen and di culty in coping with the scenario by HCPs working therein [28-30].
Comparing coping behaviors in Yemen HCPs towards COVID-19, a signi cant association was noti ed between the level of performance of participants and their occupation (p= 0.023,) which is in line with our nding which shows a signi cant relationship in the only nurse versus pharmacist comparison on venting (p=0.026), meanwhile, the years of work experience showed no signi cance in our nding which contrasts the previous nding in Yemen (p= 0.011) 19.
Eisenberg et al. (2012) had described two major elements of the coping strategies, namely "avoidant coping" and "approach coping" [31]. Avoidant coping was designated by the subscales of denial, behavioral disengagement, substance use, self-blame, venting, and self-distraction. Besides other subscales, religion and humor were regarded as adaptive coping. Similarly, approach coping was described by the subscales of active coping, positive reframing, acceptance, planning, informational support, and seeking emotional. Based on the avoidant, approach, and adaptive coping strategies; we assessed the type of wellness resources as a coping strategy in such COVID-19 adversity. We found the most respondents scored is adaptive coping based on faith-based religion, which is in contrast with a study conducted in New York by Shechter [24].
There were certain limitations in our study. Firstly, very few HCPs as respondents were available from some provinces due to the adverse scenario caused by COVID-19 as well as by the internal catastrophe of con ict. Secondly, the inherent selection bias cannot be ignored due to the exploratory kind of study.
However, our nding has investigated the psychological impact, source of stress, and coping strategies of HCPs on COVID-19 from different health care institutions from various provinces of Yemen.