Study design, area, and time period
In a web-based cross-sectional survey, Yemeni healthcare workers who provide patient healthcare services were assessed about their levels of stress, anxiety, insomnia, depression, and overall well-being. The survey took place between November 6, 2020, at 11 p.m., and April 3, 2021, at 11 p.m.
Study instrument
A questionnaire adapted from previously published studies [9, 21] was used in the current study. The questionnaire comprises six sections; Section (1) is related to socio-demographic characteristics such as age, gender, marital status, living status, occupation, educational level, the current hospital worked in, and working unit in that hospital. Section (2) deals with respondent stress (10-items). Section (3) deals with respondent anxiety (8-items). Section (4) deals with respondent insomnia (7-items). Section (5) deals with respondent depression (9-items) and Section (6) deals with respondent well-being (5-items).
Scoring of stress, anxiety, insomnia, depression, and well-being
The stress level was assessed using a 5-point Likert scale. The scores were calculated by assigning scores of 0, 1, 2, 3 and 4, to the response levels ‘never’, ‘almost never, ‘sometimes’, ‘fairly often, and ‘very often’, respectively. For questions 4, 5, 7, and 8 the scores were reversed (0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0). Then, the scores were summed together for the ten questions. The total scores recorded ranged between 0 and 40, with higher scores indicating higher levels. A score of <14 was considered low perceived stress, scores of 14–26 were considered moderate perceived stress, while a score of >26 was considered high perceived stress. Likewise, a 5-point Likert scale was used to rate insomnia items (e.g., 0 = no problem; 4 = very severe problem). Scores ranged between 0 and 28. A score of <8 was considered no clinically significant insomnia, 8–14 was considered mild insomnia, 15–21 was considered moderate insomnia, while a score of ≥22 was considered severe insomnia. Anxiety levels were assessed using a 4-point Likert scale, with the severity of anxiety calculated by allocating scores of 0, 1, 2, and 3 to the respondents’ responses, respectively. The total cumulative score ranged from 0 to 24. A score of 0– 5 was considered as minimal anxiety, 6–10 was considered mild anxiety, 11–15 was considered moderate anxiety, while the range 16–24 was considered severe anxiety. Depression levels were assessed using PHQ-9, a 4-point Likert scale. The score 0–4 was considered as no depression, 5–9 was considered as mild depression, 10–14 was considered as moderate depression, 15–19 was considered as moderately severe depression, and 20–27 was considered as severe depression. A 6-point Likert scale was used to assess the level of wellbeing. The total score of the five responses ranged from 0 to 25. A score of <13 was considered the worst possible perceived quality of life, a score of 13–18 scores was considered a moderate perceived quality of life, while a score of >19 was considered the best possible perceived quality of life. The correlation coefficient was interpreted using the following criteria: 0–0.25 = weak correlation, >0.25–0.5 = fair correlation, >0.5–0.75 = good correlation, and greater than 0.75 = excellent correlation.
Validity and reliability
Four experts (two epidemiologists and two specialists in infectious disease) have checked the content validity of the questionnaire items used in this study. The questionnaire has been adapted from English language versions and translated into the Arabic language. It was back-translated into English again to ensure content consistency in translation. Finally, the Arabic questionnaire version was pre-tested for ease of understanding of the questions by distributing 30 copies among healthcare workers. The modifications were made based on the responses in the pre-test phase.
Data collection
To avoid face-to-face contact and thus in-person interviewing due to the ongoing COVID-19 outbreak, an electronic web-based self-reported questionnaire was used to collect data, as recommended by the Ministry of Health and Population. The URL link was distributed to the HCWs via emails and social media including WhatsApp and Telegram. All HCWs who were working in the Yemeni health institutions, males and females, who were 18 years or older, and who agreed to participate were recruited for this study. The participants were encouraged to send the link to other colleagues as possible to increase the response rate of the survey. A total of 1,248 HCWs responded to the survey and are included in this study.
Ethical consideration
The study obtained ethical approval from Al-Razi University's Ethics Committee, and all methods were performed within the frame of the relevant guidelines and regulations. The objectives of the study were explained to the respondents. They were also informed that participation was voluntary and anonymity was assured and that they could withdraw from the study at any time. Before they could complete the web-based, self-report questionnaire, respondents had to confirm their voluntary participation by answering a yes-no question on the screen.
Data analysis
The collected data were managed and analyzed using Statistical Package for Social Sciences (IBM SPSS), version 24.0. Mean values and standard deviations were used to describe continuous variables, while dichotomous or categorical variables were described using the counts and percentages. Independent samples T-test and one-way ANOVA were used to compare the participants’ demographic characteristics and levels of perceived stress, anxiety, insomnia, depression, and well-being. Spearman’s correlation coefficients were used to find out the relation between stress, anxiety, insomnia, depression, and wellbeing scores. A p-value of < 0.05 levels (two-tailed) with a 95 percent confidence interval was used to determine statistical significance.