Dear editor
Coronavirus (COVID-19) is a global pandemic. Despite having reached over 200 countries across the world in a few months, some countries have been more severely affected than others, with Italy as a key example. After Italy reported its first COVID-19 case on January 30, 2020, the epidemic has rapidly spread. The sudden increase in people in need of hospitalization has had a dramatic impact on the country's world-class healthcare system, and with the higher than average mortality rate and the entire nation on lockdown since March 8, the financial and psychological impact on Italian citizens has been substantial (Lazzerini and Putoto, 2020).
Over 5 million Italian citizens live abroad. Of these, 12,241 live in the United Arab Emirates (UAE), with the 83% of them in Dubai (Annuario Statistico, 2018). Despite having settled in a new country, many – if not most – still hold professional and social ties with their country of origin and being first-generation foreign workers, have left their extended families in Italy. In the UAE, the government has promptly responded to the sudden outbreak of COVID-19 by implementing extensive preventative measures to contain the pandemic, including urging all UAE residents to practice quarantine (where necessary) or social distancing. Uncertainty about the seriousness of the risk, future unpredictability, fear of death and reduced or absent social interaction have been suggested as potential threats to individuals’ psychological wellbeing during COVID-19 pandemic (Xiang et al., 2020). While these factors should affect the population worldwide, they could have a more severe impact on foreign workers, due to additional worries related to greater financial uncertainty and lack of a social support network, and especially so in those foreign workers whose country of origin has been severely affected by COVID-19. Indeed, these individuals carry the additional burden of witnessing dramatic events happening in their home country and of being unable to reach and support their extended families back home.
We recently invited adult members of the Italian community in the UAE to complete an online survey. The study was approved by local research ethics boards (IRB approval: ZU20_077_F; MOHAP/DXB-REC/ MMM/No. 48/2020). Participants (N=148; 76% female) were answering socio-demographic questions and questions related to their experience with COVID-19 pandemic. Following, they were asked to complete the Impact of Event Scale-Revised (IES-R), the Patient Health Questionnaire-8 (PHQ-8) and the Generalized Anxiety Disorder-7 (GAD-7) to assess the presence and/or severity of symptoms of post-traumatic stress disorder (PTSD), depression, and generalized anxiety disorder (GAD), respectively. Data was collected between April 6 and April 17. The mean age of our sample was 41.44 (SD=7.71). The majority of our participants (98%) had been practicing social distancing in the past two weeks and 93% of respondents reported having family members or close friends currently living in Italy. The prevalence of PTSD, depression and GAD was calculated using the recommended cut-off scores for each measure. Previous data collected from normative samples using PHQ-8 and GAD-7 had indicated a prevalence of 8.6% for depression and a prevalence of 5% for GAD (Kroenke et al., 2009; Löwe et al., 2008). To the best of our knowledge, prevalence of PTSD as measured by the IES-R has not been reported; however the worldwide prevalence of PTSD has been reported to be around 6.8% and lower rates were found in Italian samples (Carmassi et al., 2018).
Total scores on the IES-R ranged between 0 and 57 (mean=23.41; SD=13.60) with a prevalence of PTSD (IES-R≥33) of 22.3%. Total scores on the PHQ-8 ranged between 0 and 22 (mean=6.08; SD=5.14) with a prevalence (PHQ-8 ≥10) of depressive symptoms of 20%. The total scores on the GAD-7 ranged between 0 and 57 (mean=6.51; SD=5.30) with a prevalence (GAD-7≥10) of anxiety symptoms of 23%. A logistic regression analysis controlling for age and gender, indicated that the presence of clinically relevant PTSD symptoms was predicted by the severity of both depressive [OR: 1.19, 95% CI 1.01 – 1.40] and anxiety symptoms [OR: 1.30, 95% CI 1.14 – 1.52]. This model explained 58% (Nagelkerke R2) of the variance in PTSD variable and correctly classified 61% of cases. Overall, these results highlight the presence of psychological distress among Italian foreign workers, and that clinically relevant symptoms of depression and anxiety seem to increase the risk to develop PTSD.
Similar to past pandemics, COVID-19 represents a threat to individuals’ psychological wellbeing. Our results seem to suggests that foreign workers might be a vulnerable population, in agreement with Liem and colleagues (Liem et al., 2020). Indeed, while the present results are specific for Italian citizens, they could be extended to other communities of foreign workers worldwide, especially those whose country of origin is severely affected by COVID-19 pandemic, such as the United States, Spain, France, or the United Kingdom.
It has been suggested that psychological interventions should be integrated as part of the healthcare system in response to public health emergencies (Zhou et al., 2019). The UAE's National Program for happiness and Wellbeing (NPHW) is presently offering online support for individuals feeling overwhelmed by events. With a vast portion of the UAE population being international foreign workers, online interventions could prove effective in contrasting the psychological impact of COVID-19 pandemic.
In sum, our preliminary findings suggest that Italian foreign workers living in the UAE might be at heightened risk for PTSD symptoms, depression and anxiety. The study has, of course, some notable limitations, including a small and mostly female sample and the use of non-probability sampling, limiting the generalizability of the findings. Another limitation is that our data was compared to norms that were not specific for the Italian population or for foreign workers. Despite these limitations, our study provides an early quantitative insight into the psychological challenges besetting foreign worker populations, witnessing the devastation of the pandemic on their home nation from afar. Further investigations are encouraged, focused on larger samples of international foreign workers.
Financial support
No funding was involved in the present work.
Declaration of Competing Interest
None.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2020.113113.
Appendix. Supplementary materials
References
- Annuario Statistico . In: Ministero degli Esteri. Esteri M.d., editor. 2018. [Google Scholar]
- Carmassi C., Gesi C., Corsi M., Cremone I.M., Bertelloni C.A., Massimetti E., Olivieri M.C., Conversano C., Santini M., Dell'Osso L. Exploring PTSD in emergency operators of a major University Hospital in Italy: a preliminary report on the role of gender, age, and education. Ann. Gen. Psychiatry. 2018;17(1):17. doi: 10.1186/s12991-018-0184-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kroenke K., Strine T.W., Spitzer R.L., Williams J.B., Berry J.T., Mokdad A.H. The PHQ-8 as a measure of current depression in the general population. J. Affect. Disord. 2009;114(1-3):163–173. doi: 10.1016/j.jad.2008.06.026. [DOI] [PubMed] [Google Scholar]
- Lazzerini M., Putoto G. COVID-19 in Italy: momentous decisions and many uncertainties. Lancet Glob. Health. 2020;8(5):E641–E642. doi: 10.1016/S2214-109X(20)30110-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Liem A., Wang C., Wariyanti Y., Latkin C.A., Hall B.J. The neglected health of international migrant workers in the COVID-19 epidemic. Lancet Psychiatry. 2020;7(4):e20. doi: 10.1016/S2215-0366(20)30076-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Löwe B., Decker O., Müller S., Brähler E., Schellberg D., Herzog W., Herzberg P.Y. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med. Care. 2008;46(3):266–274. doi: 10.1097/MLR.0b013e318160d093. [DOI] [PubMed] [Google Scholar]
- Xiang Y.-T., Yang Y., Li W., Zhang L., Zhang Q., Cheung T., Ng C.H. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228–229. doi: 10.1016/S2215-0366(20)30046-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Zhou Y., Liang Y., Tong H., Liu Z. Patterns of posttraumatic stress disorder and posttraumatic growth among women after an earthquake: a latent profile analysis. Asian J. Psychiatry. 2019 doi: 10.1016/j.ajp.2019.10.014. [DOI] [PubMed] [Google Scholar]; 101834 (In press).
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