Anxiety, Stress, and Depression Among Healthcare Professionals During the COVID-19 Pandemic: A Cross-Sectional Study in Morocco

Abstract

The COVID-19 pandemic has caused an enormous psychological impact worldwide. This study aimed to assess anxiety, depression, stress, and compensatory behaviors among Moroccan healthcare workers (HCWs) during COVID-19. This descriptive cross-sectional study was conducted using a snowball sampling strategy. This descriptive cross-sectional study was conducted using a snowball sampling strategy. Online surveys were sent to groups of HCWs working in Casablanca and Fez cities. Post-traumatic stress disorder (PTSD) was measured using the Impact of Event Scale revised (IES-R) scale, and the DASS-21 was used to measure anxiety, depression, and stress among participants. Compensatory behaviors used by HCWs to manage these symptoms were also investigated. The majority of participants (72.5%) experienced moderate to severe distress during the COVID-19 pandemic. The majority of participants (53.1%) reported symptoms of mild to extremely severe depression. Overall, nurses, female, and frontline HCWs experienced more stress, anxiety, and depression (P < .001). Leisure activities (29%), sport (19%), and drinking tea/coffee (19%) were the most common compensatory behaviors. Our findings suggest that psychological support and interventions targeting high-risk HCWs with heavy psychological distress are needed. It is of paramount importance to improve the psychological endurance and safeguard the mental and physical well-being of HCWs, who find themselves on the frontline of health and humanitarian crises, when they are needed the most.

What do we already know about the topic?

Healthcare workers are exposed to stress and anxiety in the workplace and this burden intensifies during health emergencies.

How does your research contribute to the field?

This study documents the psychological burden experienced by Moroccan healthcare workers during the COVID-19 pandemic.

What are your research’s implications toward theory, practice, or policy?

Our findings should guide the government and policy-makers in taking the necessary steps to maintain a healthy and motivated workforce, which can adequately respond to population needs during and outside of health emergencies.

Introduction

The coronavirus pandemic continues to wreak havoc around the world and is still causing an enormous strain on global health systems. Lockdowns and movement restrictions imposed in response to the COVID-19 outbreak have had a negative impact on the mental well-being of the world’s population.^{1 -3} Since the early days of the pandemic, the healthcare workforce has been under tremendous pressure in order to respond to urgent healthcare needs as well as to maintain delivery of routine care services.⁴ Outside of pandemics, healthcare workers (HCWs) are disproportionately exposed to stress and anxiety linked to workload, patient deaths, and other environmental stressors. This burden on the mental health of HCWs intensifies during epidemics, pandemics,⁵ and humanitarian crises, due to the additional pressure these events exert on healthcare systems.⁶ During the COVID-19 pandemic, HCWs faced an increase in hospitalization and mortality, separation from family members, a high risk of contracting the SARS-CoV2, and shortages in protective equipment and resources.

Delivering high quality patient care has been shown to be intimately linked to the mental well-being of the healthcare workforce and is well-documented by a robust body of evidence.⁷ Consequently, the psychological burden of the COVID-19 crisis on HCWs has naturally attracted the attention of several research investigations since the early days of the pandemic.⁵ Previous studies have shown that the most common mental health manifestations experienced by HCWs during the coronavirus crisis were; Post-Traumatic Stress Disorder (PTSD), anxiety, depression, acute stress, insomnia, and fear.^{8 -10} Furthermore, the findings of previous studies strongly suggest that being female, nurse, or a frontline healthcare worker is associated with higher levels of psychological manifestations.¹¹

Following the onset of the COVID-19 crisis, several remote psychological support units were established in Moroccan hospitals and mental health support platforms were launched by the Moroccan Association of Psychiatry, the Moroccan Society of Clinical Psychologists, the Moroccan Association of Psychologists and the National Order of Physicians.¹² These initiatives aimed to alleviate the impact of the pandemic on the mental health of both HCWs and the Moroccan population. Despite these efforts, 1 qualitative study showed that Moroccan healthcare personnel—especially those with underlying conditions—identified COVID-19 as the most stressful event in their careers and expressed a low level of satisfaction with the psychological support they received from their organizations and the government alike. These findings were significantly associated with a high workload and a low satisfaction with supervisors within working organization.¹³ Furthermore, 1 investigation reported a high level of burnout among Moroccan frontline HCWs during the COVID-19 pandemic.¹⁴ To the best of our knowledge, no previous quantitative study has attempted to measure the levels of stress, anxiety, and depression among Moroccan HCWs during the COVID-19 pandemic. Therefore, our aim is to investigate the prevalence of these mental health symptoms among HCWs as well as to identify the compensatory behaviors they used to manage them. This study will document the experiences of HCWs during a health crisis and should guide the policy-makers in taking the necessary steps to maintain a healthy and motivated workforce, which can adequately respond to population needs during and outside of health emergencies. This research will also help identify disproportionately at-risk groups among HCWs which should propel the design of tailored interventions.

Materials and Methods

Study Design and Population

This is a cross-sectional, descriptive study with a snowball sampling strategy conducted in June and July 2020. The inclusion criteria for recruitment was being a physician or a nurse working in a healthcare facility in Morocco during the COVID-19 pandemic regardless of the department. Pregnant women and immune-compromised healthcare professionals were excluded from the study.

Data Collection

Data were collected via an anonymous questionnaire created on Google Forms, which was sent via WhatsApp to groups of HCWs working in Casablanca and Fez cities, who were then encouraged to share it with their colleagues.

The sample size was calculated using the OpenEpi, version 3 software (www.OpenEpi.com)

$$\mathrm{n}=[\mathrm{DEFF}*{\mathrm{N}}_p(1-p)]/[(d^2/{Z^2}_{1-\alpha /2}*(\mathrm{N}-1)+p*(1-p)]$$

N is Population size (for finite population correction factor or fpc) = 1250; p is the hypothesized (%) frequency of outcome factor in the population (50% ±5; confidence limits as % of 100) (absolute ±%)(d) = 5%; DEFF (design effect = 1); Z is a constant = 1.96 for 95% confidence interval. Based on the above parameters the minimum required sample size (n) was 203 participants.

This questionnaire comprised of 3 main sections; the first section included general information, for example, gender (male or female), age (years), marital status (single, married, divorced, or widowed), dependents (child, parents, or others), profession (physician or nurse), sector (public or private), workplace (frontline: COVID-19 isolation unit, emergency and resuscitation, or non-frontline), work schedule (continuous or rotating), and years of experience ([0-5 years] [5-10 years], [10-15 years], [15-20 years], and ≥20 years), the second section measured psychological distress, we used the Impact of Event Scale revised (IES-R) a validated 22-item self-report measure of symptoms of PTSD. The IES-R is mainly used for recent and specific traumatic events. Total scores were categorized as follows: normal distress (0-23), mild distress (24-32), moderate distress (33-36), and severe distress (>37). A cut-off score of 24 was used to define PTSD.^15,16 The third section measured depression anxiety and stress using the Depression Anxiety Stress Scales (DASS-21). DASS-21 is a validated screening tool for measuring mental health status using the Depression, Anxiety, and Stress Scale. This is a 21-item measurement instrument developed by the University of New South Wales Australia, which provides independent measures of depression, stress, and anxiety with recommended severity cutoffs for the 3 subscales. The DASS-21 has been used extensively in similar studies in several other countries.^17,18 The scores for each of the 3 components were calculated by adding the scores for the relevant items and multiplying them by 2 to calculate the final score. Each subscale contains 7 questions. Questions 3, 5, 10, 13, 16, 17, and 21 measured depression, questions 2, 4, 7, 9, 15, 19, and 20 measured anxiety, and questions 1, 6, 8, 11, 12, 14, and 18 measured stress. Cut-off points of >9, >7, and >14 were used to define depression, anxiety, and stress, respectively. There were 5 levels for the cutoff point based on the DASS-21 containing score: normal, mild, moderate, severe, and extremely severe.¹⁹ The study was conducted according to the guidelines of the Helsinki Declaration. Participation in this study was voluntary and informed electronic consent was obtained from all participants.

Statistical Analysis

All statistical analyses were performed using SPSS software (version 21). The quantitative data are expressed in means (±standard deviations) and the qualitative data in numbers and percentages (%). We applied Student’s t-test (parametric distribution) and the Mann Whitney U test (nonparametric distribution) to compare quantitative variables, and the chi-square test (χ²) to test the association between qualitative variables. The significance level was set at .05. At the level of the “profession” variable, health professionals were grouped together. At the level of “workplace,” resuscitation, emergency, and isolation unit workers were groups into the “frontline” variable.

Results

Sociodemographic and General Characteristics

A total of 211 participants responded to the questionnaire, including 119 women (56.4%) and 92 men (43.6%). Almost half of the study participants (46.4%) were physicians and 53.6% were nurses. Of all participants, approximately 40.8% were primary care professionals and 59.2% worked in other settings. The 20 to 50 age group accounted for 95.7% of the study participants. Over half of the respondents (55.5%) were single and the majority (82%) worked in the public sector (Table 1).

Table 1.

Socio-Demographic Characteristics of the Study Sample.

Variables	Workforce (n = 211)	Percentage (%)
Gender
Male	92	43.4
Female	119	56.4
Age
≤20	3	1.4
20-50	202	95.7
>50	6	2.8
Marital status
Single	116	55.3
Married	88	41.7
Divorced	7	3.0
Dependent persons
Children	68	32.2
Parents	75	35.6
Others	68	32.2
Profession
Physician	98	46.4
Nurse	113	53.6
Work sector
Public	173	82.0
Private	38	18.0
Placement during COVID-19
Frontline	86	40.8
Non-frontline	125	59.2
Work schedule
Continuous	85	40.3
Alternating	126	59.7
Years of experience
[5-10 years]	158	74.9
[10-20 years]	42	19.9
≥20 years	11	5.2

DASS-21 and IESR Measurement Scores

IESR score

The majority of participants suffered from mild to severe distress (72.5%) during the pandemic, with an average score of 23.6 ± 19.6. The mean score was higher among women (26 ± 20.1) compared to men (19.3 ± 18.3), among nurses (25.3 ± 20.8) compared to physicians (20.6 ± 16.7), and among frontline HCWs (26.9 ± 20.3) compared to non-frontline HCWs (20.3 ± 18.9). All differences were statistically significant (P < .001).

DASS-21 score

Of the 211 participants, 112 (53.1%) had experienced symptoms of mild to extremely severe depression. The mean score for depression was 12 ± 9.5. Approximately 58.3% of participants have experienced mild to extremely severe anxiety with an average score of 10.6 ± 9. More than half of respondents (55.1%) have experienced stress, with an average score of 12.7 ± 8.9. In addition, female HCWs, nurses, and frontline HCWs had the highest mean scores for depression, anxiety, and stress (P < .001; Table 2).

Table 2.

Scores of the DASS-21 and IESR Measurement Scales (n (%) for Qualitative Variables and Mean ± SD for Quantitative Variables) Stratified by Gender, Profession, and Placement During COVID-19.

		All Participants	Gender			Professional category			Placement during COVID-19
			Male	Female	P value	Physicians	Nurses	P value	Frontline	Non-frontline	P value
IESR					.328			.82			.32
	Normal [0-8]	58.0 (27.0)	32.0 (15.0)	26.0 (12.5)		35.0 (16.6)	22.0 (10.3)		18.0 (8.5)	40.0 (19.1)
	Mild [9-25]	73.0 (34.6)	36.0 (17.0)	37.0 (17.5)		37.0 (17.5)	35.0 (16.4)		34.0 (16.1)	39.0 (18.5)
	Moderate [26-43]	43.0 (20.4)	15.0 (7.0)	28.0 (13.4)		15.0 (7.1)	28.0 (13.5)		19.0 (9.0)	24.0 (11.4)
	Severe [44-88]	37.0 (17.5)	9.0 (4.2)	28.0 (13.4)		11.0 (5.2)	28.0 (13.5)		15.0 (7.1)	22.0 (10.4)
	Mean ( ± SD)	23.6 ± 19.6	19.3 ± 18.3	26.0 ± 20.1	<.001	20.6 ± 16.7	25.3 ± 20.8	<.001	26.9 ± 20.3	20.3 ± 18.7	<.001
DASS-21
Depression score					.191			<.001			.133
	Normal [0-9]	99.0 (46.9)	54.0 (25.6)	45.0 (21.3)		52.0 (24.6)	47.0 (22.3)		36.0 (17.1)	63.0 (29.9)
	Mild [10-12]	24.0 (11.4)	12.0 (5.7)	12.0 (5.7)		12.0 (5.7)	12.0 (5.7)		6.0 (2.8)	17.0 (8.1)
	Moderate [13-20]	47.0 (22.3)	16.0 (7.2)	31.0 (14.7)		21.0 (10.0)	26.0 (12.3)		22.0 (10.4)	28.0 (13.3)
	Severe [21-27]	19.0 (9.0)	4.0 (1.9)	15.0 (7.1)		8.0 (3.8)	11.0 (5.2)		11.0 (5.2)	9.0 (4.3)
	Extremely severe [28-42]	22.0 (10.4)	6.0 (2.8)	16.0 (7.6)		5.0 (2.4)	17.0 (8.1)		11.0 (5.2)	8.0 (3.8)
	Mean ( ± SD)	12 ± 9.5	9.9 ± 8.5	13.6 ± 10	<.001	11.2 ± 8.9	13.7 ± 10.7	<.001	13.3 ± 9.8	11.2 ± 9.6	<.001
Anxiety score					.116			<.001			.082
	Normal [0-6]	88.0 (41.7)	48.0 (22.7)	40.0 (19)		55.0 (26.1)	33.0 (15.6)		33.0 (15.6)	56.0 (26.5)
	Mild [7-9]	19.0 (9.0)	10.0 (4.7)	9.0 (4)		9.0 (4.3)	10.0 (4.8)		5.0 (2.4)	14.0 (6.6)
	Moderate [10-14]	39.0 (18.5)	16.0 (7.6)	23.0 (11)		17.0 (8.1)	22.0 (10.5)		13.0 (6.2)	26.0 (12.3)
	Severe [15-19]	19.0 (9.0)	7.0 (3.3)	12.0 (6)		7.0 (3.3)	12.0 (5.7)		11.0 (5.2)	8.0 (3.8)
	Extremely severe [20-42]	46.0 (21.8)	11.0 (5.2)	35.0 (17)		10.0 (4.7)	36.0 (17.0)		24.0 (11.4)	21.0 (10.0)
	Mean ( ± SD)	10.5 ± 9.1	8.5 ± 8.2	12.1 ± 9.5	<.001	9 ± 7.5	11.7 ± 10	<.001	12.3 ± 9.1	9.4 ± 8.8	<.001
Stress score					.849			.085			.752
	Normal [0-10]	99.0 (44.5)	50.0 (23.6)	44.0 (20.9)		46.0 (21.8)	47.0 (22.3)		35.0 (16.6)	59 .0 (28.0)
	Mild [11-18]	59.0 (28.0)	21.0 (9.9)	38.0 (18.0)		31.0 (14.7)	27.0 (12.8)		25.0 (11.8)	34.0 (16.1)
	Moderate [19-26]	45.0 (21.3)	19.0 (9.0)	26.0 (12.4)		18.0 (8.5)	27.0 (12.8)		20.0 (9.5)	25.0 (11.8)
	Severe [27-34]	12.0 (5.7)	2.0 (1.0)	10.0 (4.7)		3.0 (1.4)	9.0 (4.3)		6.0 (2.8)	6.0 (2.8)
	Extremely severe [35-42]	1.0 (0.1)	0	1.0 (0.5)		0	1.0 (0.5)		0	1.0 (0.5)
	Mean ( ± SD)	12.7 ± 8.9	10.8 ± 8.2	14 ± 9.1	<.001	11.5 ± 7.6	13.9 ± 10	<.001	13.6 ± 9	11.7 ± 8.7	<.001

Compensatory behaviors in the event of stress

Among the participants, approximately 29% used leisure activities as compensatory behaviors to alleviate the psychological symptoms, 19% sport, 19% used tea/coffee, 6% used smoking, 3% used analgesics only, and 1% used alcohol or psychotropic drugs (Table 3).

Table 3.

Compensatory Behaviors of Healthcare Workers.

Variables	Workforce (n = 211)	Percentage (%)
Compensatory behaviors
Tea/coffee	39	19
Smoking	13	6
Alcohol	2	1
Psychotropic drugs	2	1
Analgesics	6	3
Sport	40	19
Hobbies	61	29
Others	47	22

Discussion

Our study aimed to assess stress, anxiety, and depression among Moroccan HCWs, and to identify common compensatory behaviors used to deal with the psychological burden associated with COVID-19. Overall, the majority of HCWs suffered from mild to severe levels of psychological distress, depression, anxiety, and stress during the pandemic. Nurses, females, and frontline HCWs experienced higher levels of these psychological symptoms.

The majority of participants (72.5%) in this study suffered from mild to severe levels of distress during the pandemic. This is consistent with findings from other investigations in The Philippines (IESR 19.5 ± 13.12), Canada—where 78.7% intensive care unit HCWs reported feeling “constantly under strain”²⁰—and in the United Kingdom—where 77.7% felt that they were under a lot of stress.²¹ Contrasting findings were reported among HCWs in India and Singapore, where only 5.2% suffered moderate to severe levels of psychological distress during COVID-19.²² In our study, psychological distress scores were higher among female HCWs, which is consistent with most studies.^20,21,23 However, contradicting results were reported in Saudi Arabia where male HCWs suffered from more distress compared to their female counterpart.²⁴ In addition to gender, previous studies have identified several other factors associated with the risk of PTSD among HCWs, such as younger age, fewer years of professional experience, marital status, stigma, and a history of psychiatric disorders. Adequate training and support were identified as protective factors.

In this study, nurses were more subject to psychological distress compared to other HCWs. This may be explained by their frequent contact with patients, which results in additional stress about risk of infection but may also be due to the fact that most nurses in Morocco are female. Additionally, frontline HCWs in this study suffered higher levels of psychological distress compared to non-frontline HCWs. This is supported by several other studies which show that being close to “ground zero” increases susceptibility to severe stress and trauma.^25,26 Interestingly, directly caring for SARS-CoV-2 patients and working during previous SARS outbreaks were also shown to be protective factors against traumatization²⁵; these results were often explained by higher levels of perceived knowledge, experience, and familiarity in dealing with outbreaks, which may have a mitigating effect on the feelings of uncertainty and powerlessness.²⁷ Although these interpretations remain inconclusive,²⁸ the evidence for improving workplace culture, fostering clear and transparent communication, reducing stigmatization, and increasing psychological support is unanimous.

More than half of the participants in this study experienced anxiety, stress, and symptoms of mild to severe depression. The results of this study are almost similar to those reported among HCWs in other countries such as India and Singapore (50%)²² and Bangladesh (44%).²⁹ A higher rate (72.3%) of moderate to extremely severe depression was reported in Pakistan.³⁰ In the host population, 1 systematic review and meta-analysis showed that the global prevalence of depression, anxiety, stress, and insomnia during the COVID-19 pandemic were 28.18%, 29.57%, 20.18%, and 23.5%, respectively.³¹ For anxiety, lower rates (21.1%) of moderate to severe anxiety were reported among HCWs in Saudi Arabia²⁸ and higher rates (60%) were observed in Jordan.³² This study shows that female and frontline HCWs experienced more anxiety, depression, and stress which is consistent with studies in other countries.^5,9 Other studies also identified additional psychological symptoms such as insomnia, sleep disturbance, and burnout among HCWs during COVID-19. Likewise, these psychological manifestations affected women, frontline HCWs, younger professionals, and nurses to a greater extent.³³ It is worth noting that stigma, shortages in personal protective equipment, fear of putting relatives at risk, and unhealthy rotations were identified as aggravating factors. Contrastingly, social and family support and adequate knowledge about prevention and control measures from authorities were protective factors; these factors promote mental health and psychological endurance among HCWs³⁴and should be an appropriate target for interventions that seek to safeguard the mental well-being of the healthcare workforce.³⁴ Furthermore, low self-efficacy was shown to trigger anxiety which subsequently hinders performance³⁵; consequently, training and capacity building programs are needed in order to break this vicious cycle. Given the nature of the social fabric in Morocco, the authors also suggest that social and family support should be capitalized on, and professional help should be made available for HCWs presenting with mild to severe symptoms. Tele-consultation was shown to improve quality of care and health outcomes in psychiatric care and should also be leveraged to reach HCWs in all regions in Morocco.³⁶ In fact, digital or internet cognitive behavioral therapy (CBT) has been identified as a cost-effective intervention and was shown to produce positive outcomes in the treatment of insomnia.^37,38

Leisure activities were the most common compensatory behaviors used by HCWs in this study, followed by exercise and non-alcoholic beverages such as tea or coffee. In other studies, seeking support from family and friends was the most common compensatory behavior used to manage the adverse mental health effects of the COVID-19 pandemic.³⁵ Fortunately, substance use was not a common compensatory behavior in this study, as alcohol consumption was shown to increase anxiety and may lead to impaired work performance.³⁹

Evaluation and intervention for psychosocial concerns must be undertaken in these settings. Poor mental health and stress negatively affect the employees by decreasing job performance, engagement in work, communication with coworkers, and physical capabilities, reduce absenteeism

This cross-sectional study on the psychological impact of COVID-19 on Moroccan HCWs has several strengths. To the best of our knowledge, this is the first study to measure the levels of stress, anxiety, and depression among HCWs during the pandemic and the first study to conduct subgroup analysis. However, this study has some limitations. First, we used a validated scale to measure depression and anxiety instead of a psychiatrist assessment and functional neuroimaging, which is the gold standard for diagnostic.⁴⁰ Second, we did not screen participants for comorbidities and history of depression. Third, this study did not explore potential factors were associated with anxiety, stress, and depression, which could be the subject of future research. Finally, this study was conducted in large Moroccan cities where the pressure on healthcare services is important; thus, the generalization of the results should be done with caution.

Poor mental health outcomes among HCWs have been shown to result in negative outcomes in terms of job performance, workplace communication, and absenteeism.³⁵ In addition, HCWs are at risk of burnout which has been linked to suboptimal patient care and a higher risk of medical errors. Reducing the length of work shifts, providing HCWs with the opportunity to enroll in mental health support programs, and adopting a trauma-informed approach to workplace stress are among the interventions which should be considered by policymakers.⁴¹ In addition, HCWs have different predisposition to mental illness due differences in socio-economic factors, gender, race, and other factors.⁴¹ In Morocco for example, mothers are often the primary caregivers in the family. Therefore, it is important that workplace policy does not disrupt the work-life balance of female HCWs who have the additional responsibility of looking after a child.

Conclusions

The COVID-19 pandemic has exerted an enormous pressure on the Moroccan healthcare system and its workforce, which bears the responsibility of maintaining quality care even under strenuous circumstances. The results of this study show that Moroccan HCWs have experienced moderate to severe levels of anxiety, depression, and stress and provide an insight on how they managed these psychological symptoms. It is uncertain whether the COVID-19 pandemic will recede in the near future; therefore, it is of paramount of importance to improve the psychological endurance and safeguard the mental and physical well-being of HCWs, who find themselves on the frontline of health and humanitarian crises, when they are needed the most. This may be achieved through the implementation of targeted interventions aimed at enhancing psychological support of HCWs, reducing stressors in the workplace, and capacity building.