Manuscript Details

Manuscript number JPSYCHORES_2020_497

Title Anxiety And Depression Among Healthcare Professionals During The Covid-19
Pandemic In Kosovo: A Cross Sectional Study

Article type Full Length Article

Abstract
Objectives:Despite initial evidence of the impact of the Covid-19 pandemic on the mental health of healthcare workers,
there is insufficient data on how healthcare workers are being affected in Europe, and specifically in limited resource
settings such as Kosovo. This study investigates the mental health status of healthcare professionals during the
Covid-19 pandemic in Kosovo. Methods:This is a cross-sectional study, conducted with data collected through a
structured, anonymous, self-directed questionnaire, including socio-demographic characteristics, and the Hospital
Anxiety and Depression Scale (HADS) questionnaire, via an online platform. Results:A total of 592 healthcare workers
(61.3% female and 38.7% male) participated in this study. 264, or 44.6%, of healthcare workers scored in the
abnormal range on the Hospital Anxiety and Depression Scale (HADS) anxiety subscale, and 229 respondents, or
38.7%, scored in the abnormal range for depression. The rate of anxiety (31.9%) and depression (25.8%) among
female health professionals was higher than their males counterparts (12.7% and 12.8% respectively). Female
professionals were 1.96 times more likely to develop depression (95%CI, 1.34-2.88; p=0.001) and 2.57 times more
likely to experience anxiety (95%CI, 1.77-3.75; p<0.001). Physicians had 0.38 lower odds rate for depression (95%CI,
0.24-0.58; p<0.001) and 0.66 lower odds rate for anxiety (95%CI, 0.45-0.96; p=0.029) compared to other health
professionals. Conclusion:Given the key role of health care professionals during management of the Covid-19
pandemic, interventions to address mental health tailored to the needs of Kosovar healthcare professionals, presents
itself as an immediate need that should be addressed by policymakers in the country.

Keywords Anxiety; COVID19; Depression; Healthcare Professionals; Kosovo.

Corresponding Author BERNARD TAHIRBEGOLLI

Order of Authors Florim Gallopeni, Ilirjana Bajraktari, Erza Selmani, Iliriana Aloqi Tahirbegolli,
Gazmend Sahiti, Aferdita Mustafa, Gazmend Bojaj, Venera Berisha Muharremi,
BERNARD TAHIRBEGOLLI

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Dear Editor,

It is my honor to submit the manuscript entitled “ANXIETY AND DEPRESSION AMONG

HEALTHCARE PROFESSIONALS DURING THE COVID-19 PANDEMIC IN KOSOVO: A
CROSS SECTIONAL STUDY” by Florim Gallopeni, Ilirjana Bajraktari, Erza Selmani, Iliriana
Alloqi Tahirbegolli, Gazmend Sahiti, Aferdita Mustafa, Gazmend Bojaj, Venera Berisha
Muharremi and Bernard Tahirbegolli, to be considered for publication as a original research in the
Journal of Psychosomatic Research.
In Kosovo, the first Covid-19 cases were confirmed on 13 March 2020, making Kosovo (along
with Montenegro) one of the last countries in the region, and Europe as a whole, to be affected by
the pandemic. By 8 May 2020, in Kosovo there were 862 confirmed cases of Covid-19, 28 deaths,
622 recovered patients, and 9,557 people had been tested for the disease.
The Covid-19 pandemic is the first large-scale public health emergency of its kind to affect the
Kosovan population, a society characterized by historically under-funded health system and
unsatisfactory health indicators, compared with other countries in the region and wider Europe.
This paper examines, through a cross-sectional survey, the impact of the Covid-19 pandemic on
the mental health status of healthcare professionals in public health facilities in Kosovo at all levels
of care.
Here are some of the highlights of the study:

 The rates of anxiety and depression among health professionals in Kosovo during the
Covid-19 pandemic are at disturbing levels.
 Female healthcare professionals are more likely to develop depression and anxiety
symptoms compared to their male counterparts.
 Physicians had lower odds rates for depression and anxiety compared to other
professionals.
 Immediate psychological support for Kosovar health professionals is urgently required.

We declare that this original full-length research report is original work, it has not been published
before and it is not being considered for publication elsewhere.
We know of no conflict of interest associated with this publication and no financial funds have
been provided for the publication of this article.
As a co-responding author, I declare that all other authors of this article had access to all study
data, are responsible for all contents of the article, and had authority over manuscript preparation
and the decision to submit the manuscript for publication, have read and approved this manuscript
to be considered for publication to the Journal of Psychosomatic Research. This is the first
manuscript of the research and there are no other published, submitted, or proposed papers
reporting the same or overlapping data.

Regards,
Bernard Tahirbegolli MD, PhD.
Highlights

● The rates of anxiety and depression among health professionals in Kosovo during the

Covid-19 pandemic are at disturbing levels.

● Female healthcare professionals are more likely to develop depression and anxiety

symptoms compared to their male counterparts.

● Physicians had lower odds rates for depression and anxiety compared to other

professionals.

● Immediate psychological support for Kosovar health professionals is urgently required.

ABSTRACT

Objectives: Despite initial evidence of the impact of the Covid-19 pandemic on the mental health
of healthcare workers, there is insufficient data on how healthcare workers are being affected in
Europe, and specifically in limited resource settings such as Kosovo. This study investigates the
mental health status of healthcare professionals during the Covid-19 pandemic in Kosovo.

Methods: This is a cross-sectional study, conducted with data collected through a structured,
anonymous, self-directed questionnaire, including socio-demographic characteristics, and the
Hospital Anxiety and Depression Scale (HADS) questionnaire, via an online platform.

Results: A total of 592 healthcare workers (61.3% female and 38.7% male) participated in this
study. 264, or 44.6%, of healthcare workers scored in the abnormal range on the Hospital Anxiety
and Depression Scale (HADS) anxiety subscale, and 229 respondents, or 38.7%, scored in the
abnormal range for depression. The rate of anxiety (31.9%) and depression (25.8%) among female
health professionals was higher than their males counterparts (12.7% and 12.8% respectively).
Female professionals were 1.96 times more likely to develop depression (95%CI, 1.34-2.88;
p=0.001) and 2.57 times more likely to experience anxiety (95%CI, 1.77-3.75; p<0.001).
Physicians had 0.38 lower odds rate for depression (95%CI, 0.24-0.58; p<0.001) and 0.66 lower
odds rate for anxiety (95%CI, 0.45-0.96; p=0.029) compared to other health professionals.

Conclusion: Given the key role of health care professionals during management of the Covid-19
pandemic, interventions to address mental health tailored to the needs of Kosovar healthcare
professionals, presents itself as an immediate need that should be addressed by policymakers in
the country.

Keywords: Anxiety, COVID19, Depression, Healthcare Professionals, Kosovo.

 Anxiety And Depression Among Healthcare Professionals During The Covid-19 Pandemic In
Kosovo: A Cross Sectional Study

Short Title: Anxiety and Depression During Covid-19 Pandemic In Kosovo

Florim GALLOPENI PhDcand1, Ilirjana BAJRAKTARI PhD2, Erza SELMANI BS2, Iliriana
ALLOQI TAHIRBEGOLLI PhD3,4, Gazmend SAHITI MD5, Aferdita MUASTAFA MSC3,
Gazmend BOJAJ PhD3, Venera BERISHA MUHARREMI PhD6,7, Bernard TAHIRBEGOLLI
PhD2

1 Department of Psychology of Assessment and Intervention, Heimerer College, Prishtina,

Kosovo
2 Department of Health institutions and Services Management, Heimerer College, Prishtina,
Kosovo
3 Department of Nursing, Heimerer College, Prishtina, Kosovo
4 Hematology Clinic, University Clinical Centre of Kosovo, Heimerer College, Prishtina,
Kosovo
5 National Institute of Public Health of Kosovo, Regional Office Mitrovica, Mitrovica, Kosovo
6 Department of Internal Medicine, Faculty of Medicine, University of Prishtina, Prishtina,
Kosovo
7 Endocrinology Clinic, University Clinical Centre of Kosovo, Prishtina, Kosovo

Corresponding author:
MD. PhD. Bernard Tahirbegolli

Email: btahirbegolli@gmail.com
Phone: +38343958477
Address: Kolegji Heimerer, Veranda D4, Hyrja C dhe D Lagja Kalabri, 10000 Prishtina, Kosovo
ABSTRACT

Objectives: Despite initial evidence of the impact of the Covid-19 pandemic on the mental health
of healthcare workers, there is insufficient data on how healthcare workers are being affected in
Europe, and specifically in limited resource settings such as Kosovo. This study investigates the
mental health status of healthcare professionals during the Covid-19 pandemic in Kosovo.

Methods: This is a cross-sectional study, conducted with data collected through a structured,
anonymous, self-directed questionnaire, including socio-demographic characteristics, and the
Hospital Anxiety and Depression Scale (HADS) questionnaire, via an online platform.

Results: A total of 592 healthcare workers (61.3% female and 38.7% male) participated in this
study. 264, or 44.6%, of healthcare workers scored in the abnormal range on the Hospital Anxiety
and Depression Scale (HADS) anxiety subscale, and 229 respondents, or 38.7%, scored in the
abnormal range for depression. The rate of anxiety (31.9%) and depression (25.8%) among female
health professionals was higher than their males counterparts (12.7% and 12.8% respectively).
Female professionals were 1.96 times more likely to develop depression (95%CI, 1.34-2.88;
p=0.001) and 2.57 times more likely to experience anxiety (95%CI, 1.77-3.75; p<0.001).
Physicians had 0.38 lower odds rate for depression (95%CI, 0.24-0.58; p<0.001) and 0.66 lower
odds rate for anxiety (95%CI, 0.45-0.96; p=0.029) compared to other health professionals.

Conclusion: Given the key role of health care professionals during management of the Covid-19
pandemic, interventions to address mental health tailored to the needs of Kosovar healthcare
professionals, presents itself as an immediate need that should be addressed by policymakers in
the country.

Keywords: Anxiety, COVID19, Depression, Healthcare Professionals, Kosovo.

1. Introduction

Covid-19 is an acute respiratory disease caused by a novel coronavirus occurring in the human
population. It is the 21st century’s the third epidemic coronavirus, after SARS-CoV and MERS-
CoV (Guo et al., 2020). The virus originated in bats, but it remains unknown how it was transmitted
to humans (Singhal, 2020). The first case of 2019 novel coronavirus disease (Covid-19) was
reported in November 2019 in the city of Wuhan in Central China (Chan et al., 2020) spreading to
Europe in late January 2020, and raising worldwide concern to the point where the World Health
Organization declared Covid-19 a pandemic on 11 March 2020 (Guo et al., 2020). Societies around
the globe were unprepared and have been caught off guard. In such public health emergencies,
healthcare workers are exposed to extreme psychological distress (Bai et al., 2004; Chua et al.,
2004; Wu et al., 2009). In addition to an increased risk of infection, medical staff working directly
with patients diagnosed with Covid-19 face multiple challenges and stresses which can also
increase the risk of developing mental health symptoms. Evidence also suggests that, among
mental health symptoms, fear and anxiety are likely to appear earlier, whereas depression appears
gradually but lasts longer, together with other symptoms (Chong et al., 2004, Wu et al., 2009).

Despite initial evidence of the impact of the Covid-19 pandemic on the mental health of healthcare
workers, there is insufficient data on how healthcare workers are being affected in Europe, and
specifically in limited resource settings such as Kosovo. Furthermore, healthcare workers are the
key building block of any health system, and vital to effective management of any public health
emergency. Any health condition, including mental health symptoms, that would reduce their
performance would be a further destabilizing factor in the health sector, at a time when it is already
under significant strain.

In Kosovo, the first Covid-19 cases were confirmed on 13 March 2020, making Kosovo (along
with Montenegro) one of the last countries in the region, and Europe as a whole, to be affected by
the pandemic. By 8 May 2020, in Kosovo there were 862 confirmed cases of Covid-19, 28 deaths,
622 recovered patients, and 9,557 people had been tested for the disease (NIPH, 8th May 2020).
The Covid-19 pandemic is the first large-scale public health emergency of its kind to affect the
Kosovan population, a society characterized by historically under-funded health system and
unsatisfactory health indicators, compared with other countries in the region and wider Europe.
This paper will examine, through a cross-sectional survey, the impact of the Covid-19 pandemic
on the mental health status of healthcare professionals in public health facilities in Kosovo at all
levels of care.

2. Methods

We recruited physicians, nurses and other health professionals working in public health facilities
in Kosovo to participate in this cross-sectional survey, from 4 April 2020 (when there were 140
Covid-19 cases reported by NIPH) to 15 April 2020 (when there were 423 Covid-19 cases reported
by NIPH). The study protocol was approved by the ethical commission of Heimerer College. The
procedures of this study complied fully with the provisions of the Helsinki Declaration regarding
research on human participants. Data were collected through a structured, anonymous, self-
directed questionnaire, including socio-demographic characteristics, and the Hospital Anxiety and
Depression Scale (HADS) questionnaire via the online platform. All participants electronically
provided informed consent before enrolment. Participation in the study was on a voluntary basis.

The questionnaire consists of two parts: socio-demographic data and the Hospital Anxiety and
Depression Scale (HADS).

Basic socio-demographic data collected in the study included occupation (doctor, nurse or other),
gender (male or female), age (years), marital status (unmarried, married, widowed or divorced),
living setting (urban or rural), clinical work experience (years), chronic conditions (has or does
not have), and level of care (primary, secondary or tertiary).

The Hospital Anxiety and Depression Scale (HADS) is a self-reporting psychological instrument
which was created as a tool for screening for depression and anxiety (Zigmond & Snaith, 1983).
It uses a 14-item screening scale, consisting of two 7-item joined subscales: HADS-anxiety and
HADS-depression. The scores for each subscale range from 0 to 21 and can be combined into a
single scale: the total HADS score (Bjelland, Dahl, Haug, & Neckelmann, 2002). The HADS
subscales scores can also be evaluated at three levels: Normal 0-7, Borderline abnormal 8-10, and
Abnormal 11-21. It remains difficult, however, to distinguish between anxiety and depression, and
the total HADS score has the highest positive predictive value in detecting minor psychiatric
disorders (Spinhoven et al., 1997). The instrument was previously translated and adapted into
Albanian in a study in Kosovo and Cronbach α scores were found to be 0.50-0.68 for the anxiety
subscale and 0.65-0.72 for the depression subscale (Nakayama et al., 2014).

The Statistical Package for the Social Sciences software (SPSS version 21.0) was used for data
analysis (IBM Corporation, 2012). Frequencies (n) and percentages (%) were used to summarize
categorical variables, and continuous variables are summarized with mean±standard deviation
(SD) or median and InterQuartile Rate (IQR). Distribution of normality was evaluated using
Shapiro-Wilk and Kolmogorov-Smirnov tests. The chi-square (x2) test and contingency tables
were used to compare the frequency of categorical variables. The student t-test (for two groups),
the one-way ANOVA (for more than two groups) and post hoc Tukey test were used to analyze
continuous variables. Adjusted and unadjusted binary logistic regression analyses were used to
identify significant predictors of depression and anxiety. To do so, both subscale categories,
normal and borderline categories were recognized with no anxiety or depression, and abnormal
categories with positive anxiety and depression, respectively. For all statistical tests, a p-value of
<0.05 was considered statistically significant.

3. Results
Five hundred and ninety-two (592) healthcare workers completed the questionnaire. 363, or
61.3%, were female healthcare workers, whereas 229, or 38.7 %, were male healthcare workers.
Healthcare workers were defined as physicians, nurses and others. The majority of respondents
consisted of nurses (51.4%), the median (IQR) age was 39 (32-46) years, and the median years of
clinical working experience was 12 (5-20) years, as shown in Table 1.

A significant percentage of healthcare professionals scored in the abnormal range on HADS

subscales: anxiety (264 respondents or 44.6%) and depression (229 respondents or 38.7%). There
are statistically significant differences between the frequency of gender in relation to the level of
anxiety (p<0.001) and the level of depression (p=0.008) as shown in Table 2. The analysis of t-
test shows that there is a statistically significant difference between female and male healthcare
workers regarding anxiety scores (p<0.001) but there are no statistical differences between female
and males regarding depression scores (p=0.987). No statistically significant differences were
found between the frequency of healthcare professionals in relation to the level of anxiety and the
level of depression (p=0.778). The analysis of ANOVA shows that there are no statistically
significant differences between physicians, nurses and other healthcare professionals regarding
anxiety scores (p=0.759) but there are statistical differences regarding depression scores
(p=0.028), as shown in Table 2.

There are no statistically significant differences between the frequency of the level of care in
relation to the level of anxiety (p=0.419) and the level of depression (p=0.776). However, as
presented in Table 2, the analysis of ANOVA shows that there are statistically significant
differences between primary, secondary and tertiary level of health care anxiety scores (p=0.046).
The Chi-square test shows that there are significant statistical differences between the rate of
sufficient education for Covid-19 in relation to the level of anxiety and depression among health
professionals (p=0.006 and p=0.034 respectively), as shown in Table 2.

In the unadjusted binary logistic regression analysis for depression, only two variables were found
to be significant, namely female gender and medical doctor (p=0.030 and p=0.010 respectively).
While in the adjusted model regression analysis for depression, five variables were significant,
namely age, female gender, working in a secondary health care institution, being a physician and
length of clinical working experience (in order: p=0.040, p=0.001, p=0.027, p<0.001 and p=0.025
respectively), as shown in Table 3.

In the unadjusted binary logistic regression analysis for anxiety, only the gender variable was
shown to be significant (p<0.001). Nevertheless, in the adjusted model, three variables were shown
to be significant, namely gender, working in secondary health facilities and being a medical doctor
(p<0.001, p=0.017 and p=0.029 respectively), as shown in Table 3. The other variables were not
found to have a significant effect on depression or anxiety.

4. Discussion

This is the first paper to study the mental health status of healthcare workers during the Covid-19
pandemic in Kosovo, and one of only a few such studies in Europe. The pandemic caught Kosovo
off guard, at a time when its health system was still dealing with the legacy of its almost total
collapse during the 1998-9 war, including significant gaps in healthcare provision and chronic
underfunding of institutions. Kosovo health institutions have taken measures to reduce contact and
risk of disease transmission among health professionals in health facilities and, in turn, to reduce
expenditure on personal protective equipment, given shortages of PPE during March and early
April. These measures include operating and delivering health services with one third of the normal
capacity of health professionals at all three levels of care. In this study, the main findings indicate
that 44.6 % of health workers or 264 scored in the abnormal range of the HADS anxiety subscale
and 38.7% or 229 in the abnormal range for depression. Around 47% of healthcare workers
reported borderline levels of anxiety and 52.4% reported borderline levels of depression. Less than
10% of health workers presented with a normal range of anxiety and depression scores.

In line with this, in research conducted by Lai et al. (2020) in China, with a sample of 1,830 health
workers exposed to Covid-19, over 50% of health workers participating in the study showed
symptoms of depression, 44.6% showed symptoms of anxiety, 34% showed symptoms of insomnia
and 71.5% showed symptoms of distress (Lai et al., 2020). Additionally, in a study with a sample
of 994 participants conducted by Kang et al., more than a third of the medical staff surveyed had
minor mental health problems, 34.4% had mild mental health problems, more than 1/5 had
moderate mental health problems and 6.2% had severe mental health problems (Kang et al., 2020).
Furthermore, in a study conducted by Lu et al., in a sample of 2,299 health workers, more than
22% of medical staff had mild to moderate anxiety and 2.9% had severe anxiety, compared to
17.1% and 2.9% respectively among non-medical staff. More than 11% of the health workers
surveyed experienced moderate to medium depression, and 0.3% reported extreme depression (Lu,
Wang, Lin, & Li, 2020). The Covid-19 pandemic, like any public health emergency on an
international scale, can cause psychological stress and pressure among healthcare professionals
engaged in providing healthcare services around the globe and obliged to take challenging
decisions about the allocation of resources to patients in need (Greenberg, Docherty,
Gnanapragasam, & Wessely, 2020).

Additionally, our main finding indicates that the rates of anxiety (31.9%) and depression (25.8%)
among female health professionals were likely to be higher compared to their male counterparts
(12.7% and 12.8% respectively). Likewise, incidence of anxiety in female (25%) health workers
was found to be higher than in males (11.63%) in research conducted by Huang et al (Huang, Han,
Luo, Ren, & Zhou, 2020). According to the WHO, gender is a critical determinant of mental health
and mental illness in general and scientific evidence suggests that women have a higher prevalence
of anxiety disorders in general as well as trauma-related disorders (Li & Graham, 2017; Piccinelli,
Gomez Homen, Initiative, & Organization, 1997; WHO, 2020).
Our findings indicate a risk that female health professionals were 1.96 times more likely to develop
depression (95%CI, 1.34-2.88; p=0.001) and 2.57 times more likely to experience anxiety (95%CI,
1.77-3.75; p<0.001) than male health professionals. Physicians had 0.38 lower odds rate for
depression (95%CI, 0.24-0.58; p<0.001) and 0.66 lower odds rate for anxiety (95%CI, 0.45-0.96;
p=0.029) compared to other professionals. Secondary care health professionals were 0.65 less
likely to have depression (95%CI, 0.45- 0.95; p=0.027) than colleagues in primary or tertiary care.
Likewise, Lu, W., et al., in their study, found that high-risk health workers (e.g. emergency
workers, those working in ICUs, respiratory and infectious disease departments) were 2.06 more
likely to experience anxiety and 2.02 more likely to suffer depression than non-clinical health
facility workers (Lu et al., 2020). However, the findings of the study conducted by Tan et al.
(2020), show that the prevalence ratio of anxiety and depression among non-medical health facility
workers was significantly higher than among medical personnel by 1.85 and 1.12 respectively (Tan
et al., 2020). In this regard, the reason for lower rates of anxiety can be attributed to the appropriate
knowledge of health professionals on the path of the spread of, and protection from, infectious
diseases.

Our study is not without limitations. First, the questionnaire was sent to the personal email
addresses of health professionals, and only some responded positively. Second, we used only one
mental health assessment tool, and did not compare the results with those from other evaluation
instruments. Third, during the data collection period there was also a rapid change in the
epidemiology of people infected with SARS-CoV-2 in the country, which may have had an impact
on the response of health workers. Overall, the investigation method used to collect the research
data via an online form could have made it less likely that some groups of health professionals (eg
those facing specific work challenges) would respond than others, potentially contributing to
reporting bias.

In summary, the results have shown that the rates of anxiety and depression among health
professionals in Kosovo during the Covid-19 pandemic are at disturbing levels. Female healthcare
professionals are more likely to develop depression and anxiety symptoms compared to their male
counterparts. Further studies are needed to analyze other susceptible factors affecting the
development of depression and anxiety among Kosovar healthcare professionals. However,
psychological support could help health professionals to maintain good mental health during their
engagement in healthcare facilities managing Covid-19 pandemic cases. An immediate
intervention to develop psychological support for Kosovar health professionals, in order to address
mental health issues during management of the Covid-19 pandemic is urgent and so needs to be
considered and launched immediately.

Declaration of Competing Interest

The authors declare that they have no known conflicting financial interests or personal
relationships which may have affected the research stated in this paper.

Acknowledgement
We would like to thank the Heimerer College research unit for its continued assistance in finalizing
the manuscript.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon
reasonable request.

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Table 1. Anxiety and depression level and socio-demographic characteristics of the study sample.

n (%)

Total 592 (100)

Gender

Male 229 (38.7)

Female 363 (61.3)

Age (years) (median (IQR)) 38 (31-45)

Profession

Medical Doctor 253 (42.7)

Nurse 304 (51.4)

Others 35 (5.9)

Level of care

Primary 282 (47.6)

Secondary 200 (33.8)

Tertiary 110 (18.6)

Marital status

Single 109 (18.4)

Married 462 (78.0)

Widowed 14 (2.4)

Divorced 7 (1.2)

Living setting

Urban 438 (74.0)

Rural 154 (26.0)

Clinical work experience (years) 12 (5-20)

(median (IQR))

Chronic condition

Yes 66 (11.1)

No 526 (88.9)
Table 2. HADSa subscales levels and scores according to gender, profession and level of care

Anxiety Depression Anxiety Depressio

n

Normal Borderlin Abnorma Norma Borderlin Abnormal mean mean

e l l e score score
n(%) n(%)
n(%) n(%) n(%) n(%) mean±S mean±SD
D

Total 49 279 264 53 310 229 10.3±2.1 10.0±1.9

(8.3) (47.1) (44.6) (9.0) (52.4) (38.7)

χ2=191.474, df=2, p<0.001 χ2=213.938, df=2, p<0.001

Gender

28 146 189 38 172 153 10.5±2.1 9.9±2.0

Female (4.7) (24.7) (31.9) (6.4) (29.1) (25.8)

21 133 75 (12.7) 15 138 76 (12.8) 9.8±2.0 9.9±1.6

Male (3.5) (22.5) (2.5) (23.3)

χ2=21.609, df=2, p<0.001 χ2=9.771, df=2, p=0.008 t= 3.889, t=-0.017,

p<0.001 p=0.987

Profession

Physicia 18 (3) 123 112 19 121 113 10.2±2.0 10.1±1.7

n (20.8) (18.9) (3.2) (20.4) (49.3)

29 138 137 32 166 (28) 106 10.3±2.2 9.8±1.9

Nurse (4.9) (23.3) (23.1) (5.4) (17.9)

Others 2 (.3) 18 (3) 15 (2.5) 2 (.3) 23 (3.9) 10 (1.7 10.4±2.2 10.0±2.0

 χ2=1.771, df=4, p=0.778 χ2=8.725, df=4, p=0.068 F=0.276, F=3.588,
p=0.759 p=0.028b

Levels of care

25 141 116 27 153 102 10.1±1.9 9.8±1.9

Primary (4.2) (23.8) (19.6) (4.6) (25.8) (17.2)

Seconda 14 86 (14.5) 100 17 99 (16.7) 84 (14.2) 10.6±2.2 10.1±1.9

ry (2.4) (16.9) (2.9)

10 52 (8.8) 48 (8.1) 9 (1.5) 58 (9.8) 43 (7.3)) 10.1±2.1 9.8±1.8

Tertiary (1.7)

χ2=3.907, df=4, p=0.419 χ2=1.783, df=4, p=0.776 F=3.09, F=0.726,

p=0.046 p=0.484

I have received sufficient education regarding Covid-19

Complet 15 (2.2) 66 (9.7) 38 (5.6) 18 (2.6) 66 (9.7) 35 (5.1) 9.7±2.2 9.6±2.1

ely agree

28 (4.1) 185 164 26 (3.8) 201 150 10.3±2.1 10.0±1.8

Agree (27.2) (24.1) (29.6) (22.1)

Undecid 9 (1.3) 24 (3.5) 33 (4.9) 5 (0.7) 34 (5.0) 27 (4.0) 10.3±2.2 10.3±2.0

ed

4 (0.6) 38 (5.6) 49 (7.2) 5 (0.7) 42 (6.2) 44 (6.5) 10.6±v1. 10.5±1.7

Disagree 8

χ2=21.487, df=8, p=0.006 χ2=16.676, df=8, p=0.034 F=3.64, F=3.52,

p=0.006 p=0.007

a The Hospital Anxiety and Depression Scale. b In post hoc Tukey test, nurses were shown to have
lower depression scores compared to physicians (p=0.022).
Table 3. Regression models for depression and anxiety

Unadjusted Adjusteda

Depression

Wald P Exp(B) (95% CI) Wald p Exp(B) (95% CI)

Age (years) 0.017 0.896 1.001 (0.985- 4.205 0.040 0.964 (0.927-
1.018) 0.998)

Female gender 4.734 0.030 1.467 (1.039- 11.914 0.001 1.963 (1.338-
2.071) 2.878)

Working in 1.400 0.237 1.234 (0.871- 4.914 0.027 0.653 (0.448-

secondary health 1.746) 0.952)
facility

Medical doctor 6.633 0.010 0.644 (0.461- 19.994 <0.001 0.375 (0.244-
0.900) 0.576)

Work experience 0.432 0.511 1.006 (0.989- 5.043 0.025 1.045 (1.006-
(years) 1.023) 1.086)

Anxiety

Age (years) 2.328 0.127 1.013 (0.996- - - -

1.029)

Female gender 20.847 <0.001 2.230 (1.581- 24.214 <0.001 2.572 (1.766-
3.147) 3.748)

Working in 3.561 0.059 1.390 (0.987- 5.699 0.017 0.639 (0.442-

secondary health 1.958) 0.923)
facility
 Medical doctor 0.019 0.890 1.023 (0.737- 4.740 0.029 0.655 (0.448-
1.420) 0.959)

Work experience 2.648 0.204 1.014 (0.997- - - -

(years) 1.031)

Only variables that had a significant effect in the model are presented here.
a